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PubMed1998

Acute bleeding after bone marrow transplantation (BMT)- incidence and effect on survival. A quantitative analysis in 1,402 patients.

Acute bleeding after bone marrow transplantation (BMT) was investigated in 1,402 patients receiving transplants at Johns Hopkins Hospital between January 1, 1986 and June 30, 1995. Bleeding categorization was based on daily scores of intensity used by the blood transfusion service. Moderate and severe episodes were analyzed for bleeding sites. Analysis of the cause of death and the interval of the bleeding episode to outcome endpoints was recorded. Survival estimates were computed for 1,353 BMT patients. The overall incidence was 34%. Minor bleeding was seen in 10.6%, moderate bleeding was seen in 11.3%, and severe bleeding was seen in 12% of all patients. Fourteen percent of patients had moderate or severe gastrointestinal hemorrhage, 6.4% had moderate or severe hemorrhagic cystitis, 2.8% had pulmonary hemorrhage, and 2% had intracranial hemorrhage. Sixty-one percent had 1 bleeding site and 34.4% had more than 1 site. Moderate and severe bleeding was more prevalent in allogeneic (31%) and unrelated patients (62.5%) compared with autologous patients (18.5%). Significant distribution of incidence was found among the different diagnoses, but not by disease status in acute myeloid leukemia, acute lymphoblastic leukemia, chronic myelogenous leukemia, Hodgkin's disease, and non-Hodgkin's lymphoma. Bleeding was associated with significantly reduced survival in allogeneic, autologous, and unrelated BMT and in each disease category except multiple myeloma. Survival was correlated with the bleeding intensity, bleeding site, and the number of sites. Although close temporal association was evident to mortality, bleeding was recorded as the cause of death in only the minority of cases compared with other toxicities after BMT (graft-versus-host disease, infections, and preparative regimen toxicity). Acute bleeding is a common complication after BMT that is profoundly associated with morbidity and mortality. Although bleeding was not a direct cause of death in the majority of cases, it has a potential prognostic implication as a predictor of poor outcome in clinical assessment of patients after BMT.

Acute Disease↗
PubMed1996

Aspirin related gastrointestinal bleeders have an exaggerated bleeding time response due to aspirin use.

BACKGROUND: Gastrointestinal bleeding is related to non-steroidal anti-inflammatory drug (NSAID) use, especially aspirin, but only a small subset of users bleed. AIM: To look for risk factors or mechanisms whereby aspirin may promote gastrointestinal bleeding. PATIENTS: Sixty one patients with previous aspirin related upper gastrointestinal bleeding and 61 matched controls. METHODS: Patients and controls were given 375 mg of aspirin and sequential skin bleeding time and blood aspirin levels were measured. Additional studies included platelet lumiaggregation, von Willebrand factor, Factor VIII, and coagulation studies. RESULTS: Baseline skin bleeding time was similar in bleeders and controls, but bleeders had a more prolonged skin bleeding time after aspirin use. Hyper-response was more frequent in bleeders (30% v 9.3%; p < 0.01) and was associated with more than one previous separate bleeding event and a lower packed cell volume during the preceding bleeding episode. No differences were found in other factors studied. Logistic regression analysis identified prolonged skin bleeding time after aspirin use as an independent factor contributing to aspirin related gastrointestinal bleeding (RR = 5.4; 95% CI: 1.8 to 17.1). CONCLUSIONS: 30% of patients with a history of aspirin related gastrointestinal bleeding have an exaggerated prolongation of skin bleeding time in response to aspirin, which may be a risk factor for bleeding. This intrinsic defect or to subclinical von Willebrand disease or different aspirin metabolism.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1998

Bronchoscopy with transbronchial biopsies: measurement of bleeding volume and evaluation of the predictive value of coagulation tests.

The objectives of this study were to measure the bleeding volume associated with fibreoptic bronchoscopy with transbronchial biopsies (TBB), to correlate it with coagulation tests and to compare bleeding volume in patients with and without lung transplant. A total of 104 consecutive TBB in 51 different patients was evaluated prospectively. Before each procedure, haemoglobin, blood platelets, prothrombin time (PT), activated partial thromboplastin time (aPTT) and bleeding time were measured. During the procedure, lavage fluid and blood were collected by suction. The haemoglobin concentration of the mixture was measured and bleeding volume was calculated. Clinically significant bleeding was arbitrarily defined as >20 mL blood present in lavage fluid. The mean+/-SD bleeding volume was 7+/-10 mL with no statistically significant difference between transplanted and nontransplanted patients. In eight procedures (7.7%) the bleeding volume was >20 mL (range 22-61 mL). Prebiopsy values for blood platelet counts, PT and aPTT did not predict a bleeding tendency in any of the procedures in which significant bleeding occurred. No correlation was found between bleeding time and bleeding volume in the 17 procedures performed in patients with a prolonged bleeding time (> or =10 min). The bleeding associated with transbronchial biopsies was usually minor and quantitatively similar in patients with or without lung transplant. Coagulation tests could not predict clinically significant bleeding, which may occur in patients with normal coagulation test results.

