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PubMed2000

Are there indications for intravenous acid-inhibition in the prevention and treatment of upper GI bleeding?

Administration of acid-inhibiting drugs in the prevention of stress ulcer bleeding is based on the hypothesis that pepsin activity is pH-dependent. In the treatment of peptic ulcer bleeding, acid-inhibition is based on the hypothesis that clot formation and clot lysis depend on intraluminal pH. Medications used in the prophylaxis of stress ulcer bleeding comprise antacids, sucralfate, H2-receptor antagonists and proton pump inhibitors (PPIs). Two studies show that prophylaxis with ranitidine is more effective than prophylaxis with sucralfate. PPIs give a more predictable and sustained pH control during prolonged dosing than ranitidine. Two trials show that patients who receive omeprazole run a significantly lower risk of bleeding than patients receiving ranitidine. The optimal initial treatment for bleeding peptic ulcers in patients with active bleeding or non-bleeding visible vessel is endoscopic therapy. Among patients with non-bleeding visible vessels or adherent clots who do not undergo endoscopic therapy, acid-inhibition with PPIs may significantly reduce rebleeding rate and need for surgery. After endoscopic therapy acid-inhibition with PPIs may have a beneficial effect on hemostasis. One direct comparative trial showed no significant difference in clinical outcomes between patients whether treated with high-dose or low-dose PPI. The use of multiple medications to treat concurrent conditions in ICU patients or bleeding peptic ulcer patients increases the risks of clinically important metabolic drug interactions. More recently developed PPIs are less dependent on CYP2C19 and probably have a lower potential for metabolic drug interactions. For both indications the optimal dose PPI has to be established.

Antacids↗
PubMed2002

Development and validation of a scoring system predicting failure of endoscopic epinephrine injection therapy in Taiwanese patients with bleeding peptic ulcers.

BACKGROUND: Endoscopic epinephrine injection therapy (EIT) is always the first choice of treatment for bleeding peptic ulcers, although it fails in 15% to 30% of patients. The aim of this study was to develop a new scoring system to predict the failure in EIT, and to validate this scoring model prospectively. METHODS: This study enrolled 125 patients who presented with the stigmata of hemorrhage of peptic ulcers and underwent EIT. Patients with coagulopathy were excluded from the study. Univariate analysis of the clinical and endoscopic parameters to predict failure in EIT was performed first. A multiple logistic regression was used to develop a scoring system. This scoring equation was further applied to 50 prospective patients with bleeding peptic ulcers to validate its predictive value. RESULTS: EIT failed to arrest bleeding in 32 (25.6%) patients. Shock, blood transfusion of at least 500 ml, active bleeding, and ulcer size were effective in predicting failure in EIT as calculated by univariate analysis, while multivariate analysis showed shock, active bleeding and ulcer size to be the independent predictors. The scoring equation, defined as -3.14 + 1.29 (shock) + 0.99 (active bleeding) + 0.13 (ulcer size in mm), had a sensitivity of 81.8% and a specificity of 76.9% in predicting failure of EIT in the prospective cohort of 50 bleeding patients. CONCLUSIONS: The presence of shock, active bleeding (spurting or oozing hemorrhage) and ulcer size are risk factors of failure of EIT in Taiwanese patients with bleeding peptic ulcers. The scoring system based on these three parameters can predict failure in EIT, while alternative treatment should be considered in case patients fail EIT.

Endoscopy, Gastrointestinal↗
PubMed2003

Results of emergency gastroscopy for acute upper gastrointestinal bleeding outside official hours at King Chulalongkorn Memorial Hospital.

