Senja Moratimur studies Medical Education, Earth Sciences, and Medicine. I’ve ever thinking about die is better than alive. A Rare Cause of Recurrent Hematemesis Melena. Griskalia Christine*, Irsan Hasan**. *Department of Internal Medicine, Faculty of Medicine, University of. TABLE HEMATEMESIS AND MELENA V Vascular I Inflammatory N Neoplasm Carcinomas of esophagus and lung D Degenerati ve and.
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The study was prospective, population-based and consisted of all patients who underwent upper gastrointestinal endoscopy UGEduring the year of at the National University Hospital of Iceland. An age- and gender-matched control group consisted of patients who underwent UGE during the study period and were without GIB. A total of patients underwent UGEs.
Independent predictors of clinically hematemesi bleeding were gastric ulcer OR 6. Mortality and the need for surgery during hospitalization was low in this population-based setting.
Upper gastrointestinal bleeding: incidence, etiology and outcomes in a population-based setting
Although the incidence of AUGIB has been rather extensively studied, there are only three prospective population-based studies reporting on the incidence in the last decade [ 5,8,9 ]. The incidence of AUGIB seems to be declining in the western world [ 6,8,9,14 ] which has been considered to be due to decreased incidence of Helicobacter pylori HP in western countries and an increase in implementing prevention strategies in users of non-steroidal anti-inflammatory drugs NSAIDs [ 3,7—9 ].
The use of low-dose aspirin LDA as an anticoagulant is increasing [ 17 ] and an association with increased risk of AUGIB [ 17—19 ] has been well documented. SSRIs selective serotonin reuptake inhibitors seem to be associated with an increased risk of upper gastrointestinal bleeding UGIB in some studies [ 20—23 ] but the literature is conflicting on the role of SSRIs [ 24 ] and bisphosphonates [ 25—27 ] in this context.
The aims of the current study were to study the incidence of AUGIB in a population-based setting, with a particular focus on the role of drugs in its etiology. Furthermore, the authors aimed to analyze the overall outcome in these patients. A control group of non-bleeding patients undergoing UGE during the same time period were matched 2: Definitions are mentioned below. Of all those who underwent UGE many individuals were excluded, they can be divided into five groups:.
Information about the population was provided by the Office for National Statistics in Iceland [ 30 ]. Before the endoscopic procedure, the gastroenterologist noted the indication for the endoscopy and its findings were recorded in a prospective fashion and later verified with analysis of medical records. The gastroenterologists recorded the indication for the UGE, whether or not GI bleeding was suspected or present and whether or not the bleeding was clinically significant.
Other variables noted were: Nurses in the endoscopy ward interviewed the subjects thoroughly before the endoscopy regarding their history of drug use. The drugs recorded were the following: The use of these drugs needed to be on a regular basis and not only on demand. Laboratory values were collected and were as follows: All information on transfusions is stored in an electronic information system Prosang, Databyran, Sweden and full traceability is ensured.
Controls were matched with the bleeders after collection of data from all these patients. The authors were able to match patients two-to-one and there was no selection of hematmesis patients matched. The Icelandic Medicines Registry records all prescriptions issued outside of hospitals and nursing homes in Iceland and is run by the Directorate of Health in Iceland. It has been operated since 1 January but contains data from and onward, about 2, registrations are added to the database annually.
To further improve the reliability of the drug history, records from the Icelandic Medicines Registry were examined. These records contained information on every prescription issued for the individuals participating in the study from 1 January until 31 December IMA holds information on the total amount of every individual drug sold by every wholesaler to every pharmacy, nursing home and hospital in Iceland. Information on the use or sale of prescribed drugs in these institutions was also accessible.
These data were accessed and examined by the researchers. The IMA staff was also consulted. By dividing 5, by it was found out that 14, DDD were used per day. Warfarin is only available by prescription and therefore the IMA was able to provide data on how many individuals were treated with warfarin in hospitals, nursing homes or had a prescription for warfarin.
Patients who did not have residency in the greater metropolitan area were excluded in the incidence calculations. The same assumptions and calculations were applied in the analysis of AUGIB incidence among warfarin users. Variables with a significant p -value in the univariate analysis were entered into a multiple logistic regression analyses in an attempt to identify independent predictors of having an AUGIB and clinically significant bleeding.
Senja Moratimur –
In all, The controls had a median age of 71 IQR Further information on laboratory parameters can be found in Supplementary Table I. Other common diagnoses were Mallory—Weiss syndrome Overall, 62 patients had peptic ulcer disease Table II. In 44 of those patients, a CLO test Campylobacter -like organism test was performed. A flow chart showing patients who were included in the study and the patient groups that were excluded.
The crude annual incidence of AUGIB is illustrated as well as age standardized incidence rates for certain age groups. Individuals who were non-residents of the greater metropolitan area were all excluded. The hemaremesis person in the greater metropolitan area during the study period was years old. In three patients the lesions were unspecific.
