Introduction

In accordance to current European guidelines, an emergency endoscopy in hemodynamically stable patients with suspected nonvariceal, upper gastrointestinal bleeding (nvoGI bleeding) should be performed within the first 24 hours. This practice consumes scarce human resources, especially at weekends. A recently available photometric capsule enables a prompt, non-invasive assessment of blood or haematin in the gastrointestinal tract.¹​

Aims & Methods

We investigated whether this capsule is a proficient tool to identify patients for whom an emergency endoscopy (within 24h) can be avoided.
A total of 73 patients with suspected hemodynamically stable nvoGI bleeding were included at four different sites using the photometric capsule. Capsule data were assessed after 120 minutes. All patients with a positive capsule result (bleeding index, HI>=1) underwent an upper gastrointestinal endoscopy within 12 hours (Group A). Patients with a negative result (HI<1.0) received a proton pump inhibitor at a standard dose twice daily and underwent endoscopy within 48 to 96 hours (Group B). If clinical or laboratory signs of acute bleeding became apparent in the meantime, an early endoscopy (within 12h) was performed.

Results

​​​​Mean modified Glasgow-Blatchford score (mGBS) was 8.9 for all 73 patients. Among the 41 patients of Group B, two patients (4.8%) received early endoscopy due to persistent hypotension (<90mmHg syst.) (1x cardiac tumor, 1x Forrest III ulcer, both without active bleeding). Two patients received no endoscopy (1 patient refused, 1 patient suffered from a stroke). Active bleeding was excluded in the remaining 37 patients (sensitivity regarding active bleeding = 100%, negative predictive value = 100%). In Group A, (n=32), emergency endoscopy was performed on average within 2.7 h and detected active bleeding sources in nine patients (28.1%). There were no technical, capsule-associated or bleeding-associated complications as assessed within 30 days of follow-up.

Conclusion

Due to the very high negative predictive value in detecting active upper GI-bleeding, the applied novel photometric capsule can reliably identify patients in whom emergent endoscopy is not necessary.

References

¹ Schmidt et al. Endosc Int Open 2019 Jun;7(6):E774-E781. doi: 10.1055/a-0880-531

Disclosure

M. Brand: Ovesco: study funding
A. Meining: Ovesco: consultant
A. Küllmer: Ovesco: lecture fees, study funding
A. Schmidt: Ovesco: lecture fees, study funding

Introduction

Acute upper gastrointestinal bleeding and timing to endoscopy are a recognised as risk factors for mortality. European Guidelines * suggest that the hemodynamical resuscitation could be performed before the endoscopy, however, indications are lacking about the timing of blood transfusions.

Aims & Methods

The aim of the study is to evaluate the transfusion timing to reduce death risk in patients with upper gastrointestinal bleeding. This is a prospective multicentre cohort study, including all consecutive hospitalized patients with upper gastrointestinal bleeding (UGIB). Clinical, endoscopic source of bleeding, medical and endoscopic treatment, time to endoscopy, and timing to transfusion were collected. We adopted the ESGE* guidelines to define the need for transfusion, timing to endoscopy and mortality. We considered timing to transfusion before or after the endoscopic procedure. Statistics: multivariate backward logistic regression was used to estimate the adjusted odds ratio death risk for variables with main clinical relevance or highly statistical significance at univariate analyses. Variables identified by the logistic regression were used into the propensity-score matching to compare the death risk between the two groups.

Results

2,017 out of 3324 patients received a transfusion and were included in the analysis; the mean age was 69.7 [±15.1], male was 1,365 (67.7%); the source of bleeding was non-variceal in 1634 patients (81 %), 178 patients died (8.8%); 69 out of 700 (9.9 %) died in the group transfusion before endoscopy; 109 out 1317 (8.3 %) in the group transfusion after endoscopy with an OR 1.2 (C.I. 95% .86 to 1.68) p<= 0.23. Mortality between the two groups did not significantly differ when haemoglobin levels at admission were considered, nor after adjustment for potential confounding variables, including ASA score, in-hospital bleeding, haematemesis at presentation, shock at admission, altered mental status and timing to endoscopy. Propensity score matching analysis indicated that among patients who received a transfusion, the risk of death decreased when the transfusion was administered before the endoscopy and the haemoglobin level was below 7 g/dL (coefficient = -0.06, p = 0.06; see Table).

Conclusion

Red pack cell transfusions before or after endoscopy did not modify the death risk in patients with acute upper gastrointestinal bleeding; the death risk was less frequent in patients transfused before endoscopy and with a haemoglobin value lower than 7 gr/l. However, this risk increased in those patients transfused before endoscopy and with a haemoglobin value > 8 gr/l.