This study was to evaluate the epidemiological characteristics, etiology and therapeutic outcome of active upper gastrointestinal bleeding in patients who underwent emergency gastroscopy outside official hours at the Gastroenterology Unit, King Chulalongkorn Memorial Hospital. From January to December 2002, 103 emergency gastroscopies were performed in 99 patients. There were 66 men and 33 women (mean age 55.4 years, range 22-98 years). Causes of bleeding were esophageal varices (29/99; 29.3%), gastric ulcer (25/99; 25.3%), duodenal ulcer (9/99; 9.1%), gastric varices (9/99; 9.1%) and miscellaneous (12/99; 12.1%). Etiology of bleeding was uncertain in 10.1 per cent of the cases. Therapeutic modalities for variceal bleeding were banding (78.6%), sclerotherapy (10.7%) and glue injection (10.7%). Endoscopic therapies for patients with non variceal bleeding were: epinephrine injection with bipolar coaptation (48.1%), epinephrine injection only (11.1%), bipolar coaptation alone (7.4%), heater probe (7.4%), epinephrine injection combined with heater probe (11.1%), epinephrine injection with bipolar coaptation and hemoclipping (7.4%), hemoclipping (3.7%), epinephrine injection with hemoclipping (3.7%). Initial hemostasis was achieved in 91.2 per cent of the patients (91/99). Recurrent bleeding within 72 hours developed in 9.1 per cent of patients (9/99). Of these, eight patients (88.9%) underwent re-endoscopy and bleeding was stopped in 62.5 per cent (5/8). And 2.0 per cent of patients (2/99) had to go for emergency surgery after failed therapeutic endoscopy. Overall mortality was 15.2 per cent (15/99). In conclusion, emergency gastroscopy can offer not only diagnostic but also therapeutic modality for patients with acute upper gastrointestinal bleeding. Endoscopic therapy is effective for both initial hemostasis and recurrent bleeding.

Adult↗
PubMed2003

[The clinical usefulness of balloon occluded retrograde transvenous obliteration in gastric variceal bleeding].

BACKGROUND/AIMS: Gastric variceal bleeding is difficult to treat endoscopically because the hemodynamics of the gastric varix are different from that of the esophageal varix. Transjugular intrahepatic portosystemic shunt (TIPS), which has been used widely, does not always result in the regression of gastric varix and it may aggravate the hepatic encephalopathy. Balloon occluded retrograde transvenous obliteration (BRTO) was introduced as a new procedure for gastric variceal bleeding with minimal invasiveness. The purpose of this study was to evaluate the therapeutic effects and complications on follow-up of BRTO as a new treatment option for gastric variceal bleeding. METHODS: Patients with gastric variceal bleeding, who were treated with BRTO form September, 2001 to April, 2003, were included in the study. After the definite confirmation of the shunts with abdominal CT, the sclerosing agent, 5% ethanolamine oleate, was injected into the gastric varix during occlusion through gastrorenal shunts. The procedure was deemed a technical success when the clotting of the sclerosing agent was observed without leakage, and a clinical success when bleeding stopped and the varix decreased in size or was eradicated during the follow-up period (6-23 months, mean: 17.7). RESULTS: Technical success was achieved in 12 of 13 patients (92%) with gastric variceal bleeding. There were no significant side effects. In the one case of failure, the bleeding was controlled with TIPS. Eleven of the 12 patients who had technical success were shown to be clinically successful. The follow-up endoscopic exam showed some aggravation of pre-existing esophageal varices in four patients and a new development of esophageal varices in two patients. Endoscopic variceal ligation was done on one patient in whom esophageal variceal bleeding was present during the follow-up period. CONCLUSIONS: BRTO was proven to be a feasible, safe and less invasive procedure than TIPS and found to be an effective treatment of a gastric variceal bleeding. Considering the possible aggravation of pre-existing esophageal varices or the new development of esophageal varices, regular endoscopic examinations might be needed during the follow-up period.

Adult↗
PubMed2004

Eptifibatide and risk of bleeding after failed thrombolysis.