Adult↗
PubMed1995

[Quantitative bleeding time].

Bleeding time, which reflects the interaction of the platelets with the damaged vessel wall and the subsequent formation of the primary hemostatic plug, has been widely used in the diagnosis of bleeding disorders, especially platelet abnormalities. We have developed a computerized method to measure the bleeding pattern and the amount of blood loss from the bleeding time incision (quantitative bleeding time). In 87 normal subjects (51 males and 36 females), the bleeding time was 389 +/- 137 sec and the amount of blood loss was 15.7 +/- 7.2 microliters (mean +/- S.D.). The bleeding pattern was classified into four types (I-IV). Type II showed the prolongation of the bleeding time, continuous constant bleeding, and considerably large amount of blood loss from the incision. This type which includes severe von Willebrand disease and serious thrombocytopenia is related to the severe bleeding tendency. Type III exhibited the prolongation of the bleeding time keeping a trace of blood loss from the incision. In type III patients, the bleeding tendency was generally mild despite the prolonged bleeding time as in patients with moderate thrombocytopenia or aspirin ingestion. Measurement of bleeding pattern and blood loss will provide a useful information to evaluate the defect of primary hemostasis.

Adolescent↗
PubMed2000

Progestogens versus oestrogens and progestogens for irregular uterine bleeding associated with anovulation.

BACKGROUND: Dysfunctional uterine bleeding (DUB) is "excessively heavy, prolonged or frequent bleeding of uterine origin which is not due to pregnancy or to recognizable pelvic or systemic disease". Anovulation may be inferred from a number of observations but in the normal clinical situation, anovulation is often assumed when a woman presents with heavy, prolonged or frequent bleeding, particularly in those at the extremes of reproductive life and in women known to have the polycystic ovarian syndrome. Menstrual bleeding that is irregular or excessive is usually poorly tolerated by the majority of women. Changes in the length of the menstrual cycle generally imply disturbances of the hypothalamo-pituitary-ovarian (HPO) axis. In anovulatory DUB with acyclic (irregular) oestrogen production there will be no progesterone withdrawal from oestrogen primed endometrium and so cycles are irregular. Prolonged oestrogen stimulation may cause a build up of endometrium with erratic bleeding as it breaks down and is expelled. This is the rationale for using cyclical progestogens during the second half of the menstrual cycle in order to provoke a regular withdrawal bleed. Continuous progestogen is intended to induce endometrial atrophy and hence to prevent oestrogen-stimulated endometrial proliferation. Progestogens, and oestrogens and progestogens in combination are already widely used in the management of irregular or excessive bleeding due to DUB, but the regime, dose and type of progestogen used varies widely with little consensus about the optimum treatment approach. OBJECTIVES: To determine the effectiveness and acceptability of progestogens alone, and oestrogens and progestogens in combination in the management of irregular bleeding associated with anovulation. SEARCH STRATEGY: The search strategy of the Menstrual Disorders Group was used to identify all randomised trials of progestogens alone or in combination with oestrogens in the management of irregular menstrual bleeding associated with anovulation. In addition a search of the Cochrane Controlled Trials Register was undertaken. SELECTION CRITERIA: All randomised controlled trials of progestogens (via any route) alone or in combination with oestrogens in the treatment of irregular bleeding associated with anovulation. DATA COLLECTION AND ANALYSIS: Study quality assessment and data extraction were carried out independently by two reviewers. Both reviewers were experts in the content matter. MAIN RESULTS: No randomised trials were identified which compared progestogens with oestrogens and progestogens in the management of irregular bleeding associated with anovulation. Only one small, non-randomised study compared two progestogen regimes in the management of heavy and irregular bleeding in subjects with confirmed anovulation. One randomised study compared the effects of two progestogens on endometrial histology in subjects with a variety of menstrual symptoms, half of whom had cystic glandular hyperplasia. No studies were found which compared progestogens with oestrogens and progestogens in combination or with placebo in the management of irregular bleeding associated with anovulation. REVIEWER'S CONCLUSIONS: There is a paucity of randomised studies relating to the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular bleeding associated with anovulation. Further research is needed to establish the role of these treatments in the management of this common gynaecological problem.