References

* Ian M. Gralnek et al. Endoscopy 2021; 53: 300–332

Introduction

Antiplatelets and anticoagulants significantly increase the risk of upper gastrointestinal bleeding by impairing normal clotting mechanisms. Patients on dual or combined therapy often present with more severe bleeds and poorer endoscopic control. This leads to higher rates of rebleeding, complications, and mortality compared to those not on these therapies.

Aims & Methods

To evaluate the risk and outcomes of non-variceal upper gastrointestinal bleeding (UGIB) in patients on single antiplatelet therapy, dual antiplatelet therapy, and combined antiplatelet-anticoagulant therapy, and to assess associated morbidity, mortality, and rebleeding rates.
A prospective study was conducted involving 150 patients (90 males, 60 females) aged 40–60 years, presenting with upper GI bleeding between 1st January 2023 till 1st January 2025. Patients had co-morbid conditions including hypertension, diabetes mellitus, coronary artery disease, or prior cerebrovascular events, and were on their respective medications for at least 3 months. Patients using NSAIDs, having liver disease, or known bleeding disorders were excluded. Clinical presentations included melena, hematemesis, or both. All patients underwent upper GI endoscopy, with Forrest classification used to characterize ulcers. Laboratory investigations included CBC, LFTs, renal function, PT, and APTT. Bleeding profiles and endoscopic outcomes were analyzed across three medication groups: single antiplatelet (n=60), dual antiplatelet (n=50), and combined antiplatelet-anticoagulant therapy (n=40).

Results

UGIB was reported in 6 (10%) of the single antiplatelet group, 16 (32%) of the dual antiplatelet group, and 14 (35%) of the combined therapy group. Endoscopic findings predominantly revealed Forrest class IIA ulcers. Patients on dual or combined therapy had poorer endoscopic hemostasis. Four patients experienced rebleeding refractory to standard endoscopic measures, requiring angioembolization. One mortality was recorded in the dual antiplatelet group due to massive bleeding and shock.

Conclusion

Dual antiplatelet and combined antiplatelet-anticoagulant therapies significantly increase the risk and severity of non-variceal UGIB, with higher rates of poor endoscopic hemostasis, rebleeding, and mortality. These findings underscore the importance of risk stratification and prophylactic strategies in patients requiring long-term antithrombotic therapy.

References

1. Hao, W., Liu, A., Zhu, H. et al. Risk factors and management of gastrointestinal bleeding in patients with or without antiplatelet and anticoagulation therapy: a multicenter real-world prospective study. BMC Gastroenterol 24, 155 (2024). https://doi.org/10.1186/s12876-024-03238-3
2. Risk of Gastrointestinal Bleeding Increases With Combinations of Antithrombotic Agents and Patient Age Abraham, Neena S. et al. Clinical Gastroenterology and Hepatology, Volume 18, Issue 2, 337 - 346.e19

Introduction

Non-variceal upper gastrointestinal bleeding (nvUGIB) mortality has improved but remains high. Guidelines on nvUGIB often focusing on pre- and endoscopic management. However, more data on causes of death are needed, because non-bleeding specific mortality is unlikely to be improved by interventional advances.

Aims & Methods

The aims of this retrospective analysis of a single tertiary center registry of patients with nvUGIB were to assess causes of death in patients with nvUGIB and characterize this cohort. All hospitalized patients evaluated for suspected non-variceal UGIB (i.e., patients undergoing endoscopy) at our endoscopy unit between January 2018 and October 2020, either due to presentation for nvUGIB or with a suspected bleeding episode during hospitalization for any reason, were included in a prospective registry. Data on pre-endoscopic signs/symptoms of UGIB, epidemiological data, laboratory values, and medications were extracted from the electronic health record. Endoscopy reports were individually searched and relevant data including the most likely culprit lesion in the opinion of the endoscopist as well as respective hemostatic treatment extracted.