The safety of adjunct eptifibatide in the setting of rescue angioplasty (PTCA) with or without stenting after full-dose thrombolytic therapy is not well defined. Our study was undertaken to assess the risk of hemorrhagic complications following use of eptifibatide in patients undergoing rescue PTCA/stenting following failed thrombolysis. Clinical records of 43 consecutive patients (53% males) who received eptifibatide during rescue PTCA/stenting following full-dose fibrinolytic therapy were reviewed. Data were collected for: timing of rescue PTCA following fibrinolytic use; concomitant use of other antiplatelet agents; hospital length of stay; in-hospital mortality; and incidence of bleeding complications. Bleeding complications were categorized as major or minor according to Thrombolysis in Myocardial Infarction (TIMI) study group criteria. Overall bleeding complications developed in 13 patients (30%), with 4 patients (9%) experiencing major bleeding. Univariate predictors of major bleeding complications were: older age; female sex; lower baseline platelet count; and time to initiation of eptifibatide following failed thrombolysis. On multivariate analysis, the only predictors of bleeding were gender (27% in females versus 3% in males; odds ratio, 1.7; 95% confidence interval, 0.1-0.9) and time to initiation of eptifibatide following failed thrombolysis (4.6 +/- 2 hours versus 11 +/- 9 hours; p<0.04; 95% confidence interval, 2.1-11.4). Use of potent antiplatelet agents during rescue PTCA/stenting results in an increased risk of bleeding. Careful attention to predictors of bleeding and, in particular, delaying eptifibatide administration following full-dose fibrinolytic use may result in the reduction of major and minor bleeding complications.

Aged↗
PubMedDate not supplied

Presentation and natural history of variceal bleeding in patients with portal hypertension due to extrahepatic portal venous obstruction.

BACKGROUND: The natural history of portal hypertension due to extrahepatic portal venous obstruction (EHPVO) in the presence of a non-cirrhotic liver is not well understood. AIM: To evaluate the presenting features and the natural history of EHPVO by assessing the bleed patterns prior to definitive management in these patients. METHODS: Two hundred and seven consecutive patients presenting with history of variceal bleeding due to EHPVO were studied prospectively. Clinical, hematological and biochemical features on presentation, and pattern and severity of bleeding prior to institution of endoscopic therapy or surgery were recorded. RESULTS: Ascites was observed in 16% and was invariably transient. Splenomegaly was present in 82%, with hypersplenism in 22%; however, hypersplenism was symptomatic in only 6% of patients. In 127 patients having more than one episode of bleeding, the frequency of bleeding episodes was 0.94/year and transfusion requirment was 1.47 units/year. No fixed pattern of frequency of variceal bleeding was identified. However, number of bleed episodes and transfusion units requirement correlated with each other. The maximum severity of bleeding was between the ages of 12 and 19 years. CONCLUSION: Hypersplenism causing symptoms is rare in EHPVO presenting with variceal bleed.

Adolescent↗
PubMedDate not supplied

Helicobacter pylori is not a risk factor for stress ulcer bleeding in polytraumatized patients.

BACKGROUND/AIMS: The pathogenesis of acute stress-related hemorrhage in critically ill polytraumatized patients is uncertain and any role of Helicobacter pylori infection is unknown. The aim of our study was to evaluate the relationship between Helicobacter pylori serological status of patients developing stress-related bleeding and those with no appearance of upper gastrointestinal bleeding. METHODOLOGY: In our single-center prospective cohort study we investigated over a 3-year period all consecutive patients with upper gastrointestinal hemorrhage for Helicobacter pylori infection by serology. Control group comprised 101 such patients with no evidence of hemorrhage. RESULTS: Of 396 assessable patients, stress-related upper gastrointestinal bleeding was observed in 11 (3.1%) patients. Six (55%) of the 11 bleeding patients and 45 (45%) of the 101 control group patients had serological evidence of Helicobacter pylori infection (p=0.5). Bleeding developed significantly more often in patients with more serious injury (for ISS, p=0.04, for TRISS p=0.03). Bleeding patients showed insignificantly higher mortality (36% vs. 15%; p=0.09). CONCLUSIONS: Helicobacter pylori infection was not significantly more prevalent in polytraumatized patients with hemorrhage when compared with control group. Our data suggest that the infection with Helicobacter pylori does not play an important role in bleeding, indicating no causative role for it in upper gastrointestinal hemorrhage of polytraumatized patients. The incidence of bleeding is low and bleeding develops usually later, in the meantime is the Helicobacter pylori infection eradicated with the antibiotics used for another purpose.