Adult↗
PubMed1984

Controlled trial of medical therapy for active upper gastrointestinal bleeding and prevention of rebleeding.

UNLABELLED: This multicentered, placebo-controlled trial evaluated the efficacy of medical therapy to stop bleeding in 285 patients with active upper gastrointestinal bleeding (bleeding phase) and 194 patients who had ceased gastrointestinal bleeding and in whom therapy was instituted to prevent rebleeding during the same hospitalization (prevention phase). Patients in the bleeding phase were given cimetidine (300 mg every six hours) or intravenous placebo. There was no significant overall difference between intravenous cimetidine (71 percent) and placebo (77 percent) in stopping acute upper gastrointestinal bleeding. There was also no significant difference noted between intravenous cimetidine and placebo when specific bleeding lesions were evaluated. Once gastrointestinal bleeding had stopped, recurrence of bleeding while receiving prevention therapy (cimetidine tablets 300 mg one three times a day and at bedtime, or Mylanta II liquid 30 ml every hour, or cimetidine plus hourly antacids, or placebo) was evaluated in 194 of the patients in the bleeding phase. Twenty-four percent (12 of 51 patients) rebled while receiving cimetidine, 13 percent (five of 39 patients) rebled while receiving hourly antacids, 11 percent (six of 54 patients) rebled while receiving cimetidine plus hourly antacids, and 26 percent (13 of 50 patients) rebled while receiving placebo. None of these prevention regimens reached statistical significance (p = 0.13). Evaluation of specific bleeding lesions within this group also failed to show any significant value of prevention therapy. IN CONCLUSION: (1) intravenous cimetidine offers no advantage over placebo in stopping active upper gastrointestinal bleeding; (2) the occurrence of rebleeding during the same hospitalization does not appear to be significantly affected by any of the medical regimens used for prevention. These findings would suggest that the cessation of active bleeding and the prevention of recurrent upper gastrointestinal bleeding during a single hospitalization appear to be unaffected by therapy directed at acid neutralization or reduction.

Adult↗
PubMed1995

Histologic evidence of old intrauterine bleeding is more frequent in prematurity.

OBJECTIVE: Our purpose was to study the incidence and location of histologic evidence of intrauterine bleeding in preterm and term placentas. STUDY DESIGN: A total of 462 consecutive placentas delivered at < 32 weeks' gestation, from which cases of placenta previa, stillbirth, and multiple gestation were excluded, were compared with 108 consecutive term placentas (with similar exclusion criteria) in regard to the presence of hemosiderin in decidua of basal plate or placental membranes. Of the 462 preterm cases, 448 charts made specific reference to the presence or absence of vaginal bleeding. Bloody show alone was not considered bleeding. The blinded scoring of lesions (including acute ascending infection, uteroplacental vascular pathologic processes and related ischemic damage, chronic inflammation, and coagulation related lesions) was analyzed by contingency tables (p < 0.05 significant). RESULTS: A total of 196 of 462 (43%) preterm placentas had any decidual hemosiderin compared with one of 108 (0.8%) at term (p < 0.00001). Among the preterm cases, hemosiderin was significantly more common in preeclampsia (45/76, 60%) and in cases clinically diagnosed as nonhypertensive abruptio placentae (21/33, 64%) than in premature membrane rupture (72/192, 37.5%) and preterm labor (58/161, 36%, p < 0.003). The incidence of placental lesions in preterm cases with extraplacental membrane hemosiderin was not different than it was in cases without hemosiderin. Placental lesions related to basal-plate decidual hemosiderin in the preterm cases were villous infarct (p < 0.0001), uteroplacental vessels with absence of physiologic change (p < 0.003) and increased numbers of circulating nucleated erythrocytes (p < 0.0007), uteroplacental thrombosis (p < 0.0001), and villous fibrosis (p < 0.0001) and hypovascularity (p < 0.0001). Among the preterm cases, 23 of 48 (48%) with first-trimester bleeding, 33 of 66 (50%) with second-trimester bleeding, and 31 of 64 (48%) with multiple episodes of bleeding had decidual hemosiderin (p < 0.0001). A clinical history of gestational bleeding was significantly less common in cases of preterm preeclampsia with histologic evidence of bleeding (four of 73, 5.5%) than in nonhypertensive abruptio placentae (18/31, 58%), premature rupture of membranes (52/183, 28%), or preterm labor (31/161, 19%, p < 0.0001). Hemosiderin was not related to clinical bleeding < 72 hours of delivery (p > 0.20). CONCLUSIONS: Decidual bleeding is common in all clinical types of preterm birth and is most common in preterm preeclampsia and nonhypertensive abruption placentae. A clinical history of bleeding is not correlated with the presence of decidual hemosiderin. Bleeding in the basal plate is related to histologic evidence of chronic uteroplacental vascular pathologic processes, which in cases of spontaneous prematurity (premature rupture of membranes, preterm labor, nonhypertensive abruptio placentae) may be associated with decidual bleeding which occasionally may be clinically manifested as gestational bleeding.

