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ABSTRACT Background Methods Results Conclusions Studies have reported the benefits of tranexamic acid (TXA) in controlling bleeding across various conditions. However, the effect of TXA in upper gastrointestinal bleeding (UGIB) remains controversial, and its therapeutic impact when combined with acid suppression, particularly proton pump inhibitors (PPIs), which are considered first‐line therapy for bleeding peptic ulcers, has not been reported.We systematically searched PubMed, Embase, and Google Scholar from January 1987 to June 2024 using predefined keywords to identify RCTs meeting our inclusion criteria, including details of TXA dosage, route of administration, and choice of acid suppressants. Data from selected trials were extracted, and a meta‐analysis was performed using random‐effects modeling.Six trials with 709 participants were included. Baseline patient characteristics in the selected trials were balanced. The rebleeding rate, mortality, need for blood transfusion, units of blood transfused, and need for salvage therapy were compared. The TXA with acid suppression group significantly reduced the risk of rebleeding (RR: 0.63, 95% CI: 0.41–0.96), units of blood transfused (mean difference: −1.08, 95% CI: −1.44 to −0.71), and the need for salvage therapy (RR: 0.28, 95% CI: 0.12–0.64). No significant difference was observed in mortality rate (RR: 0.74) and need for blood transfusion (RR: 1.01) between the two groups, but outcomes favored the TXA and acid suppression group.We suggest combining TXA with acid suppression as a first‐line therapy for UGIB patients. Further trials should be conducted to determine the optimal dose and route of TXA administration for better care. [ABSTRACT FROM AUTHOR]

The relationship between exposure to ambient air pollutants and emergency attendance for upper gastrointestinal bleeding (UGIB) remains inconclusive. This study examines the association between short‐term exposure to various ambient pollutants and the risk of UGIB emergency attendance. Data on daily UGIB emergency attendance, ambient pollutants, and meteorological conditions in Hong Kong were collected from 2017 to 2022. A time‐series study using a distributed lag non‐linear model to analyze the data, considering lag days. Stratified analysis was performed based on sex, seasons, and the COVID‐19 pandemic period. The burden was quantified using attributable fraction (AF) and number (AN). The study included 31,577 UGIB emergency records. Exposure to high levels of PM2.5 significantly increased the risk of UGIB emergency attendance from lag day 3 (RR: 1.012) to day 6 (RR: 1.008). High NO2 exposure also posed a significant risk from lag day 0 (RR: 1.026) to day 2 (RR: 1.014), and from lag day 5 (RR: 1.013) to day 7 (RR: 1.024). However, there was no association between UGIB and high O3 levels. The attributable burden of high‐concentration NO2 exposure was higher compared to those of PM2.5. Males and elderly individuals (≥65 years) faced a higher risk of UGIB emergencies, particularly during cold seasons. Our study suggests that both PM2.5 and NO2 exposure are associated with an increased risk of emergency attendance for UGIB. Ambient pollutant exposure has a stronger effect on UGIB in males and the elderly, particularly during cold seasons. Plain Language Summary: Our research in Hong Kong from 2017 to 2022 investigated the impact of brief exposure to air pollution on emergency visits for upper gastrointestinal bleeding (UGIB). We examined various types of air pollutants, including fine particulate matter (PM) and ozone, with a specific focus on identifying the most harmful pollutants and their temporal patterns. Our findings demonstrate that even a slight increase in levels of fine PM and nitrogen dioxide can significantly contribute to an upsurge in emergency cases of UGIB. Notably, these effects are more pronounced during colder months and in the elderly. The burden was more severe before the COVID‐19 pandemic. This study underscores the direct influence of air pollution on public health and emphasizes the imperative need to enhance air quality, particularly in densely populated urban areas. Our finding could help to inform public health policies and to promote measures aiming at reducing individuals' exposure to pollutants. Key Points: Short‐term exposure to high concentration of PM2.5 and NO2 significantly raise upper gastrointestinal bleeding (UGIB) emergency visitsThe impact of air pollution on the occurrence of UGIB emergencies is exacerbated by cold weather and among the elderly populationThe results of our study underscore the necessity for policy interventions aimed at enhancing air quality and promoting health safety [ABSTRACT FROM AUTHOR]

Key Clinical Message: The occurrence of terlipressin‐induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin‐induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin‐induced skin necrosis. We present a 50‐year‐old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin‐induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post‐terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin‐induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash. [ABSTRACT FROM AUTHOR]

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non‐bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs) comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random‐effects meta‐analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8 years and a mean follow up of 20 days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.16–0.95, 268 participants). However, there was no difference in mortality (RR = 0.90, 95% CI 0.23–3.59, 52 participants) or need for ulcer surgery (RR = 0.48, 95% CI 0.10–2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Upper gastrointestinal bleeding due to primary aortoesophageal fistula is a rare clinical condition burdened with high mortality rate. However, the outcomes are closely related to the level of clinical awareness, the complementary and multidisciplinary approach during the diagnostic workup, and the selected treatment option. We present an atypical case of an aneurysm of the thoracoabdominal aorta complicated with primary aortoesophageal fistula (AEF). A 55‐year‐old male with no previous diseases, presented with prolonged and intense back pain and upper gastrointestinal bleeding. The gastroscopy detected an unusual culprit lesion in the distal esophagus resembling an esophageal wall defect, and the computed tomography revealed an aneurysm of the thoracoabdominal aorta, remarkable surrounding hematoma, and active contrast extravasation. Despite the urgent surgical repair, a lethal outcome occurred. AEF patients require high clinical awareness and complementary multidisciplinary approach in order to provide a rapid diagnosis and optimal treatment. [ABSTRACT FROM AUTHOR]

Background and Aim: This study investigates the effectiveness of bedside ultrasonography in predicting blood transfusion requirements in patients with upper gastrointestinal bleeding (UGIB). It focuses on evaluating the inferior vena cava (IVC) diameter, IVC collapsibility index (CI), and stroke volume (SV) as ultrasonographic measures. Methods: A hundred adult patients enrolled in this prospective clinical study. The patients were divided into two groups (group 1: only saline administered group, group 2: saline and blood administered group). IVC diameter, IVC CI, and SV were measured at the time of admission and after treatment. Results: At the initial admission, group 1 exhibited an IVC CI of 20.4% and an SV of 65.0 mL, whereas group 2 displayed an IVC CI of 26.6% and an SV of 58.0 mL. Upon analyzing the relationship between the Glasgow–Blatchford score (GBS) and SV, we identified a significant negative correlation (r = −0.7350; P < 0.001). Similarly, a weak negative correlation was observed between the Rockall score (RS) and SV (r = −0.4718; P < 0.001). It is worth noting that patients with UGIB require blood transfusion if their SV falls below 62.5 mL, with an area under the curve (AUC) of 89.1% and a 95% confidence interval (CI) ranging from 82.8% to 95.4%. Conclusion: IVC CI and SV can be used as parameters to predict the need for blood transfusion in the ED in patients with UGIB. [ABSTRACT FROM AUTHOR]