Adult↗
PubMed1992

[Treatment of gynecologic bleeding disorders].

Conclusions reached at an expert meeting arranged by the Medical Products Agency (Läkemedelsverket) in Sweden on the treatment of gynaecological bleeding disorders are presented. An active approach to endometrial diagnosis is recommended when bleeding is protracted and does not respond to medication, and when bleeding occurs more than one year after menopause. A period of expectation is permissible in women younger than 45 years. Exfoliative endometrial diagnosis is highly sensitive and specific and, in recent years, the traditional curettage has been reappraised as the first method of choice. Bleeding during anovulatory cycles is usually managed by treatment with progestagens. Menorrhagia may be diminished by oral contraception, tranexamic acid or NSAID. Endometrial resection offers a promising alternative to hysterectomy. Genital infection is another common cause of irregular bleeding in sexually active women and must be treated before invasive procedures are undertaken. Abnormal bleeding in patients with endometriosis often improves as a result of the treatment given to alleviate other symptoms such as pain. Bleeding irregularities caused by gynaecological malignancy, particularly contact bleeding in cancer of the cervix, are seen during the reproductive years and are accessible for diagnosis. The authors also discuss irregular bleeding caused by coagulopathia or treatment with hormones, as well as the effect of antifibrinolytic drugs.

Adult↗
PubMed1992

Bleeding gastric and duodenal ulcers: endoscopic therapy versus surgery.

From a retrospective review of 156 patients with actively bleeding peptic ulcers, 61 patients had gastric ulcers and 95 patients had duodenal ulcers. Patients presented with hematemesis or melena or a combination of the two. Forty patients with gastric ulcers and 53 patients with duodenal ulcers were in shock. Twenty-five patients with gastric ulcers underwent surgery. Bleeding was controlled in all patients, but in the postoperative period five patients died of myocardial infarction, pulmonary embolism or septic multisystem organ failure. Of 36 patients who underwent endoscopic epinephrine sclerosis of the bleeding gastric ulcer, hemorrhage was controlled in 34. Two patients required reoperation for bleeding after surgery; both survived. Fifty patients with duodenal ulcers had surgery. Bleeding was controlled in all patients, but in the postoperative period 10 died of myocardial infarction and multisystem organ failure. Of 45 patients who underwent endoscopic sclerosis, bleeding was controlled in 40. Five patients required reoperation for bleeding after surgery; all survived. The authors conclude that endoscopic sclerosis should be the initial treatment for actively bleeding gastric and duodenal ulcers. If bleeding continues or recurs then surgery should be carried out.

Adult↗
PubMed2005

[Surgery in patients with bleeding disorders--expensive treatment for a small group of patients].

BACKGROUND: During surgical procedures, patients with bleeding disorders have a major risk of bleeding complications. To reduce the risk of bleeding it is necessary to provide pre-, peri- and postoperative antihaemorrhagic therapy. In less severe bleeding disorders, pharmacologic treatment may be sufficient, but in patients with severe bleeding disorders there is always a need for clotting factor concentrates. MATERIALS AND METHODS: This study includes all patients with bleeding disorders admitted to Rikshospitalet University Hospital between 1997 and 2003 for surgical procedures during which therapy with clotting factor concentrates was mandatory. RESULTS AND INTERPRETATION: Over the study period, 135 patients underwent a total of 255 different surgical procedures. In 47% of the patients there was a causal relationship between the need for surgery and the bleeding disorder. Our results show that patients with severe bleeding disorders, including patients with inhibitors, can be treated safely provided that the patients receive adequate treatment with clotting factor concentrates. However, substitution therapy with clotting factor concentrates is very expensive. Cost related to substitution therapy is the main determinant of how many patients with severe bleeding disorders can undergo elective surgery in our hospital each year.

Blood Coagulation Disorders↗
PubMed2005

Diagnosis of gastrointestinal bleeding in adults.