DD Hematemesis Melena
In a logistic regression hematmesis, use of the following drugs was independently related to bleeders: The use of drugs considered a priori to be potentially related to increased risk of GI bleeding. A comparison of clinically and non-clinically significant bleeding revealed that gastric ulcers were more common in the former group Table IV.
In a stepwise multiple logistic regression with clinically significant bleeding as the dependent variable, the following variables were found to be independent predictors of clinically significant bleeding: Comparison between patients with clinically significant bleeding and patients with non-clinically significant bleeding. An analysis of the Rockall score revealed a statistical difference in hemoglobin vs.
Of the 14, individuals in the greater metropolitan area treated with LDA, 53 had a bleeding episode and therefore 1 in every patients treated experienced AUGIB. In all, 21 of the treated with warfarin had a bleeding hematemmesis, meaning 1 in every 70 individuals treated experienced AUGIB. Of the 93 patients requiring blood transfusion, 45 Almost all patients were diagnosed with the first UGE Further information on endoscopic hemostasis is available in Supplementary Table II.
Only three patients 1. One M77 patient with end-stage obstructive pulmonary disease had three bleeding gastric ulcers and the bleeding caused a cardiac arrest Table V. The second patient M57 had an incarcerated hernia which resulted in abdominal compartment syndrome and ischemia of the stomach and small bowel Table V. Out of the two patients who were successfully surgically treated, one patient had a perforated gastric ulcer M31 whereas the other had a bleeding duodenal ulcer M58 Table V.
AUGIB was more prevalent among men and older people. Partly, this might be explained by the mwlena nature of some of these studies. It has been demonstrated that case finding of GI bleeders with a prospective method was clearly superior to case finding based on ICD codes [ 1 ]. Recently, a study from the Netherlands has confirmed this [ 33 ].
Socioeconomic background has been found to be important in some studies as the most socially deprived were two times more likely than the least socially deprived to have an UGIB [ 2,4 ], which might play a part in the explanation for the varying incidence. The incidence of AUGIB is decreasing in the western world according to most time-trend analyses [ 3,5,7—9 ] but not all [ 4 ].
This is most likely related to a decrease in the prevalence of peptic ulcer disease, due to decreased prevalence of H. All of these time-trend analyzing studies had their former time period in the 80s or 90s and the latter time period after [ 3,7—9 ].
In the last 10 years, only three well-designed prospective population-based studies have analyzed the incidence of AUGIB. Given that the incidence has been similar in these four prospective studies performed axkep the last decade, it is a relevant question whether AUGIB melea has reached its plateau after the decrease in incidence in recent decades.
In all studies except one [ 34 ], duodenal ulcers were more common than gastric ulcers. The proportion of esophagitis as a cause of bleeding had a wide range of occurrence 1.
A larger portion of the bleeders were using warfarin than non-bleeders. Most case—control studies evaluating the risk of AUGIB during warfarin therapy have a cohort of individuals who have atrial fibrillation, have undergone coronary stenting hemwtemesis have had a heart valve replacement. Case—control population-based studies that cover the general population are largely lacking. One population-based retrospective case—control study performed in the UK demonstrated an increased risk of AUGIB for individuals using melenz [ 35 ].
Therefore, the authors concluded that warfarin might increase the risk of AUGIB in the population-based setting. The authors’ methodology by which the incidence of AUGIB in drug users was obtained is not without flaws.
There are at least three hemxtemesis that might have confounded the results: However, LDA is the most sold drug in Iceland and although there might have been remnants in stock at the end ofthere should also have been remnants in stock from to the beginning of This point does not apply to warfarin since the amount of DDD was obtained by serviced prescriptions and not by wholesale; 2 pharmacies in the greater metropolitan area tend to be cheaper than the ones outside it, which means that some amount of DDD might have been sold to individuals with residency outside the greater metropolitan area.
This point does not apply to warfarin since the authors were able to exclude patients with residency outside of the greater metropolitan area in the warfarin calculations. Factors 1 and 2 make the incidence seem higher than it should be, factor 3 makes the incidence seem lower than it should be. Therefore, it cannot be ruled out that the incidence of AUGIB is in reality lower in LDA users than the authors reported and higher for warfarin users.
This study results are not in accordance with this, but more studies are needed to show whether NSAID users are at risk of more severe GI bleeding. The population-based nature of the current study may also be a partial explanation. Hematemeesis surgery for AUGIB used to be common, but the need for acute surgery has steadily been decreasing in the last decades [ 13 asekp.
The need for acute surgery in this study was only 1. The administration of blood transfusion was very similar to several other studies [ 5,8,29 ] but higher than in some [ 11,28 ]. If deaths, only associated with bleeding are included in the calculations, then the mortality rate amounts to 2.
The main limitation of the current study is lack of power, especially regarding drug intake. However, this limitation is ameliorated by a very thorough drug history.
First, patients were interviewed regarding drug intake, second, their medical records were reviewed and third, information was obtained from a Pharmaceutical Database holding information on every prescription made in Iceland from onward.
Another limitation of this study is that individuals with AUGIB might have died without undergoing endoscopy, although this is rare. The authors were uncertain that the mortality reported by them might in fact be higher.