Upper gastrointestinal bleeding (UGIB) in COVID‐19 presents challenges in patient management. Existing studies lack comprehensive review due to varied designs, samples, and demographics. A meta‐analysis can provide valuable insights into the incidence, features, and outcomes of UGIB in COVID‐19. A comprehensive literature search was carried out using several databases. We considered all appropriate observational studies from all over the world. Mantel‐Haenszel odds ratios and associated 95% confidence intervals (CIs) were produced to report the overall effect size using random effect models. Besides, Random effects models were used to calculate the overall pooled prevalence. Funnel plots, Egger regression tests, and Begg‐Mazumdar's rank correlation test were used to appraise publication bias. Data from 21 articles consisting of 26,933 COVID‐19 patients were considered. The pooled estimate of UGIB prevalence in patients admitted with COVID‐19 across studies was 2.10% (95% CI, 1.23–3.13). Similarly, the overall pooled estimate for severity, mortality, and rebleeding in COVID‐19 patients with UGIB was 55% (95% CI, 37.01–72.68), 29% (95% CI, 19.26–40.20) and 12.7% (95% CI, 7.88–18.42) respectively. Further, UGIB in COVID‐19 patients was associated with increased odds of severity (OR = 3.52, 95% CI 1.80–6.88, P = 0.001) and mortality (OR = 2.16, 95% CI 1.33–3.51, P = 0.002) compared with patients without UGIB. No significant publication bias was evident in the meta‐analysis. The results of our study indicate that UGIB in individuals with COVID‐19 is linked to negative outcomes such as severe illness, higher mortality rates, and an increased risk of re‐bleeding. These findings highlight the significance of identifying UGIB as a significant complication in COVID‐19 cases and emphasise the importance of timely clinical assessment and proper treatment. [ABSTRACT FROM AUTHOR]

A 73‐year‐old female with metastatic renal cell carcinoma (RCC) presented with melena and lethargy. She was found to be iron deficient with a hemoglobin of 101 g/L. Her gastroscopy found six irregular pedunculated non‐bleeding polyps, 10–20 mm in diameter. Histopathology of the resected polyp returned as metastatic clear cell renal cell carcinoma. Gastric metastases from any primary malignancy are rare and metastatic RCC accounts for only 7% of these tumors. Furthermore, while RCC commonly metastasises to the lung, bone and lymph nodes, metastasis to the gastrointestinal tract is extremely rare, occurring in <1% of patients. Presentation of RCC as a gastric polyp is usually a late event, and on average occurs 6.7 years after initial diagnosis of RCC. Therefore, this case highlights a rare but important late complication of RCC, presenting as gastrointestinal bleeding secondary to gastric metastases. [ABSTRACT FROM AUTHOR]

Background and Aim: Although acute upper gastrointestinal bleeding (UGIB) can lead to anemia, evidence regarding the effects of oral iron supplementation on UGIB‐induced anemia following discharge remains lacking. The present study aimed to investigate the effects of oral iron supplementation on hemoglobin response and iron storage in patients with anemia secondary to nonvariceal UGIB. Methods: This randomized controlled trial included 151 patients with nonvariceal UGIB who had anemia at discharge. Patients were assigned to a 1:1 block in which they were either administered 6 weeks of 600 mg/d oral ferrous fumarate (treatment group, n = 77) or treated without iron supplementation (control group, n = 74). The primary outcome was composite hemoglobin response (hemoglobin elevation greater than 2 g/dL or no anemia at the end of treatment [EOT]). Results: The proportion of patients achieving composite hemoglobin response was greater in the treatment group than in the control group (72.7% vs 45.9%; adjusted risk ratio [RR], 2.980; P = 0.004). At EOT, the percentage change in the hemoglobin level (34.2 ± 24.8% vs 19.4 ± 19.9%; adjusted coefficient, 11.543; P < 0.001) was significantly higher in the treatment group than in the control group; however, the proportions of patients with a serum ferritin level <30 μg/L and a transferrin saturation <16% were lower in the treatment group (all P < 0.05). No significant differences in treatment‐associated adverse effects and adherence rates were observed between the groups. Conclusion: Oral iron supplementation exerts beneficial effects on anemia and iron storage following nonvariceal UGIB without significantly impacting rates of adverse effects or adherence. [ABSTRACT FROM AUTHOR]

Background and Aim: Evidence on the impact of frailty in patients with upper gastrointestinal bleed (UGIB) is limited. This study aims to define the role of frailty as defined by Canadian Study of Health and Aging clinical frailty scale (CSHA‐CFS) in predicting mortality in UGIB. Methods: A prospective single‐center cohort study was conducted over 21 months on all consecutive patients with UGIB. Data on demographics, lab parameters, Glasgow Blatchford score, CSHA‐CFS, Charlson Comorbidity Index, and AIMS65 score was recorded. The primary outcome was all‐cause inpatient mortality. The secondary outcomes were all‐cause 30‐day mortality, 30‐day rebleeding, 30‐day readmission, hospital length of stay (LoS), intensive care unit (ICU) admission, need for repeat endoscopy, and need for blood transfusion. The data were evaluated using univariate and multivariate analysis. Results: There were 298 eligible patients, of which 63% were males, median age was 68 years, 44% were from non‐English‐speaking background, and 72% had major comorbidities. The all‐cause inpatient and 30‐day mortality were 9.4% and 10.7%, respectively. In the multivariate analysis, CHSA‐CFS was the independent predictor of all‐cause inpatient mortality (OR 1.66; 95% CI 1.13–2.143; P = 0.010) and all‐cause 30‐day mortality (OR 1.83; 95% CI 1.26–2.67; P = 0.002). CHSA‐CFS was not a significant predictor of 30‐day rebleed, 30‐day readmission, ICU admission, hospital LoS, or need for blood transfusion. Conclusion: Frailty is an important independent predictor of mortality in patients with UGIB. Frailty assessment can guide clinical decision making and allow targeting of health‐care resource (Australia/New Zealand Clinical Trial Registry number: ACTRN12622000821796). [ABSTRACT FROM AUTHOR]