The clinical evaluation of gastrointestinal bleeding depends on the hemodynamic status of the patient and the suspected source of the bleeding. Patients presenting with upper gastrointestinal or massive lower gastrointestinal bleeding, postural hypotension, or hemodynamic instability require inpatient stabilization and evaluation. The diagnostic tool of choice for all cases of upper gastrointestinal bleeding is esophagogastroduodenoscopy; for acute lower gastrointestinal bleeding, it is colonoscopy, or arteriography if the bleeding is too brisk. When bleeding cannot be identified and controlled, intraoperative enteroscopy or arteriography may help localize the bleeding source, facilitating segmental resection of the bowel. If no upper gastrointestinal or large bowel source of bleeding is identified, the small bowel can be investigated using a barium-contrast upper gastrointestinal series with small bowel follow-through, enteroclysis, push enteroscopy, technetium-99m-tagged red blood cell scan, arteriography, or a Meckel's scan. These tests may be used alone or in combination.

Acute Disease↗
PubMed2005

Esophageal bleeding disorders.

PURPOSE OF REVIEW: Management of esophageal bleeding disorder remains a challenging problem. This review focuses on studies published in previous 12 months that provided further understanding on the appropriate treatment of various esophageal bleeding disorders. Other uncommon causes of esophageal bleeding will also be discussed in this review. RECENT FINDINGS: With the advances in endoscopic and pharmacological treatments, mortality of variceal hemorrhage has been substantially reduced. Apart from its major role in initial treatment of variceal bleeding, mounting evidence shows that band ligation is a safe alternative to beta-blocker for primary prophylaxis and may even be used as an adjunct to the transjugular intrahepatic portosystemic stent shunt to obviate the need of long-term surveillance. While vasoactive agents remain the most important pharmacological treatment of esophageal variceal bleeding, antibiotic prophylaxis is also increasingly recognized to play a role in prevention of variceal rebleeding. The benefit of beta-blocker has now been extended to halt the progression of esophageal varices and combination of beta-blocker and band ligation remains the most cost-effective treatment strategy for secondary prophylaxis of variceal bleeding. Other new treatments such as endoloop and recombination factor VII have produced promising results. The clinical courses of variceal bleeding in patients with hepatocellular carcinoma and acute necrotizing esophagitis are now better defined. SUMMARY: There are significant advances in the treatment of esophageal variceal bleeding and further understanding on the management and clinical courses of various esophageal bleeding disorders.

Adrenergic beta-Antagonists↗
PubMed2005

[Effect of transjugular intrahepatic portosystemic shunt for variceal bleeding in hepatocellular carcinoma patients with portal vein thrombosis].

BACKGROUND/AIMS: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is commonly used in patients with variceal bleeding. However, this procedure is contraindicated in hepatocellular carcinoma patients with portal vein thrombosis. This study was done to evaluate the effect of TIPS in those patients with variceal bleeding. METHODS: Between 1997 and 2004, six hepatocellular carcinoma (HCC) patients with portal vein thrombosis were enrolled in this study due to their variceal bleeding. All the patients underwent TIPS placement to treat the variceal bleeding that had not responded to endoscopic treatment. Effective shunt creation was assessed by the decrease of the portal pressure gradient (less than 12 mmHg) or if good patency and flow were seen on a doppler examination. RESULTS: Shunts were successfully created in all the patients and the bleeding was immediately controlled in the active bleeding cases. The bleeding was caused by esophageal varices in one patient and, by gastric varices in five patients. The HCC types were diffuse or massive in five patients, and a single nodule was present in one patient. All the patients had portal vein thrombosis. Rebleeding was noted in two patients at 10 days and 3 months, respectively, due to the shunt occlusion. Hepatic encephalopathy was noted in two patients. The causes of death were hepatorenal syndrome after 2 weeks in one patient, bleeding due to portal hypertensive gastropathy after 3 weeks in another, and cancer progression after 4 months in third patient. CONCLUSIONS: For HCC patients with portal vein thrombosis, TIPS can be an effective treatment modality if uncontrolled variceal bleeding presents when using endoscopic hemostasis or pharmacologic therapy. However, further studies are needed.

