Introduction

Several risk stratification scores have been developed for predicting endoscopic treatment or patient survival in non-variceal upper gastrointestinal bleeding (NVUGIB).

Aims & Methods

Our aim was to compare the performance of some previously described scores such as Canada-United Kingdom-Adelaide score (CANUKA), Glasgow-Blatchford score (GBS), Harbinger score, neutrophil-to-lymphocyte ratio (NLR), red cell distribution width (RDW) and Rockall (pre-endoscopy and complete) scores in predicting with the following outcomes in patients with variceal upper gastrointestinal bleeding (VUGIB): 30-day mortality, in-hospital mortality, need for interventional radiological procedure, need for RBC transfusion and rebleeding. Patients undergoing emergency endoscopy for upper GI bleeding at the Department of Emergency Medicine at Semmelweis University between January 1, 2022 and December 31, 2023 were included in a retrospective cohort analysis. Cases with VUGIB were managed according to the ESGE guideline. Statistical methods included ROC analysis, through which we obtained the AUROC values.

Results

There were 126 patients with VUGIB (79 males, 47 females, mean age 58). In-hospital rebleeding rate was 7.9% (n=10/126) for VUGIB. Second look endoscopy was performed in 30 cases (23.8%). The indication for second look endoscopy was inadequate index endoscopy in 10 cases, suspicion of re-bleeding in 6 cases, control of endoscopic intervention in 12 cases. The 30-day mortality rate was 23.8% (n=30/126). Due to missing data in 5 patients scoring systems were analyzed in 121 patients. Area under receiver operator characteristic curves (AUROC) for predicting various outcomes were as follow: 30-day mortality (HARBINGER: 0.63, CANUKA: 0.75, Rockall (pre-endoscopy): 0.73, Rockall (complete): 0.73, GBS: 0.71, NLR: 0.65, RDW: 0,54); in-hospital mortality (HARBINGER: 0.59, CANUKA: 0.7, Rockall (pre-endoscopy): 0.67, Rockall (complete): 0.67, GBS: 0.65, NLR: 0.63, RDW: 0.56); need for interventional radiological procedure (HARBINGER: 0.62, CANUKA: 0.49, Rockall (pre-endoscopy): 0.56, Rockall (complete): 0.56, GBS: 0.54, NLR: 0.54, RDW: 0.67); need for RBC transfusion (HARBINGER: 0.66, CANUKA: 0.83, Rockall (pre-endoscopy): 0.7, Rockall (complete): 0.7, GBS: 0.78, NLR: 0.65, RDW: 0.63); rebleeding (HARBINGER: 0.45, CANUKA: 0.44, Rockall (pre-endoscopy): 0.42, Rockall (complete): 0.42, GBS: 0.5, NLR: 0.53, RDW: 0.56).

Conclusion

Currently available risk stratification scores developed mainly for NVUGIB, when used for VUGIB have a suboptimal performance (AUROC ≤0.8) in predicting important clinical outcomes as mortality, rebleeding, need for endoscopic or interventional radiological procedure. CANUKA was clinically effective and superior to other scoring systems in estimating the need for RBC transfusion. Further prospective studies on larger patient cohorts are needed to further analyze and improve risk stratification scores for VUGIB.

Disclosure

No Conflict of Interest

Introduction

Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common emergency with high morbidity and mortality. Lactate levels and comorbidity indices, such as the Charlson Comorbidity Index (CCI), have shown promise in predicting patient outcomes. While these parameters individually provide valuable prognostic insights, their collective utility in predicting mortality among NVUGIB patients has not been explored.

Aims & Methods

The data for this study were collected from hospital records of patients admitted to Hitit University Hospital with NVUGIB between June 2021 and June 2024.
Demographic information, including age, gender, chronic illnesses, current medications, and history of previous gastrointestinal bleeding, was retrieved from computer database. Clinical data, such as outcomes (discharge or death), reasons for mortality, length of hospital stay were documented. Laboratory parameters, including lactate levels were recorded. Additionally, CCI and Glasgow Blatchford Score (GBS) were calculated for each patient.
Patients were stratified based on mortality status, which was considered the primary outcome. The associations between mortality and potential predictive factors were statistically analyzed. To improve mortality prediction, parameters that were significant in the logistic regression analysis were combined and assessed independently.