Abruptio Placentae↗
PubMed2005

Effect of needle tract bleeding on occurrence of pneumothorax after transthoracic needle biopsy.

PURPOSE: Occasionally bleeding along the needle trajectory is observed at post-biopsy computed tomographic sections. This study was designed to evaluate the possible effect of needle tract bleeding on the occurrence of pneumothorax and on requirement of chest tube insertion. MATERIALS AND METHODS: Two hundred eighty-four needle biopsies performed in 275 patients in whom the needle traversed the aerated lung parenchyma were retrospectively reviewed. Bleeding along the needle tract, occurrence of pneumothorax and need for chest tube insertion, type and size of the needle, size of the lesion, length of the lung traversed by the needle, presence or absence of emphysema were noted. Effect of these factors on the rate of pneumothorax and needle-tract bleeding was evaluated. The data were analyzed by chi2 test. RESULTS: Pneumothorax developed in 100 (35%) out of 284 procedures requiring chest tube placement in 16 (16%). Variables that were significantly associated with an increased risk of pneumothorax were depth of the lesion (P < 0.001) and severity of emphysema (P < 0.05). There was bleeding along the needle tract in 18.6% (n = 53) of the procedures. Pneumothorax occurred in 18 (33.9%) out of 53 procedures in which tract-bleeding was observed and in 82 (35.4%) out of 231 procedures in which tract-bleeding was not seen. The difference between the two groups was not significant (P > 0.05). However, analysis of the relation between length of lung traversed by the needle, tract-bleeding and pneumothorax rate indicated that tract-bleeding had a preventive effect on development of pneumothorax (P < 0.001). Occurrence of tract bleeding also had preventive effect on pneumothorax in the presence of emphysema (P < 0.05). The only variable which had effect on occurrence of tract-bleeding was the length of the lung traversed by needle (p < 0.001). Requirement for chest tube insertion was smaller in the tract-bleeding group than non-tract bleeding group, 11% (2/18) to 17% (14/82), respectively. But this difference was not significant statistically (P > 0.05). CONCLUSION: Bleeding in the needle tract has a preventive effect on the occurrence of the pneumothorax in deep-seated lesions and in the presence of emphysema, although it does not affect the overall rate of pneumothorax.

Adult↗
PubMed2006

A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes.

OBJECTIVES: The goal of this study was to determine the association between Thrombolysis In Myocardial Infarction (TIMI) and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) bleeding and clinical outcomes. BACKGROUND: There are limited data on the relative utility of either scale at predicting clinical outcomes in patients with non-ST-segment elevation acute coronary syndromes (ACS). METHODS: Pooled data from two randomized trials of patients with ACS (n = 15,454) were analyzed to determine the association between TIMI and GUSTO bleeding and 30-day and 6-month death/myocardial infarction (MI) using Cox proportional hazards modeling that included bleeding as a time-dependent covariate. RESULTS: There was a stepwise increase in the adjusted hazard of 30-day death/MI with worsening GUSTO bleeding (hazard ratio [95% confidence interval], GUSTO mild 1.20 [1.05 to 1.37]; moderate 3.28 [2.88 to 3.73]; severe 5.57 [4.33 to 7.17]), and an increased risk with all three levels of TIMI bleeding (TIMI minimal 1.84 [1.63 to 2.08]; TIMI minor 1.64 [1.31 to 2.04]; major 1.45 [1.23 to 1.70]). When both bleeding scales were included in the same model, the risk with GUSTO bleeding persisted; however, the association between TIMI bleeding and outcome was no longer significant. CONCLUSIONS: Both scales identify ACS patients with bleeding complications at risk for adverse outcomes. In a model that included both definitions, the risk with GUSTO bleeding persisted while the risk with TIMI bleeding did not. This suggests that bleeding assessed with clinical criteria is more important than that assessed by laboratory criteria in terms of outcomes. Future clinical trials should consider using a combination of the GUSTO bleeding scale and the need for transfusion to assess bleeding complications.