Adult↗
PubMedDate not supplied

Bacterial infection and acute bleeding from upper gastrointestinal tract in patients with liver cirrhosis.

BACKGROUND/AIMS: Acute bleeding from the upper gastrointestinal tract is a common and serious complication of liver cirrhosis. It is believed that bacterial infection may be the immediate cause of the bleeding and the latest meta-analyses show that bacterial infection is an independent predictive factor of the failure to stop bleeding. METHODOLOGY: The authors evaluated the presence of bacterial infection (blood, urine, throat and ascitic fluid) in 35 consecutive patients with liver cirrhosis and acute bleeding with portal hypertension and compared these results with a group of 35 patients with liver cirrhosis with portal hypertension without acute bleeding. RESULTS: According to the results obtained, there is a statistically higher incidence of bacterial infection among patients with acute bleeding with portal hypertension (25 of 35 patients, 71%) than among patients with liver cirrhosis and portal hypertension without acute bleeding (14 of 35 patients, 40%, p < 0.01). The incidence of bacteriological findings in blood and throat samples is statistically higher in patients with acute bleeding as opposed to the control group (p < 0.05). CONCLUSIONS: These results confirm the necessity of administering antibiotic prophylaxis to all cirrhotic patients with variceal bleeding, not just to those with confirmed infection or symptoms thereof.

Adult↗
PubMed2006

[Chronic gastrointestinal bleeding of unknown cause].

Two patients with chronic gastrointestinal bleeding are reported. One patient had chronic occult bleeding with iron deficiency. Extensive evaluations performed during a period of two years in three different medical centres did not reveal the cause of the bleeding. The patient was admitted to the local hospital with acute abdominal pain. After a review of her clinical record, she was offered exploratory laparotomy. A large malignant tumour of the caecum was found. Right hemicolectomy was performed. Metastatic disease was, however, diagnosed three years later. The other patient was admitted with melena and anaemia three times during a period of two years. On the last occasion, the rectal bleeding was severe. The patient was transferred to the university medical centre. Extensive investigations did not disclose the cause of the bleeding. The cause was, however, supposed to be diverticular disease of the sigmoid colon. Laparoscopic sigmoid resection was preformed. Four weeks later the patient was once more admitted to the local hospital with severe anaemia and rectal bleeding. A formal laparotomy was performed without any further medical examinations. Ulcerations of the mucosa were found at four places in the distal part of the small intestine. Intestinal resection was performed. Diagnostic evaluation of gastrointestinal bleeding should be swift and aggressive. Modern diagnostic technology successfully identifies the cause of bleeding in 95% of patients with gastrointestinal bleeding. In highly selected patients, however, explorative surgery may still be needed as the definitive diagnostic technique.

Aged↗
PubMed2005

[Role of non-steroidal anti-inflammatory drugs on upper gastrointestinal bleeding].

UNLABELLED: Peptic ulcer is a common complication of upper gastrointestinal (uGI) bleeding, which refers to 20% of patients with duodenal and gastric ulcer. Non-steroidal anti-inflammatory drugs (NSAIDs) use is a well-known risk factor for ulcer formation and uGI bleeding. AIM OF THE STUDY: The evaluation of location and the cause od uGI bleeding and its association with NSDAIDs use. MATERIAL AND METHODS: We conducted a retrospective analysis of all patients hospitalized in our department from 2000 to 2001. RESULTS: Upper gastrointestinal bleeding was an indication for 3% of hospitalizations in our department. The cause of the bleeding was as follows: NSAIDs use side effect in 21 (42%) patients, portal hypertension in 6 (12%), acenocumarol overdosage in 2 (4%), not specified in 17 (34%). 13 (62%) of 21 NSAIDs-users chronically ingested small doses of acetylsalicylic acid. The most common sources of bleeding were: duodenal ulcer in 20 (40%), gastric or esophageal ulcer in 10 (20%), erosive gastroduodenitis in 8 (16%), esophageal varices in 6 (12%), not specified in 2 (4%) and not specified after acenocumarol overdosage in 2 (4%). One patient had coexisting gastric and duodenal ulcers, and one patient had coexisting erosive gastritis and duodenal ulcer In NSAIDs-users group, there were 9 (43%) patients with erosive gastroduodenitis, 8 (38%) with duodenal ulcer and 4 (19%) with gastric ulcer. CONCLUSION: On the basis of our observations we concluded that NSAIDs use (especially cardiological doses of acetylsalicylic acid) is a common cause of upper gastrointestinal bleeding. The most common source of bleeding in this group was erosive gastroduodenitis. The age over 65 years was an additional risk factor for uGI bleeding.