Background & Aims: Alcohol‐related hepatitis (AH) encompasses a high mortality. AH might be a concomitant event in patients with acute variceal bleeding (AVB). The current study aimed to assess the prevalence of AH in patients with AVB and to compare the clinical outcomes of AH patients to other alcohol‐related liver disease (ALD) phenotypes and viral cirrhosis. Methods: Multicentre, observational study including 916 patients with AVB falling under the next categories: AH (n = 99), ALD cirrhosis actively drinking (d‐ALD) (n = 285), ALD cirrhosis abstinent from alcohol (a‐ALD) (n = 227) and viral cirrhosis (n = 305). We used a Cox proportional hazards model to calculate adjusted hazard ratio (HR) of death adjusted by MELD. Results: The prevalence of AH was 16% considering only ALD patients. AH patients exhibited more complications. Forty‐two days transplant‐free survival was worse among AH, but statistical differences were only observed between AH and d‐ALD groups (84 vs. 93%; p = 0.005), when adjusted by MELD no differences were observed between AH and the other groups. At one‐year, survival of AH patients (72.7%) was similar to the other groups; when adjusted by MELD mortality HR was better in AH compared to a‐ALD (0.48; 0.29–0.8, p = 0.004). Finally, active drinkers who remained abstinent presented better survival, independently of having AH. Conclusions: Contrary to expected, AH patients with AVB present no worse one‐year survival than other patients with different alcohol‐related phenotypes or viral cirrhosis. Abstinence influences long‐term survival and could explain these counterintuitive results. [ABSTRACT FROM AUTHOR]

Background and Aim: Although Dieulafoy's lesion (DL) is an important cause of nonvariceal upper gastrointestinal (GI) bleeding, few studies have investigated the clinico‐epidemiological outcomes due to its rarity. Here, we investigated clinical features of upper GI bleeding caused by peptic ulcer (PU) or DL and compared endoscopic treatment outcomes. Methods: Patients with upper GI bleeding resulting from PU or DL who visited emergency room between January 2013 and December 2017 were eligible. Clinical features and treatment outcomes were retrospectively investigated. Results: Overall, 728 patients with upper GI bleeding due to PU (n = 669) and DL (n = 59) were enrolled. The median age was 64 years (interquartile range [IQR], 56–75 years), and 74.3% were male. Endoscopic intervention was performed in 53.7% (n = 359) and 98.3% (n = 58) of the PU and DL groups, respectively (P < 0.0001). Patients were matched by sex, age, body mass index, comorbidity, and past medical history, and 190 PU and 52 DL were finally selected. The rebleeding rates within 7 (7.37% vs 17.31%, P = 0.037) and 30 (7.37% vs 26.92%, P < 0.001) days after initial endoscopy were significantly lower in the PU than in the DL group after propensity score matching. During the median follow‐up period of 52 months (IQR, 34–70 months), there was no difference in overall survival rate (67.9% vs 82.7%, P = 0.518). Conclusions: Although DL is a rare cause of upper GI bleeding, it requires endoscopic hemostasis more frequently and has a higher rate of rebleeding than PU even after therapeutic endoscopy. Endoscopists should pay attention and perform active endoscopic hemostasis for DL bleeding. [ABSTRACT FROM AUTHOR]

Summary: Background: Vitamin C is an essential dietary nutrient important for collagen synthesis, including within the gastrointestinal tract. Aim: We aimed to document the prevalence of Vitamin C deficiency (VCD) in patients who present with upper gastrointestinal bleeding (UGIB) and its association with clinical outcomes. Methods: We conducted a prospective cohort study of patients presenting with UGIB. Fasting Vitamin C levels were collected at admission. Primary outcomes were the prevalence of VCD (Vitamin C level <23 μmol/L, severe VCD < 12 μmol/L) and a composite outcome of adverse events, stratified by VCD status. Secondary outcomes were prolonged hospitalisation and the need for ICU admission. Results: A total of 227 patients were included (mean age 64.5 years, males 63.9%). VCD was identified in 74 (32.6%) and severe deficiency in 32 (14.1%) patients. VCD was associated with a higher composite endpoint of AE (45.9% vs 24.8%, p < 0.01), higher in‐hospital mortality (9.5% vs 1.3%, p < 0.01), increased prolonged admissions (62.2% versus 47.1%, p = 0.03) and increased rebleeding (17.6% vs 7.8%, p = 0.03), compared with patients with normal Vitamin C levels. Multivariate logistic regression models showed that VCD was independently associated with the composite endpoint of AE. Conclusion: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding and length of stay. Interventional studies are required to determine the impact of early Vitamin C supplementation on clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The effectiveness of the Doppler endoscopic probe (DEP) remains unclear in nonvariceal upper gastrointestinal bleeding (NVUGIB). We thus performed a systematic review characterizing the effectiveness of DEP in patients with NVUGIB addressing this question. Methods: A literature search was done until July 2021 using MEDLINE, EMBASE, and ISI Web of Science. A series of meta‐analyses were performed assessing outcomes among observational and interventional studies for DEP signal positive and negative lesions as well as DEP‐assisted versus standard endoscopies. The primary outcome was "overall rebleeding"; secondary outcomes included all‐cause mortality, bleeding‐related mortality, need for surgery, length of stay, intensive care unit stay, and angiography. Results: Fourteen studies were included from 1911 citations identified. Observational studies compared bleeding lesions with DEP‐positive versus DEP‐negative signals (11 studies, n = 800 prehemostasis; five studies, n = 148 with posthemostasis data). Three interventional studies (n = 308) compared DEP‐assisted to standard endoscopy management. DEP signal positive versus negative lesions either prior to or following any possible hemostasis were at greater risk of overall rebleeding (odds ratio [OR] 6.54 [2.36, 18.11] and OR 25.96 [6.74, 100.0], respectively). The use of DEP during upper endoscopy significantly reduced overall rebleeding rates (OR 0.27 [0.14, 0.54]). When removing outcomes analysis for which only one study was available, all evaluable outcomes were improved with DEP characterization of management guidance except for all‐cause mortality. Conclusion: Although with low certainty evidence, DEP‐related information improves on sole visual prediction of rebleeding in NVUGIB, with DEP‐guided management yielding decreased overall rebleeding, bleeding‐related mortality, and need for surgery. [ABSTRACT FROM AUTHOR]

Background: Although post‐bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). Methods: Data on duodenal ulcers with evidence of endoscopically‐active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in‐hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. Results: Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically‐confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in‐hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in‐hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs. Conclusion: This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location. [ABSTRACT FROM AUTHOR]