Angina, Unstable↗
PubMed2000

A nation's experience of bleeding complications during laparoscopy.

BACKGROUND: Bleeding complications during laparoscopic surgery are rare but probably underreported. The aim of the current study was to elucidate the clinical relevance of bleeding complications and major vascular injuries during standard laparoscopic procedures. PATIENTS AND METHODS: The Swiss Association of Laparoscopic and Thoracoscopic Surgery (SALTS) prospectively collected the data on 14,243 patients undergoing different standard laparoscopic procedures (1995 to 1997). These data were analyzed with special interest in intraoperative and postoperative bleeding complications and major vascular injuries. RESULTS: In all, 331 patients (2.3%) had intraoperative bleeding complications. Whereas 44 patients suffered from an external bleed of the abdominal wall, the bleeding was internal in the remaining 287. Thirty-three patients with internal bleeding required blood transfusion with a mean blood loss of 1,630 mL. Surgical hemostasis was necessary in 68% of external and 91% of internal bleeds. There were 250 patients (1.8%) with postoperative bleeding complications. External bleeding occurred in 143 patients, and 107 patients developed internal bleeding. External bleeding was mainly treated conservatively (92%), whereas 50% of internal bleeds required further surgical intervention. Major vascular injuries occurred in 12 patients (incidence 0.08%) with open treatment being necessary in all cases. CONCLUSIONS: Bleeding complications are, in fact, common during laparoscopic surgery. Meticulous dissection technique, immediate recognition, and adequate surgical treatment are mandatory for their management.

Abdominal Muscles↗
PubMed2004

The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated.

BACKGROUND: Peptic ulcer disease is considered the cause of upper-GI bleeding in 50% of cases. A recent decline in the proportion of cases of upper-GI bleeding because of a peptic ulcer was noted by us. The objectives of this study were to evaluate the frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding peptic ulcers with a non-bleeding visible vessel. METHODS: Patients with upper-GI bleeding seen from December 1999 until April 2001 at a tertiary, university-affiliated medical center were studied prospectively. The Clinical Outcome Research Initiative (CORI) database was used to correlate the single institution data with nationwide data. Endoscopic data in the CORI database for patients who had endoscopy for upper-GI bleeding between December 1999 and July 2001 were retrieved and analyzed. RESULTS: A total of 126 patients were included in the prospective study. The endoscopic findings were: peptic ulcer in 31.8%: 95% confidence interval (CI) [23.7%, 40.6%] of patients; a non-bleeding visible vessel was present in 10%: 95% CI[2.8%, 23.7%] of these peptic ulcers. From the nationwide CORI database, data for 7822 patients with upper-GI bleeding were obtained. The endoscopic findings were: peptic ulcer in 20.6%:95% CI[19.7%, 21.5%] of patients with upper-GI bleeding; a non-bleeding visible vessel was present in 7.3%: 95% CI[6.1%, 8.6%] of the ulcers. CONCLUSIONS: The frequency of peptic ulcer in patients with upper-GI bleeding and the proportion of bleeding ulcers with a non-bleeding visible vessel are less than previously reported.

Adult↗
PubMed2005

A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding.

BACKGROUND: Capsule endoscopy enables noninvasive diagnostic examination of the entire small intestine. However, sensitivity and specificity of capsule endoscopy have not been adequately defined. We, therefore, compared capsule endoscopy by using intraoperative enteroscopy as a criterion standard in patients with obscure GI bleeding. METHODS: Forty-seven consecutive patients with obscure GI bleeding (11 with ongoing overt bleeding, 24 with previous overt bleeding, and 12 with obscure-occult bleeding) from two German gastroenterologic centers were included. All patients who had a prior nondiagnostic evaluation, including upper endoscopy, colonoscopy with a retrograde examination of the distal ileum, and push enteroscopy, underwent capsule endoscopy followed by intraoperative enteroscopy. RESULTS: Capsule endoscopy identified lesions in 100% of the patients with ongoing overt bleeding, 67% of the patients with previous overt bleeding, and 67% of the patients with obscure-occult bleeding. Angiectasias were the most common source of bleeding (n = 22). Capsule endoscopy showed the source of bleeding in 74.4% of all patients. The method was more effective in patients with ongoing bleeding. Compared with intraoperative enteroscopy sensitivity, specificity, and positive and negative predictive values of capsule endoscopy were 95%, 75%, 95%, and 86%, respectively. CONCLUSIONS: Capsule endoscopy has high sensitivity and specificity to detect a bleeding source in patients with obscure GI bleeding. Thus, wireless capsule endoscopy can be recommended as part of the routine work-up in patients with obscure GI bleeding.