Adult↗
PubMed1991

Identification of risk factors for bleeding during treatment of acute venous thromboembolism with heparin or low molecular weight heparin.

In a prospective double-blind trial, we treated 194 patients with acute venous thromboembolism with heparin or low molecular weight heparin (LMWH; Fragmin). To evaluate the most important prognostic factors for bleeding, the presenting clinical features of the patients, the patients' anticoagulant responses, and the doses of the drugs were analyzed using univariate and multivariate regression analyses. No significant differences in clinical risk factors associated with bleeding were observed between heparin and LMWH. The univariate analyses ranked the parameters in the following order of importance: World Health Organization (WHO) performance status, history of bleeding tendency, cardiopulmonary resuscitation, recent trauma or surgery, leukocyte counts, platelet counts, duration of symptoms, and body surface area. Patients with WHO grade 4 had an eightfold increase in risk of bleeding as compared with WHO grade 1. Assessment of the individual contribution of each variable using multivariate regression analysis showed that the WHO performance status was the most important independent factor predicting major bleeding. A history of a bleeding tendency, recent trauma or surgery, and body surface area were also independent risk factors. The risk of bleeding was influenced by two factors related to the treatment, the patient's anticoagulant response as measured with the anti-Xa assay and the dose of the drug expressed as U/24 h/m2. An increased risk of bleeding was only observed at mean anti-Xa levels greater than 0.8 U/mL for both drugs. Significantly more major bleedings occurred in patients treated with high doses of the drugs, an observation that was independent of the concomitant anti-Xa levels. It should be considered whether choosing an appropriate initial dose adapted to the patient's body surface area and clinical risk factors can improve the efficacy to safety ratio of heparin treatment.

Dose-Response Relationship, Drug↗
PubMed2001

Acute gastrointestinal bleeding: Part II.

OBJECTIVE: To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation. DATA SOURCES: Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding. SUMMARY OF REVIEW: Oesophageal varices are a common source of upper gastrointestinal bleeding in patients who have portal hypertension. Management requires resuscitation and treatment of associated coagulation disturbances along with intravenous octreotide (50 microg followed by 50 microg/hr for 48 hr) before endoscopy is performed. Octreotide is more effective than vasopressin in controlling acute variceal suppressant and has fewer side effects compared with glypressin. To provide haemostasis, endoscopic variceal sclerosis has largely been replaced by variceal ligation using an overtube and small elastic 'o' rings to band the bleeding variceal channels. If bleeding continues then Balloon tamponade and intravenous fibrinolytic inhibitors (e.g. tranexamic acid 3-6 g i.v. daily) are used for 24 hr before endoscopy (with variceal ligation) is repeated. If the variceal bleeding is resistant to repeated banding, portal decompression using transjugular intrahepatic portosystemic shunt or surgical shunt should be considered. While beta adrenergic blockers (e.g. propranalol) are indicated to reduce the incidence of rebleeding, they are contraindicated in a patient with actively bleeding oesophageal varices. CONCLUSIONS: Acute oesophageal variceal bleeding can often be managed successfully using octreotide and variceal ligation. If bleeding continues then transjugular intrahepatic portosystemic shunt or surgical shunt should be considered.

Journal Article↗