Aims: Studies detailing endoscopic findings and hemostatic interventions for upper gastrointestinal bleeding after cardiovascular surgery are scarce. We conducted this study to determine the frequency and findings of emergent esophagogastroduodenoscopy (EGD) after cardiovascular surgery and the effect of bleeding requiring hemostatic intervention on clinical outcomes. Methods and Results: We retrospectively reviewed records of emergent EGD examinations conducted within 30 days after cardiovascular surgery at a tertiary referral center in Japan from April 2011 to March 2020. Of 1625 patients undergoing cardiovascular surgery, 47 underwent emergent EGD. Sources of bleeding were identified in 30 cases, including transesophageal echocardiogram (TEE)‐related injuries (8 patients), gastric ulcers (7 patients), and duodenal ulcers (7 patients). Patients who required endoscopic hemostatic intervention had more TEE‐related injuries (43% vs 3%, P = 0.005), gastric ulcers (35% vs 6%, P = 0.018), or ulcers in the first part of the duodenum (29% vs 0%, P = 0.006) than those who did not. Intraoperative TEE did not increase the need for endoscopic intervention (71% vs 64%, P = 0.435). Intraoperative TEE and the need for endoscopic intervention did not affect length of stay or all‐cause mortality. Only one death was associated with gastrointestinal bleeding. Conclusion: Despite the potential severity of bleeding after cardiovascular surgery, most cases can be managed endoscopically with no increase in hospital stay or mortality. [ABSTRACT FROM AUTHOR]

Objects: Although anti‐thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti‐thrombotic agents on in‐hospital mortality following UGIB. Methods: Information on clinical parameters, including usage of anti‐thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high‐volume centers in Japan between 2011 and 2018. The all‐cause in‐hospital mortality rate was evaluated according to the usage of anti‐thrombotic agents. Results: Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty‐five (29.3%) patients used anti‐thrombotic agents. The all‐cause in‐hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end‐stage malignancy, 96 deaths (bleeding‐related, n = 22 ; non‐bleeding‐related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti‐thrombotic users was significantly higher than that in non‐users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti‐thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non‐users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%). Conclusions: Although the usage of anti‐thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti‐thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti‐thrombotic agents. [ABSTRACT FROM AUTHOR]

Summary: Background: The long‐term effects of H. pylori eradication in preventing upper GI bleeding (UGIB) remains unknown. Aim: To determine the long‐term risks of UGIB after H. pylori eradication Methods: We included all patients who had received clarithromycin‐containing triple therapy for the treatment of H. pyliori infection between 2003 and 2012, without subsequent need for re‐treatment. We included a propensity score (PS)‐matched endoscopy cohort of H. pylori‐negative patients as controls. The primary endpoint was the risk of subsequent UGIB. A multivariable Cox model was used to compute the hazard ratio (HR) of UGIB. Results: We included 62 738 H. pylori‐eradicated and 62 738 PS‐matched H. pylori‐negative patients, with a median follow‐up of 8.1 years (IQR 5.5‐10.6). The incidence of UGIB was 20.8 (95% CI 19.5‐22.1) and 13.6 (95% CI 12.7‐14.7) per 10 000 person‐years in H. pylori‐eradicated and H. pylori‐negative patients, respectively. Compared to controls, H. pylori‐eradicated patients had a significantly higher risk of UGIB (HR: 1.65, 95% CI 1.49‐1.83). The risk of UGIB in H. pylori‐eradicated patients increased after the first 2 years of follow up (HR: 2.18, 95% CI 1.91‐2.49). Age‐stratified analysis showed that patients >45 years had higher UGIB risk, even after eradication. Conclusions: Despite H. pylori eradication, the long‐term risk of UGIB was still higher than in H. pylori‐negative control subjects. The protective effects of eradication therapy in preventing UGIB appeared to be limited to younger patients, and to within the first 2 years after eradication. [ABSTRACT FROM AUTHOR]

Background and Aim: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC‐325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. Methods: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. Results: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7–12). The median Rockall score was 8 (IQR, 7–9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30‐day rebleed, 20% of patients died within 30 days (all‐cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient. Conclusions: Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor‐related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor. [ABSTRACT FROM AUTHOR]

Background and Aim: Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. Methods: We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. Results: Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7 ± 11.7 years with 89.7% men. Median duration of bleeding before diagnosis was 10 days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12 months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post‐endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. Conclusions: Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases. [ABSTRACT FROM AUTHOR]

Background and Aim: Clopidogrel is widely prescribed for patients with of aspirin‐related upper gastrointestinal bleeding (UGIB) history. This study aimed to compare the risk of a major adverse cardiovascular event (MACE), UGIB, and mortality between aspirin and clopidogrel in patients at risk of bleeding. Methods: We analyzed adult patients at high risk of UGIB following aspirin‐related bleeding for secondary MACE prevention between 2000 and 2012. Secondary prevention was for those patients who had ever been hospitalized for cardiovascular disease and reused aspirin or changed to clopidogrel after discharge. Study endpoints were recurrence of MACE, UGIB, and death in 90 days of follow‐up. The associations between study outcomes and the use of clopidogrel (vs aspirin) were analyzed. Results: Among 947 eligible patients, 653 reused aspirin (in combination with a proton‐pump inhibitor), and 294 were treated with clopidogrel (in combination with a proton‐pump inhibitor) after discharge for UGIB. Compared with aspirin treatment, clopidogrel showed an increased risk of MACE (adjusted hazard ratio [aHR] 1.65; 95% confidence interval [CI] 0.87–3.12) and UGIB (aHR 1.25; 95% CI 0.66–2.36), but without statistical significance in 90 days' follow‐up. Clopidogrel use was associated with greater than four times the risk of any cause of mortality (aHR 4.84; 95% CI 1.59–14.75), but the significance did not hold in propensity score‐matched cohort analysis (P = 0.06). Conclusions: A nonsignificant difference between clopidogrel and aspirin for short‐term MACE prevention as well as UGIB recurrence was found in the present study. Further research to assess 90‐day mortality would assist clinical decision making. [ABSTRACT FROM AUTHOR]

The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri‐endoscopy care. Apart from validating clinical scores, artificial intelligence‐assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over‐the‐scope clips have high success rates as rescue or even first‐line treatments in difficult‐to‐treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first‐line treatment options. Endoscopic ultrasound‐guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self‐expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence‐based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes. [ABSTRACT FROM AUTHOR]