Results

Among 1135 patients – 41.7% women, mean age 70.4 (±15.7) years, median length of stay 8 (IQR 4;16) days – 92 (8.1%) died during hospitalization and were further analyzed. Mean age was 73.2 (±12.9) years, 44.5% were women, 36% of patients were on anticoagulation, 27% on antiplatelet therapy, and 9% on both. The median Charlson comorbidity index was 5 (IQR 3;6.8), the CHA2DS2-VASc-Score 3 (IQR 2;5). However, the median AIMS65 score was only 2 (IQR 1;2). Median time from admission to death was 17 (IQR 6.5;30) and from endoscopy to death 11 (IQR 4;21.5) days. The most common sources of bleeding as determined by endoscopy reports were: uncertain (24%), peptic ulcer (21%), esophagitis (14%), and non-peptic ulcers (9%). Adherence to guideline-based endoscopic peptic ulcer management recommendations was 70%. Radiological intervention for bleeding was performed in 1%, surgical intervention in 8.7%. Patients who died were older (73.2 vs. 70 years, p=0.0336), had lower hemoglobin nadirs (7.1 vs. 7.8 g/dL, p<0.0001), high c-reactive protein levels (p<0.0001) and creatinine (p<0.01), had longer lengths of stay (LOS) (median LOS 17 vs. 8 days, p<0.0001), and longer times from admission to endoscopy (median 3 days vs. 1 day, p<0.0001). However, sex was not associated with mortality (p=0.58). Looking at bleeding in association with causes of death, mostly (n=55, 59.8%), bleeding was categorized as a bystander. Only 32.6% of causes of death were judged as directly due to or likely associated with the bleeding episode, and these patients had a higher AIMS65 (p=0.0301). Only 12% died due to an unmanageable bleeding (or change to best supportive care). Overall, the following major groups of causes of death were identified: malignancy (18.5%), multi-organ failure (17.4%), infection/sepsis (15.2%), bleeding-associated (15.2%), cardiovascular (13.0%), and others (23.9%).

Conclusion

UGIB mortality remains relatively high despite management advances. However, only a minority of patients die due to UGIB and even among those most deaths are related to sequelae of the bleeding instead of unmanageable bleeding. Patients who die are older, likely sicker, and suffer from many comorbidities. Based on these data, it is uncertain whether focusing on endoscopic management improvements will significantly change UGIB-related mortality. Possibly, the focus should be shifted to improving general/internal medicine or geriatric care.

Introduction

A global surge in anticoagulant use raises concerns about managing acute upper gastrointestinal bleeding (AUGIB) in affected patients.

Aims & Methods

This study presents findings from a large UK multicenter study of AUGIB in patients on anticoagulants.A prospective multicenter observational study included adults (>16 years) from 152 UK hospitals with AUGIB between 3 May- 2 Jul , 2022.

Results

Of 5101 AUGIB cases enrolled, 31%(1566) were on anticoagulants – 10%(n=159) warfarin, 58%(n=912) direct oral anticoagulants (DOACs), and 34%(n=530) heparin (prophylactic dose – 76%, therapeutic dose – 18%, and bridging therapy – 2%). The median age was 78 yrs (IQR 68-85), with 58% being new admissions. Anticoagulants were discontinued post-AUGIB in 87%. The major hemorrhage protocol activated for 4%. Transfusion rates were: 59% packed red blood cells, 7% prothrombin complex concentrate (PCC), 5% fresh frozen plasma, 3% platelets, 0.8% cryoprecipitate, and 0.3% fibrinogen. For DOACs (n=912) a reversal agent was needed for 6% (46% - andexanet alfa and 54% -PCC). Glasgow-Blatchford score (GBS) categorized patients into: 3% low-risk(GBS 0-1), 16% medium-risk(2-6), 33% higher-risk(7-11),and 34% very high-risk(≥12). Inpatient endoscopy was performed in 85%(n=1335). Time to endoscopy from presentation was: 0-6 hrs 5%, 6-24 hrs 32%, 24-48 hrs 25%, and >48 hrs 24%. Bleeding etiologies identified (n=798) included: peptic ulceration (49%), esophagitis (26%), varices (8%), portal hypertensive gastropathy (4%), malignancy (7%), and other (27%). Stigmata of recent bleeding observed in 29% (390/1335) of cases, leading to endotherapy in 25% (328/1335). Anticoagulants resumed while in-patient for 46% (613/1335) – 19% within 24 hrs, 14% 24-48 hrs, 9% 48-72 hrs, and 41% >72 hrs after the index endoscopy. 10% (136/1335) had evidence of further in-patient bleeding after the index endoscopy. Overall, 10%(160/1566) had >1 endoscopy, 1% (16) underwent surgery, and 2.8% (44) had interventional radiology. Median length of stay was 7 days (IQR 4-13), with in-patient mortality at 13%(211). A multivariable logistic regression revealed delayed endoscopy (>48 hrs) was associated with reduced rebleeding odds (OR:0.19,95%CI:0.04-0.99), while early endoscopy (0-6 hrs) was linked to higher rebleeding odds (OR:1.81,95%CI:0.44-7.46).Importantly, stigmata of recent bleeding on endoscopy significantly elevated rebleeding odds (OR:4.88,95%CI:1.75-13.64), emphasizing its prognostic relevance in AUGIB.

Conclusion

A third of AUGIB patients in this multi-center UK study were on anticoagulants at the time of presentation. Real-world evidence underscores the importance of appropriate resuscitation and careful restarting of the anticoagulants based on the indication. Further development of predictive models to guide the time to restart different anticoagulants is needed.