Adolescent↗
PubMedDate not supplied

Changes in level of consciousness and association with hyperglycemia as tool for predicting and preventing re-bleeding after spontaneous subarachnoid hemorrhage.

INTRODUCTION: It is crucial to predict and prevent re-bleeding from ruptured intracranial aneurysms in patients with subarachnoid hemorrhage (SAH). During the prehospital period and on arrival to the hospital, blood glucose and serum potassium levels, as well as changes in levels of consciousness were assessed in patients in the acute stage of spontaneous subarachnoid hemorrhage. These assessments were analyzed as possible risk factors for re-bleeding and as potential contributors to the prevention of re-bleeding, both in prehospital care and after hospital admission. METHODS: Upon the arrival of 202 patients with spontaneous subarachnoid hemorrhage, the following indications were examined retrospectively: (1) presence/absence of re-bleeding; (2) time interval between the onset of SAH and re-bleeding; (3) level of consciousness using the Glasgow Coma Scale (GCS) score before and on arrival; (4) amount and distribution of subarachnoid blood using Fisher's Computerized Tomography Classification; (5) blood pressure; (6) blood glucose concentration; and (7) serum potassium concentration. The patients were hospitalized in the Yokohama City University Critical Care and Emergency Center (Yokohama, Japan) between January 1991 and December 2000. The re-bleeding rate was analyzed using the chi-square (chi2 test, and the averages and standard deviations of hematological data were compared using the Mann-Whitney U-test. The level of statistical significance was set at p < 0.05. RESULTS: The overall re-bleeding rate was 20.8%. Among 119 patients with a GCS score of 3-7 before arrival, 42 (35.3%) had re-bleeding, but none of the 83 patients with a GCS score of 8-15 before arrival had re-bleeding. Of 105 patients with a GCS score of 13-15 on arrival, 14 (51.8%) of 27 patients whose consciousness level was a GCS score of 3-7 before arrival experienced re-bleeding. The re-bleeding rate of this group was high. Moreover, this rebleeding group had a significantly higher blood glucose concentration than did the patients whose GCS score was 13-15 both before and on arrival. Between the patients with or without re-bleeding, there was no significant difference in the blood pressure on arrival or in distribution according to Fisher's Computerized Tomography Classification CONCLUSION: Since the re-bleeding rate is high in patients who have hyperglycemia and a history of a level of consciousness as low as a GCS score of 3-7, a detailed assessment of level of consciousness and blood glucose tests performed on arrival provide important information that will contribute to predicting and preventing re-bleeding. This may be extended to the prehospital phase, because blood glucose tests are simple and safe when performed by paramedics.

Consciousness↗
PubMed1997

Role of Helicobacter pylori infection on upper gastrointestinal bleeding in the elderly: a case-control study.

Nonsteroidal antiinflammatory drug (NSAID) use is known to be associated with a high incidence of upper gastrointestinal tract bleeding in the elderly. The increased prevalence of Helicobacter pylori (HP) infection, which also occurs with age, suggests that an interaction between NSAID use and HP infection may explain the higher incidence of ulcer complications in the elderly. The aim of the present study was to determine if a relationship exists between HP infection and NSAID use in elderly patients with upper gastrointestinal bleeding. This was a case-control study on 146 elderly patients (73/group). The bleeding group consisted of 37 males and 36 females (mean age 80.4 years, range 70-96) with symptoms (hematemesis, melena, anemia with loss of more than 3 g hemoglobin), and endoscopic stigmata of bleeding. The control group consisted of 73 age- and sex-matched patients with the same endoscopic diagnosis but with no endoscopic stigmata of bleeding. NSAID use was evaluated by interview at the time of endoscopy, and HP infection was confirmed in all cases by histology and the rapid urease test. Statistical analyses were performed using the chi-square test and logistic regression. In both groups, 46.57% of patients were affected with gastric ulcer, 36.98% with duodenal ulcer, and 16.43% with erosive gastritis. The bleeding group had a significantly higher percentage of NSAID users (53.42% vs 19.17%, P < 0.0001) and a lower percentage of HP-positive patients (47.94% vs 72.60%, P = 0.004). The NSAID use pattern was as follows: occasional users (sporadic, as needed during the previous week): 53.8% of bleeding cases and 50% of controls; acute users (continuous therapy for less than one month): 17.9% of bleeding cases and 28.5% of controls; and chronic users (continuous therapy for more than one month): 28.2% of bleeding cases and 21.4% of controls. The logistic regression demonstrated that NSAID use was significantly related to an increase risk of bleeding both in gastric (odds ratio: 4.98, 95% CI: 1.83-13.6) and duodenal ulcer patients (odds ratio: 10.2, 95% CI: 2.25-46.7) while HP-positivity presented a significant inverse relationship with bleeding only in subjects with gastric lesions (odds ratio: 0.20, 95% CI: 0.07-0.55). NSAID use and HP infection were also shown to be independent, unrelated factors, with the overall risk of bleeding in HP-positive NSAID users identified to be significantly less than in HP-negative NSAID users. In conclusion, in elderly patients: (1) NSAID use increases the risk of upper gastrointestinal bleeding while HP infection was associated with a low risk for gastric bleeding; and (2) the two factors are independent variables, therefore the HP-positive NSAID user has a lower risk than the HP-negative NSAID user.