Results

A total of 390 patients with acute upper gastrointestinal bleeding were initially assessed. Of these, 180 patients were excluded due to missing data, leaving 210 patients included in the final study cohort. Key variables such as age, CCI, GBS, length of hospital stay, and mortality status were presented. Laboratory findings upon admission and the etiological distribution of gastrointestinal bleeding sources were also detailed.
Variables significantly associated with mortality in the univariate analysis include age, CCI, GBS, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate levels. In the logistic regression analysis, significant predictors of mortality were CCI (OR: 1.318, p=0.001) and lactate levels (OR: 1.575, p=0.003). GBS was not a predictor for mortality (p=0.468). CCI plus lactate levels were significantly higher in deceased patients compared to survivors (12.96 vs.7.31, p<0.001).
The correlation coefficients (r) showed significant positive correlations between the combination of lactate levels and CCI with GBS (r=0.498, p<0.001), length of stay (r=0.213, p=0.014), age (r=0.634, p<0.001) and urea levels (r=0.417, p<0.001). No significant correlation was found with AST or ALT.
ROC curves for lactate levels, CCI and CCI plus lactate levels predicting mortality showed that the area under the curve (AUC) for lactate was 0.704 (95% CI: 0.577–0.830, p=0.002) with a cut-off value of 1.83, yielding a sensitivity of 76% and a specificity of 52%. For CCI, the AUC was 0.769 (95% CI: 0.670–0.869, p<0.001) with a cut-off value of 6.5, showing a sensitivity of 76% and a specificity of 70%. And for the ‘CCI plus lactate’ level, the AUC was higher as 0.799 (95% CI: 0.703–0.895, p<0.001) with a cut-off value of 8.3, showing a sensitivity of 88% and a specificity of 62%.

Conclusion

Both lactate levels and the CCI are valuable tools for predicting mortality in NVUGIB patients. Our findings support the use of these parameters collectively to improve risk stratification. Combining lactate levels and CCI offers the advantage of better predicting mortality and improving sensitivity compared to using lactate levels or CCI alone.

Introduction

Despite its widespread use, the benefit of pre-endoscopic fresh frozen plasma (FFP) transfusion in acute upper gastrointestinal bleeding (AUGIB) with mild to moderate coagulopathy remains unproven. Current guidelines are inconsistent, and indiscriminate use of FFP—particularly in patients with variceal bleeding—may expose patients to harm without improving outcomes.

Aims & Methods

To assess the impact of pre-endoscopic FFP transfusion on clinical outcomes, including 30-day mortality, in patients with AUGIB and an INR between 1.5 and 2.5. We conducted a multicenter retrospective cohort study at one university-affiliated and one tertiary care hospital in Thailand between January 2016 and December 2020. Adult patients with AUGIB and INR 1.5–2.5 were included. Patients were stratified into FFP and non-FFP groups based on transfusion prior to endoscopy. Multivariable logistic regression was performed to adjust for age, comorbidities, bleeding etiology, and hemodynamic parameters. Subgroup analysis was conducted in patients with variceal bleeding.

Results

Among 244 patients (158 FFP; 86 non-FFP), those receiving FFP had significantly higher in-hospital mortality (24.1% vs. 7.0%; p = 0.001), pulmonary edema (23.4% vs. 4.7%; p < 0.001), and longer hospital stay (mean 8.1 vs. 5.8 days; p < 0.001). After adjustment, FFP transfusion remained independently associated with in-hospital mortality (adjusted OR 5.65; 95% CI 2.13–14.99; p < 0.001) and pulmonary edema (adjusted OR 5.56; 95% CI 1.59–19.44; p = 0.007). In patients with variceal bleeding, the adverse effect of FFP was more pronounced. The adjusted 30-day mortality was higher in the FFP group (adjusted OR 2.38; p = 0.075), though this did not reach statistical significance.

Conclusion

Pre-endoscopic FFP transfusion in AUGIB patients with INR 1.5–2.5 is associated with increased risk of in-hospital mortality and volume-related complications, particularly in variceal bleeding. These findings support a more selective and individualized transfusion approach and challenge the routine use of FFP in this population. Prospective studies are warranted to validate these observations and guide evidence-based transfusion thresholds.

References

1. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917.
2. Beattie C, Chakravarthy M. Fresh Frozen Plasma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554919/
3. de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C; Baveno VII Faculty. Baveno VII - Renewing consensus in portal hypertension. J Hepatol. 2022 Apr;76(4):959-974.

Introduction

ERCP is a commonly used endoscopic procedure for diagnosing and treating disorders of pancreaticobiliary system. NSAIDs have been proven to minimize the risk of post-ERCP pancreatitis, which occurs in approximately 8% of average-risk procedures (1,2). This study aimed to analyze the occurrence of post-ERCP pancreatitis in patients in whom ERCP was performed for the first time, before and after the use of NSAIDs in routine clinical practice.