Background and Aim: Upper gastrointestinal bleeding (UGIB) has a high mortality rate and requires efficient and directed acute management. This project aimed to assess patient outcomes following changes to UGIB management protocols at Northern Hospital, Victoria, Australia. Changes involved streamlining management under a single inpatient unit, earlier endoscopy, blood transfusion thresholds, and risk stratification. Methods: This was a cohort study of 400 patients aged ≥18 years admitted to Northern Hospital who underwent endoscopy for acute UGIB. Data of preprotocol changes (Group 1) and prospectively postprotocol changes (Group 2) were collected retrospectively. Primary outcomes were inpatient mortality, rebleeding, radiologic or surgical intervention, and endoscopic reintervention. Secondary outcomes included length of stay (LOS) ≥4 days and blood units transfused. Univariate analyses were conducted comparing groups and associations between variables and outcomes, followed by multivariate analyses for each outcome. Results: There was no difference in mortality on multivariate analysis (P = 0.95). Rebleeding reduced by 4% (adjusted odds ratio [AOR] 0.48; P = 0.03), LOS ≥4 days reduced by 15.1% (AOR 0.46; P < 0.00) and median blood units transfused decreased with adjusted incidence rate ratio of 0.81 (P = 0.00). Early endoscopy (i.e. ≤12 h) for all patients increased by 15% (P < 0.00) and there were 12% more high‐risk patients (i.e. Glasgow–Blatchford score ≥ 12) in Group 2 (P = 0.01). Conclusion: Following changes to UGIB protocols at this Australian hospital, endoscopic times decreased with reductions in rebleeding, LOS ≥4 days, and blood transfusion rates. These findings demonstrate improved outcomes after the implementation of new treatment targets focusing on streamlined care of patients presenting with UGIB. [ABSTRACT FROM AUTHOR]

Purpose Upper gastrointestinal bleeding (UGIB) is a severe and frequent drug‐related event. In order to enable efficient drug safety alert generation in the French National Healthcare System database (SNDS), we assessed and calibrated empirically case‐based designs to identify drug associated with UGIB risk. Methods: All cases of UGIB were extracted from SNDS (2009‐2014) using two definitions. Positive and negative drug controls were used to compare 196 self‐controlled case series (SCCS), case‐control (CC) and case‐population (CP) design variants. Each variant was evaluated in a 1/10th population sample using area under the receiver operating curve (AUC) and mean square error (MSE). Parameters that had major impacts on results were identified through logistic regression. Optimal designs were replicated in the unsampled population. Results: Using a specific UGIB definition, AUCs ranged from 0.64 to 0.80, 0.44 to 0.61 and 0.50 to 0.67, for SCCS, CC and CP, respectively. MSE ranged from 0.07 to 0.39, 0.83 to 1.33 and 1.96 to 4.6, respectively. Univariate regressions showed that high AUCs were achieved with SCCS with multiple drug adjustment and a 30‐day risk window starting at exposure. The top‐performing SCCS variant in the unsampled population yielded an AUC = 0.84 and MSE = 0.14, with 10/36 negative controls presenting significant estimates. Conclusions: SCCS adjusting for multiple drugs and using a 30‐day risk window has the potential to generate UGIB‐related alerts in the SNDS and hypotheses on its potential population impact. Negative control implementation highlighted that low systematic error was generated but that protopathic bias and confounding by indication remained unaddressed issues. [ABSTRACT FROM AUTHOR]

Background and Aim: Risk stratification is recommended in all patients with acute variceal bleeding (AVB). It remains unclear whether liver disease severity or upper gastrointestinal bleeding (UGIB) scoring algorithms offer superior predictive ability. We aimed to validate the AIMS65 score as a predictor of mortality in AVB, and to compare AIMS65 with established UGIB and liver disease severity risk stratification scores. Methods: International Classification of Diseases, Tenth Revision codes identified patients presenting with AVB to three tertiary centers over a 48‐month period. Patients were risk‐stratified using AIMS65, Rockall, pre‐endoscopy Rockall, Child‐Pugh, Model for End‐stage Liver Disease (MELD) and United Kingdom MELD (UKELD) scores. Primary outcomes were inpatient and 6‐week mortality and inpatient rebleeding. Results: Two hundred and twenty‐three patients were included. Inpatient and 6‐week mortality were 13.9% and 15.5% respectively. Prediction of inpatient mortality by AIMS65 (area under the receiver‐operating characteristic curve [AUROC: 0.84]) was equivalent to UGIB (Rockall: 0.79, pre‐Rockall: 0.78) and liver risk scores (MELD: 0.81, UKELD: 0.79, Child‐Pugh: 0.78). AIMS65 score ≥3 best defined high‐ and low‐risk groups for inpatient mortality (mortality 37.7% vs 4.9%). AIMS65 (AUROC: 0.62) was equivalent to UGIB risk scores (pre‐Rockall: 0.64, Rockall: 0.70) in predicting inpatient rebleeding and superior to liver risk scores (MELD: 0.56, UKELD: 0.57, Child‐Pugh: 0.60). Conclusions: AIMS65 is equivalent to established UGIB and liver disease severity risk stratification scores in predicting mortality, and superior to liver scores in predicting rebleeding. [ABSTRACT FROM AUTHOR]

Background and aim: Antibiotic prophylaxis should be instituted for cirrhotic patients with upper gastrointestinal bleeding (UGIB), but the benefit on compensated patients remains undetermined. We aimed to compare the clinical outcomes between cirrhotic patients without major complications with UGIB with and without antibiotic prophylaxis. Methods: We conducted this population‐based cohort study by using Taiwanese Longitudinal Health Insurance Database 2000 (LHID2000, between 1997 to 2013), aged 18 years or older with a hospital discharge diagnosis of cirrhosis (n = 64,506), UGIB (n = 7,784), and endoscopic therapy (n = 2,292). After strict exclusions, 1205 patients were enrolled and were divided into antibiotic exposure (n = 558) and non‐exposure (n = 647) groups. The outcomes were rebleeding and mortality. Results: After completing the analysis adjusted by death, the rebleeding rates within 4 weeks were significantly lower in patients with antibiotic prophylaxis (3.05% versus 6.03%, P = 0.0142) and those with endoscopic therapy (0.72% vs 3.09%, P = 0.0033) but not significant after 3 months and onwards. Male patients aged > 55, high CCI score ≧ 4, and UGIB of variceal etiologies were benefited from rebleeding. The use of antibiotics did not significantly impact 6‐week mortality (adjusted hazard ratio: 1.07, 95%CI: 0.41~2.75; P = 0.8943). Old age, multiple comorbidities, and UGIB of variceal etiologies were risk factors of all‐cause mortality. Conclusions: The current study suggested that cirrhotic patients without major complications who suffered from UGIB were benefited by the use of antibiotics to prevent rebleeding within 4 weeks after endoscopic treatment of UGIB especially for those with age > 55, high CCI score ≧ 4, and UGIB of variceal etiologies. [ABSTRACT FROM AUTHOR]