Aged↗
PubMed2001

Testicular tissue bleeding as an indicator of gonadal salvageability in testicular torsion surgery.

OBJECTIVE: To investigate the reliability of using bleeding from the cut surface of testicular tissue during surgery for testicular torsion to assess testicular viability, compared with the duration of symptoms and preoperative findings on testicular Doppler ultrasonography (DUS). PATIENTS AND METHODS: The study comprised 19 children with testicular torsion who underwent surgery; all underwent DUS before surgery. During surgery the tunica vaginalis of the affected gonad was incised and a deep incision made through the medulla after obtaining a wedge biopsy for histological examination. After waiting up to 10 min to assess any fresh arterial bleeding from the cut surface, the patients were categorized using three grades; grade I (sufficient bleeding, i.e. bleeding or oozing when the biopsy was obtained); grade II (insufficient bleeding, no bleeding immediately after the incision but starting within 10 min); and grade III (no bleeding within 10 min). The final surgical decision on whether to save the testis was made according to the grade of testicular tissue bleeding; grade I and II testes were saved and grade III testes were removed. The biopsies were histopathologically examined and classified as haemorrhagic, necrotic or indeterminate. The patients were followed up at 15 days and at 1, 3, 6 and 12 months, with the affected testis examined using DUS. At the end of the study, the sensitivity and specificity of the duration of symptoms, characteristics of blood flow on DUS and grading of testicular tissue bleeding at surgery were calculated for predicting testis viability, using the histopathological diagnosis as the reference standard. RESULTS: The sensitivity, specificity, positive and negative predictive values were respectively 100%, 90%, 90% and 100% for a duration of symptoms of > 10 h, 78%, 80%, 78% and 80% for DUS findings, and 100%, 78%, 83% and 100% for testicular tissue bleeding in predicting gonad viability after torsion, respectively. CONCLUSION: Although the 10 h limit for the duration of symptoms seems a more accurate predictor of the fate of a twisted testis than were the other variables, testicular tissue bleeding may also be a good indicator of gonadal viability during surgery. The surgeon should wait up to 10 min after incising the testicular tissue deep to the medulla before deciding the type of surgery. In cases where bleeding from the cut surface is sufficient or insufficient (according to the proposed grading system), orchidopexy is the treatment of choice. The salvaged testes should be assessed during follow-up, especially in those who had had insufficient bleeding at surgery and/or a duration of symptoms > 10 h, to assess for any delayed damage to the untwisted testis. If no bleeding is seen during surgery the best option is to remove the affected testis.

Adolescent↗
PubMed2002

Long-term outcome of patients with gastrointestinal bleeding of obscure origin explored by push enteroscopy.

BACKGROUND AND STUDY AIMS: Little is known of the long-term outcome in patients with gastrointestinal bleeding of obscure origin, who undergo investigation by means of push enteroscopy. The aim of this study was to assess the rate of recurrent bleeding and its predictive factors in patients with gastrointestinal bleeding of obscure origin, after exploration by push enteroscopy. PATIENTS AND METHODS: 105 patients with gastrointestinal bleeding of obscure origin (iron-deficiency anemia: n = 56; overt bleeding: n = 49) underwent exploration by push enteroscopy from December 1994 to December 1998. They were classified into three groups according to enteroscopy findings: no lesion found (group A; 56 patients), arteriovenous malformations (group B; 18 patients), and other gastrointestinal lesions (group C; 31 patients). Actuarial rates of rebleeding during follow-up were calculated and factors associated with rebleeding were assessed by means of univariate and multivariate analysis. RESULTS: Follow-up data were obtained for 101 patients (96 %). The mean follow-up was 29 months (6 - 54 months). The 2-year actuarial rate of rebleeding was 31 % in the overall population, and 27.6 %, 56 % and 24 % in groups A, B, and C, respectively (P = 0.13). The number of previous bleeding episodes and the number of packed red cell units transfused were two independent factors predictive of recurrent bleeding. The modality of recurrent bleeding (anemia or overt bleeding) was similar to that of the initial episode in 94 % of cases. In group A, a gastrointestinal lesion was found after rebleeding in one of the 12 patients with iron-deficiency anemia, and in four of the five patients with overt bleeding. CONCLUSION: Recurrent bleeding occurs in about one-third of patients who undergo investigation by push enteroscopy for gastrointestinal bleeding of obscure origin, with a trend towards more frequent rebleeding in patients with arteriovenous malformations. Frequent previous bleeding episodes and transfusion requirements are predictive of recurrent bleeding.

