Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding: General Topics

The Rockall score was validated in patients with upper gastrointestinal hemorrhage in one study, and was found to be a promising tool to triage patients for early discharge, ward admission, or intensive care admission [1]. Although the incidence of Rockall low-risk, nonvariceal upper gastrointestinal bleeding admissions was found to be high in one study, adverse outcomes are rare, so that there is excessive utilization of health-care resources in these patients [2]. Studying the main determinants affecting the prognosis and length of hospital stay revealed that the prognosis was mainly affected by the initial risk score and by variceal hemorrhage, whereas the length of hospital stay was mainly affected by the initial risk score and by the presence of comorbidity [3]. A multilayered artificial neural network was constructed using clinical variables available at initial evaluation and tested on 327 patients. This system was found to be valuable in predicting the presence of stigmata of recent hemorrhage and the need for endoscopic therapy, and may therefore be useful in selecting patients with upper gastrointestinal hemorrhage for urgent endoscopy [4].

It has been suggested that observational units in emergency departments implementing specific treatment protocols might improve the management of patients with upper gastrointestinal bleeding, and might optimize cost-effectiveness [5]. The value of endoscopy in critically ill patients was studied retrospectively in 214 patients with upper gastrointestinal hemorrhage, in whom early accurate endoscopy with appropriate therapeutic intervention was associated with improved outcomes [6]. To assess the efficacy of early endoscopy for low-risk patients with nonvariceal upper gastrointestinal bleeding, the English-language literature on the topic from 1980 to the present was reviewed. Although the majority of the evidence suggests that early endoscopy reduces resource utilization while preserving patient safety, most studies suffer from “methodological shortcomings,” according to the authors, so that firm conclusions still await well-designed randomized controlled studies [7].

The lack of a pathogenic role for Helicobacter pylori infection in stress ulcers was confirmed in a German study including cardiosurgical patients receiving ranitidine prophylaxis [8]. Upper gastrointestinal bleeding was found to show seasonal variations, with the highest incidence in the winter and spring months. The monthly prevalence correlated with nonsteroidal anti-inflammatory drug (NSAID) prescriptions [9]. A national survey from the Netherlands demonstrated the differences in the management of peptic ulcer bleeding between gastroenterologists and internists, as the former perform endoscopic therapy more often in Forrest Ib, IIa, and IIb ulcers. In 93 % of cases, endoscopic injection therapy was used as the primary treatment. Epinephrine combined with polidocanol was the substance most commonly injected. Acid-suppressant therapy was given in 97 % of cases. Eradication was confirmed in only 64 % of patients with H. pylori infection [10].

References

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