Background and Aim: Risk stratification for upper gastrointestinal bleeding (UGIB) is recommended. However, scoring system accuracy is suboptimal, and score calculation can be complex. Our aim was to develop a new score, the MAP(ASH) score, with information available in the emergency room and to validate it. Methods: The score was built from a prospective database of patients with UGIB and validated in an international database of 3012 patients from six hospitals. Outcomes were 30‐day mortality, endoscopic intervention, any intervention (red blood transfusion, endoscopic treatment, interventional radiology, surgery, or death), and rebleeding. Accuracy to predict outcomes was assessed by the area under the receiver operating characteristic curve (AUROC). Results: Five hundred forty‐seven patients were included in the development cohort. Impaired mental status, albumin < 2.5 g/dL, pulse > 100, American Society of Anesthesiologists score > 2, systolic blood pressure < 90 mmHg, and hemoglobin < 10 g/dL were included in the score. The model had a good predictive accuracy for intervention (AUROC = 0.83; 95% confidence interval [CI]: 0.79–0.88) and fair for mortality (AUROC = 0.74; 95% CI: 0.68–0.81). Regarding endoscopic intervention, AUROC was 0.61 (95% CI: 0.56–0.66) in the original cohort and 0.69 (95% CI: 0.66–0.71) in the validation cohort, showing a poor performance, similar to other scores. For rebleeding, the MAP(ASH) (AUROC 0.73; 95% CI: 0.69–0.77) was similar to Glasgow Blatchford score (AUROC = 0.72; 95% CI: 0.67–0.76) but superior to AIMS65 (AUROC = 0.64; 95% CI: 0.59–0.68). Conclusion: MAP(ASH) is a simple pre‐endoscopy risk score to predict intervention after UGIB, with fair discrimination at predicting mortality. Because of its applicability, it could be an option in clinical practice. [ABSTRACT FROM AUTHOR]

Background and Aim: Upper gastrointestinal bleeding (UGIB) is a serious complication of portal hypertension in cirrhotic patients. The objective of this study is to identify the risk factors for morbidity and mortality occurring after an UGIB attack. Methods: A total of 1097 UGIB attacks in 690 patients with liver cirrhosis were studied. Their clinical, laboratory, and endoscopic data were reviewed. Results: Mean age 53.2 ± 10.6 (20–90) years, 78% men and the main cause of liver disease was hepatitis C (94.9%). Complications occurred after 467 attacks (42.6%): hepatic encephalopathy 31.4%, spontaneous bacterial peritonitis 18%, renal impairment 13.2%, and re‐bleeding in 7.8%, while 199 patients (18.1%) died. Complications followed 78.4% of bleeding from gastric varices, 75% of post‐interventional ulcers, 10.8% of peptic ulcers, and 5.9% of telangiectasias. By univariate analysis: packed red blood cells units transfused, transaminases, Child–Pugh (CP), model of end‐stage liver disease (MELD), and albumin–bilirubin (ALBI) scores, beside the presence of hepatocellular carcinoma (HCC), previous hemorrhage in the previous 6 months, and the source of bleeding, were associated with occurrence of complications. By multivariate analysis, independent predictors of complications were CP, MELD, and ALBI scores (odds ratio, 95% confidence interval: 5.63, 3.55–8.93; 1.15, 1.11–1.19; and 2.11, 1.4–3.19, respectively) beside the presence of HCC (4.89, 2.48–9.64). Mortality predictors were packed red blood cells units transfused (1.11, 1.01–1.24), CP (5.1, 1.42–18.25) MELD (1.27, 1.21–1.32) scores, and presence of HCC (6.62, 2.93–14.95). Conclusion: High CP, MELD, and ALBI scores beside the presence of HCC could predict poor outcome of UGIB. In the absence of these risk factors, early discharge could be considered if the source of bleeding is peptic ulcer or telangiectasia. [ABSTRACT FROM AUTHOR]

Background and Aim: Upper gastrointestinal bleeding is a rare and potentially life‐threatening condition in children. Herein, clinical features and risk factors in children with upper gastrointestinal bleeding were analyzed, and a clinical scoring system was constructed to assess severity. Methods: This retrospective cohort study involved 224 children hospitalized with upper gastrointestinal bleeding between January 2012 and April 2018. Demographic data, clinical information, and laboratory test results on admission were statistically examined. Results: Out of 224 upper gastrointestinal bleeding cases, 76 were diagnosed as severe and 148 as mild cases according to the rate of blood loss and severity. Severe group was significantly different from mild group in 23 items including age, number of patients aged more than 7 years, and so forth (P < 0.01 or P < 0.05). Positive detection rate of bleeding etiology was gradually decreased (P < 0.01) in relation to delay in timing of endoscopy. Analysis of logistic regression evinced five independent risk factors for severe cases to be associated with poor consciousness, hemoglobin < 80 g/L, hemoglobin drop of > 20 g/L, hematochezia, and anemic appearance (P < 0.01 or P < 0.05). Using these five parameters, a number of scoring models were tested. The most predictive resulted in a scoring system constructed with a total of 16 and a cutoff for intervention of 8. Conclusions: Amalgamation of risk factors with the scoring system plays an important role in assessing upper gastrointestinal bleeding severity in children. [ABSTRACT FROM AUTHOR]