Adolescent↗
PubMed2006

Bleeding manifestations in severely thrombocytopenic children with immune thrombocytopenic purpura.

OBJECTIVE: To report the observations on various bleeding manifestations in children with immune thrombocytopenic purpura (ITP) having severe thrombocytopenia (platelet count (PC) < 20,000/microl) and to compare the differences in bleeding manifestations at levels of PC at < 10,000/microl compared with between 10,000 and 20,000/microl. STUDY DESIGN: It is a retrospective analysis of bleeding manifestations in children with ITP (n = 58) having severe thrombocytopenia recorded between July 1999 and June 2002. A total of 164 episodes of severe thrombocytopenia were observed. During 31 episodes (18.9%), no bleeding manifestations were observed. When bleeding was observed cutaneous bleeds were the commonest manifestations occurring in 124 episodes. Of these 124 instances, in 82 (66.1%) episodes only cutaneous bleeding was observed while in remaining 42 (33.9%) episodes cutaneous bleeding was associated with other bleeding sites. Other common bleeds observed included epistaxis 22 (13.4%), oral bleeding 21 (12.8%) and gastro-intestinal bleeding 5 (3.04%). Comparison of the bleeding manifestations during episodes when the PC was < 10,000/microl and those between 10,000 and 20,000/microl showed that in 76.6% episodes with the count at > 10,000/microl no or only cutaneous bleeds were observed (clinically mild disease) compared to 59.45% episodes with episodes having PC < 10,000/microl (z score 2.37, p < 0.05). There was no statistically significant difference in proportion of patients having clinically mild disease during acute or chronic phase of the disease. CONCLUSION: During episodes of severe thrombocytopenia, most children have clinically mild disease. When the PC is < 10,000/microl clinically mild disease is observed less often compared to episodes with PC 10,000-20,000/microl. Based on these observations, it can be recommended that during severe thrombocytopenia, particularly when the PC is between 10,000-20,22,000/microl, patients can be safely managed with watchful waiting without any specific therapeutic intervention.

Adolescent↗
PubMed2001

Severe gastrointestinal bleeding after hematopoietic cell transplantation, 1987-1997: incidence, causes, and outcome.

OBJECTIVE: Severe GI bleeding after hematopoietic cell transplantation is commonly due to lesions that are unusual in nontransplant patients. The frequency of GI bleeding appears to have decreased over the last decade, but the reasons have not been readily apparent. We sought to determine the incidence of severe bleeding during two time periods, to describe the causes and outcomes of bleeding, and to analyze the reasons behind an apparent decline in severe bleeding over the decade covered. METHODS: During 1986-1987 and 1996-1997, we followed all patients with and without severe bleeding at our institution, a marrow transplant center. RESULTS: Over this decade, the incidence of severe bleeding declined from 50/467 (10.7%) to 15/635 (2.4%) (p < 0.0001). Overall mortality from intestinal bleeding declined from 3.6% to 0.9% (p = 0.002), but mortality in those with bleeding remained high (34% vs 40%). The onset (day 42 vs 47) and platelet counts (35,994 vs 37,600/microl) were similar, but the sites and causes of bleeding were different. During 1986-1987, 27/50 patients bled from multiple GI sites, viral and fungal ulcers, or graft-versus-host disease (GVHD). Over the decade, bleeding from GVHD had decreased 80% (p < 0.0001), and bleeding from viral (p < 0.0001) and fungal (p = 0.023) ulcers almost disappeared. CONCLUSIONS: The incidence of severe GI bleeding has declined significantly over the last decade because of prevention of viral and fungal infections and severe acute GVHD. However, severe bleeding after transplant remains a highly morbid event, particularly among patients with GVHD.

Adult↗