Aims & Methods

Between January 2012 and December 2014 and between January 2019 and December 2021, 621 and 664 patients, respectively, were consecutively evaluated. In all those patients therapeutic ERCP procedure with biliary sphyncteroctomy has been done for the first time and the post-procedure complications were consecutively evaluated. NSAIDs were administered in a form of rectal suppositories at least an hour before the procedure. Post-ERCP pancreatitis was defined as an appearance of pain with elevated amylase concentrations at least 3x above the upper limit of normal for more than 24 hours after the procedure. Chi-Square test and Mann-Whitney U tests were used to compare discrete and continuous variables where p<0.05 was considered statistically significant.

Results

A total of 1285 ERCP-naïve patients were analyzed. Patients were split into two groups, one receiving and the other not receiving NSAID prophylaxis (667 vs 618 patients, respectively). Patients who received NSAID prophylaxis showed a significantly lower incidence of post-ERCP pancreatitis (2.9% vs. 7.8%, p<0.05) and transient hyperamylasemia (9.3% vs. 28.2%, p<0.05), as well (Table 1).

Table 1. NSAID non-NSAID

Conclusion

Real-life experience from a single tertiary center demonstrated that including NSAID prophylaxis into standard clinical practice resulted in a considerable reduction in post-ERCP pancreatitis and hyperamylasemia.

References

1. Buxbaum JL, Freeman M, Amateau SK, Chalhoub JM, Coelho-Prabhu N, Desai M, Elhanafi SE, Forbes N, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan WH, Sheth SG, Thiruvengadam NR, Thosani NC, Qumseya BJ; (ASGE Standards of Practice Committee Chair). American Society for Gastrointestinal Endoscopy guideline on post-ERCP pancreatitis prevention strategies: summary and recommendations. Gastrointest Endosc. 2023 Feb;97(2):153-162. doi: 10.1016/j.gie.2022.10.005. Epub 2022 Dec 12. PMID: 36517310.
2. Pekgöz M. Post-endoscopic retrograde cholangiopancreatography pancreatitis: A systematic review for prevention and treatment. World J Gastroenterol 2019;25:4019-4042.

Disclosure

no conflict of interest

Introduction

The number of individuals who will be treated for and cured from HCV infection world-wide is expected to exceed 1 million per year for the next decade. In those with compensated advanced chronic liver disease (cACLD), the risks of de-novo hepatocellular carcinoma (HCC) and hepatic decompensation are decreased but not completely abolished by HCV-cure. Thus, risk stratification is key to decrease resource utilization by individualizing post-treatment management. We evaluated whether the incidences of HCC and hepatic decompensation decrease with time after HCV-cure and whether the discriminatory ability of a one-time post-treatment assessment is maintained during long-term follow-up.

Aims & Methods

We retrospectively analyzed cACLD patients with paired liver stiffness measurement (LSM) & platelet count (PLT) before and after HCV-cure by interferon-free therapies from 7 European regions. Cumulative incidence curves were used to estimate the incidence of hepatic decompensation/HCC over time in the overall group and throughout previously defined risk strata: Baveno VII criteria for clinically significant portal hypertension after HCV-cure (CSPH excluded: FU-LSM <12kPa & FU-PLT >150G/L; CSPH ruled-in: FU-LSM ≥25kPa), and Semmler et al., J Hepatol 2022 (algorithm based on age, LSM, albumin and alcohol consumption) for HCC.

Results

2347 patients (mean age 60±12 years, 60% male, 21% obese, 21% diabetes) with a median LSM of 16.3kPa (IQR: 12.1-24.5, 25% ≥25kPa) before HCV-cure were followed for a median of 6.0 years after treatment. Interestingly, the incidence of first hepatic decompensation was strictly linear with 65 patients (2.8%) developing hepatic decompensation before eventually being diagnosed with HCC (incidence rate 0.57/100 patient years, incidence at 6 years: 3.1%). Similarly, incidence of HCC was also linear with 184 patients (7.8%) developing HCC (incidence rate 1.60/100 patient years, incidence at 6 years: 8.3%). Stratifying the risks for hepatic decompensation according to Baveno VII identified patients with a distinct prognosis during long-term follow-up (incidence at 6 years: 0.3% [CSPH excluded] vs. 2.1% [Gray-zone] vs. 15.6% [CSPH ruled-in]). Similarly, cumulative HCC incidence at 6 years was 15.8% in the high-risk group vs. 5.4% in the low-risk group according to Semmler et al. Results were similar when limiting prediction to events occurring >3 years after HCV-cure.

Conclusion

In patients with cACLD, the risks of hepatic decompensation, and more importantly, HCC remain constant after HCV-cure, even in the long-term (>3 years). A one-time post-treatment risk stratification based on non-invasive criteria confers important prognostic information that is maintained during long-time follow-up, as the hazards over time remain proportional.