Objective: To investigate the correlation of tumor necrosis factor α (TNF‐α) polymorphisms with upper gastrointestinal bleeding (UGIB) induced by enteric‐coated aspirin in coronary heart disease (CHD) patients. Methods: In total, 154 CHD patients taking enteric‐coated aspirin were enrolled in this study. Patients were divided into the UGIB group (n = 57) and non‐UGIB group (n = 97) based on the presence or absence of signs of UGIB, respectively. TNF‐α polymorphism (‐857C > T, ‐863C > A, and ‐1031T > C) genotyping was performed using polymerase chain reaction (PCR) amplification with sequence‐specific primers (PCR‐SSP). Results: Patients who had the CC genotype and C allele of ‐1031T > C exhibited a significantly increase risk of UGIB after receiving enteric‐coated aspirin (CC vs. TT: odds (OR) (95% confidence interval (CI)): 7.568 (1.527–37.49), P = 0.005; C vs. T: OR (95% CI): 1.852 (1.036–3.312), P = 0.036). Patients who had CA and CA + AA genotypes and the A allele of ‐863C > A also exhibited an increased risk of aspirin‐induced UGIB (CA vs. CC: OR (95% CI): 2.415 (1.143–5.101), P = 0.019: CA + AA vs. CC: OR (95% CI): 2.218 (1.123–4.381), P = 0.021; A vs. C: OR (95% CI): 1.788 (1.039–3.078), P = 0.035). However, the TNF‐α ‐857 C > T polymorphism was unrelated to the induction of UGIB by enteric‐coated aspirin in CHD patients (P > 0.05). In addition, the haplotypes of CCC (‐1031T > C, ‐863C > A, and ‐857C > T) markedly reduced the risk of aspirin‐induced UGIB in CHD patients. Conclusion: TNF‐α ‐863A and ‐1031C increased the risk of UGIB induction by enteric‐coated aspirin in CHD patients, whereas TNF‐α ‐857C > T was not correlated with the UGIB risk. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal bleeding is a commonly seen multidisciplinary clinical condition in emergency departments which has high treatment cost and mortality in company with hospital admission. Risk evaluation before endoscopy is based on clinical and laboratory findings at patient's emergency visit. Objective: The purpose of this study is to investigate the efficacy of "Glasgow-Blatchford scale + lactate levels" to predict the mortality of patients detected with gastrointestinal bleeding in the emergency department. Methods: A total of 107 patients with preliminary diagnosis of upper gastrointestinal bleeding included in the study after approval of the ethics committee were prospectively evaluated. Glasgow-Blatchford scale scores were calculated and venous blood lactate levels were assessed. Need for blood transfusion in the follow-up, the amount of transfusion, and mortality in the next 6 months were evaluated. Results: A statistically significant difference was found in mortality rates between the lactate and Glasgow-Blatchford scale cohorts in our study (p = 0.001 and p < 0.01, respectively). The mortality rate was significantly higher in the lactate(+) GBS(+) cases compared to the lactate(–) GBS(+), lactate(+) GBS(–), and lactate(–) GBS(–) cases compared to the bilateral comparisons (p = 0.004, p = 0.001, p = 0.001, and p < 0.01, respectively). There was a statistically significant relationship between the rate of erythrocyte suspension replacement in the cases according to Glasgow-Blatchford scale levels (p = 0.001 and p < 0.01, respectively). The incidence of erythrocyte suspension replacement was 7.393 times greater in patients with Glasgow-Blatchford scale score of 12 and above. Conclusion: Glasgow-Blatchford scale is highly sensitive to the determination of mortality risk and the need for blood transfusion in upper gastrointestinal bleeding. Glasgow-Blatchford scale with lactate evaluation is more sensitive and more significant than Glasgow-Blatchford scale alone. This significance provides us to establish "modified Glasgow-Blatchford scale." In the future, studies which will use Glasgow-Blatchford scale supported by lactate could be increased and the results should be supported more. [ABSTRACT FROM AUTHOR]

Abstract: This study aimed to identify the incidence of perioperative acute upper gastrointestinal bleeding (UGIB) in our hip fracture patients; to evaluate the characteristics, management and clinical outcomes of these patients; and to explore risk factors and protective factors. Of the 1691 consecutive patients admitted for surgical management of hip fractures, 11 (0.65%) had UGIB and a further four patients for each case were selected as controls for evaluation of risk factors and protective factors. Pre‐existing peptic ulcer disease was identified as a risk factor for acute UGIB (odds ratio 7.9; 95% confidence interval: 1.1–54.9). This study reported a very low incidence of UGIB in hip fracture patients. Despite being a high‐risk population, timely endoscopic evaluation can be safely undertaken to optimise patient outcome. When risk factors such as history of peptic ulcer disease are present, additional precaution including gastro‐protective agent and nutritional support should be undertaken. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Esophageal inflammatory myofibroblastic tumors (IMT) are extremely rare, and the understanding on the clinical presentation is limited. IMT of esophagus should be considered as a differential diagnosis in the context of unexplained upper gastrointestinal bleeding and rapidly progressing dysphagia in young patients. [ABSTRACT FROM AUTHOR]

Background In register-based pharmacoepidemiological studies, each day of follow-up is usually categorized either as exposed or unexposed. However, there is an underlying continuous probability of exposure, and by insisting on a dichotomy, researchers unwillingly force a nondifferential misclassification into their analyses. We have recently developed a model whereby probability of exposure can be modeled, and we tested this on an empirical case of nonsteroidal anti-inflammatory drug (NSAID)-induced upper gastrointestinal bleeding (UGIB). Methods We used a case-controls data set, consisting of 3568 cases of severe UGIB and 35 552 matched controls. Exposure to NSAID was based on 3 different conventional dichotomous measures. In addition, we tested 3 probabilistic exposure measures, a simple univariate backward-recurrence model, a 'full' multivariable model, and a 'reduced' multivariable model. Odds ratios (ORs) and 95% confidence intervals for the association between NSAID use and UGIB were calculated by conditional logistic regression, while adjusting for preselected confounders. Results Compared to the conventional dichotomous exposure measures, the probabilistic exposure measures generated adjusted ORs in the upper range (4.37-4.75) while at the same time having the most narrow confidence intervals (ratio between upper and lower confidence limit, 1.46-1.50). Some ORs generated by conventional measures were higher than the probabilistic ORs, but only when the assumed period of intake was unrealistically short. Conclusion The pattern of high ORs and narrow confidence intervals in probabilistic exposure measures is compatible with less nondifferential misclassification of exposure than in a dichotomous exposure model. Probabilistic exposure measures appear to be an attractive alternative to conventional exposure measures. [ABSTRACT FROM AUTHOR]

Aim Acute gastrointestinal bleeding is a potentially life-threatening condition that requires rapid assessment and dynamic management. Several scoring systems are used to predict mortality and rebleeding in such cases. The aim of the present study was to compare three scoring systems for predicting short-term mortality, rebleeding, duration of hospitalization and the need for blood transfusion in elderly patients with upper gastrointestinal bleeding. Methods The present study included 335 elderly patients with upper gastrointestinal bleeding. Pre- and post-endoscopic Rockall, Glasgow-Blatchford and AIMS65 scores were calculated. The ability of these scores to predict rebleeding, mortality, duration of hospitalization and the need for blood transfusion was determined. Results Pre- (4.5) and post-endoscopic (7.5) Rockall scores were superior to the Glasgow-Blatchford (12.5) score for predicting mortality ( P = 0.006 and P = 0.015). Likewise, pre- (4.5) and post-endoscopic Rockall scores were superior to the respective Glasgow-Blatchford scores for predicting rebleeding ( P = 0.013 and P = 0.03). There was an association between duration of hospitalization and mortality; as the duration of hospitalization increased the mortality rate increased. In all, 94% of patients hospitalized for a mean of 5 days were alive versus 56.1% of those hospitalized for 20 days, and 20.2% of those hospitalized for 40 days. Conclusions In elderly patients with upper gastrointestinal bleeding, the Rockall score is clinically more useful for predicting mortality and rebleeding than the Glasgow-Blatchford and AIMS65 scores; however, for predicting duration of hospitalization and the need for blood transfusion, the Glasgow-Blatchford score is superior to the Rockall and AIMS65 scores. Geriatr Gerontol Int 2017; 17: 575-583. [ABSTRACT FROM AUTHOR]

Background and Aim Early transjugular intrahepatic portosystemic shunt (TIPS) used as preventive therapy prior to recurrent bleeding has been recommended in patients presenting with acute esophageal variceal bleeding (EVB) who are at high risk of further bleeding and death. We investigated the impact of early TIPS on outcomes of US patients hospitalized with EVB from 2000 to 2010. Methods The Nationwide Inpatient Sample database was queried to identify patients with EVB and decompensated cirrhosis (because early TIPS is recommended only in high-risk patients). The primary outcome was in-hospital death, and secondary outcomes included rebleeding and hepatic encephalopathy. Early preventive TIPS was defined by placement within 3 days of hospitalization for acute EVB after one session of endoscopic therapy. Rescue TIPS was defined as TIPS after two interventions for EVB. Results The study included 142 539 patients. From 2000 to 2010, the age-adjusted in-hospital mortality rate decreased 37.2% from 656 per 100 000 to 412 per 100 000 ( P <0.01), while early and rescue TIPS increased (0.22% to 0.70%; P < 0.01 and 1.1% to 6.1%; P < 0.01). On multivariate analysis, as compared with no TIPS, early TIPS was associated with decreased inpatient mortality (risk ratio [RR] = 0.87; 95% confidence interval [CI], 0.84-0.90) and rebleeding (RR = 0.56; 95% CI, 0.45-0.71) without an increase in hepatic encephalopathy (RR = 1.01; 95% CI, 0.93-1.11). Conclusion Early preventive TIPS in patients with EVB and decompensated cirrhosis was associated with significant in-hospital reductions in rebleeding and mortality without a significant increase in encephalopathy in 'real-world' US clinical practice. [ABSTRACT FROM AUTHOR]

Background and Aim Upper gastrointestinal bleeding (UGIB) is a threatening condition leading to urgent hospitalization. This study aims to investigate etiology and outcome in UGIB patients in Iran. Methods Medical records of GIB patients admitted to Alzahra referral hospital (in Isfahan) during 2010-2015 were retrospectively reviewed for demographic data, comorbidities, history of smoking and taking non-steroidal anti-inflammatory drugs (NSAIDs), presenting symptoms, endoscopic findings, therapeutic endoscopy, blood products' infusion, surgical intervention, rebleeding, and mortality. Results A total of 4747 patients were enrolled in the study (69.2% men, mean age = 55.46 ± 21.98 years). Hematemesis was the most frequent presenting symptom (63.5%). Peptic ulcer (duodenal ulcer in most cases) was seen as the main reason for UGIB (42.4%). Rebleeding (present in 16.5% of patients) was found to be more frequent in patients with older age, presenting sign of hematochezia and hypotension, history of taking NSAIDs and smoking, presence of comorbidities, history of bleeding because of UGI tract neoplasm and esophageal varices, history of needing blood products' infusion, and history of therapeutic endoscopy or surgical intervention ( P < 0.005). We found that mortality (5.5% in total) was also higher in the same group of patients that were seen to have a higher tendency for rebleeding ( P < 0.005). Conclusion Peptic ulcers are the most common cause of UGIB. Comorbidities, hemodynamic instability, high-risk endoscopic stigmata, history of smoking and taking NSAIDs, gastric and esophageal malignancies, may be important predisposing factors for rebleeding and mortality in patients with UGIB. [ABSTRACT FROM AUTHOR]

Background With proton pump inhibitors and current sophisticated endoscopic techniques, the number of patients requiring surgical intervention for upper gastrointestinal bleeding has decreased considerably while trans-arterial embolization is being used more often. There are few direct comparisons between the effectiveness of surgery and embolization. Methods A retrospective study of patients from two Australian teaching hospitals who had surgery or trans-arterial embolization ( n = 103) for severe upper gastrointestinal haemorrhage between 2004 and 2012 was carried out. Patient demographics, co-morbidities, disease pathology, length of stay, complications, and overall clinical outcome and mortality were compared. Results There were 65 men and 38 women. The median age was 70 (range 36-95) years. Patients requiring emergency surgical intervention ( n = 79) or trans-arterial embolization ( n = 24) were compared. The rate of re-bleeding after embolization (42%) was significantly higher compared with the surgery group (19%) ( P = 0.02). The requirement for further intervention (either surgery or embolization) was also higher in the embolization group (33%) compared with the surgery group (13%) ( P = 0.03). There was no statistical difference in mortality between the embolization group (5/24, 20.8%) and the surgical group (13/79, 16.5%) ( P = 0.75). Conclusion Emergency surgery and embolization are required in 2.6% of patients with upper gastrointestinal bleeding. Both techniques have high mortalities reflecting the age, co-morbidities and severity of bleeding in this patient group. [ABSTRACT FROM AUTHOR]

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori ( HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research. [ABSTRACT FROM AUTHOR]

Background and Aim: Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB. Methods: During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis. Results: A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization. Conclusion: In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB. [ABSTRACT FROM AUTHOR]

Background and Aim: The Glasgow-Blatchford score (GBS) and Rockall score (RS) are widely used to assess risk in patients with upper gastrointestinal bleeding (UGIB). We compared both scoring systems and evaluated their clinical usefulness. Methods: Between February 2011 and December 2013, 1584 patients with nonvariceal UGIB were included in the study. A prospective study was conducted to compare the performance of the GBS, pre-RS, and full RS. We compared the performance of these scores using receiver operating characteristic curves. Results: For prediction of the need for hospital-based intervention, the GBS was similar to the full RS (area under the receiver operating characteristic curves [AUROC] 0.705 vs 0.727; P = 0.282) and superior to the pre-RS (AUROC 0.705 vs 0.601; P < 0.0001). In predicting death, the full RS was superior to the GBS (AUROC 0.758 vs 0.644; P = 0.0006) and similar to the pre-RS (AUROC 0.758 vs 0.754; P = 0.869). In predicting rebleeding, the full RS was superior to both GBS (AUROC 0.642 vs 0.585; P = 0.031) and pre-RS (AUROC 0.642 vs 0.593; P = 0.0003). Of 1584 patients, 13 (0.8%) scored 0 on the GBS. Therapeutic intervention was not performed in any of these patients. Conclusions: The GBS is more useful than the pre-RS for predicting the need for hospital-based intervention. A cutoff value of 0 for low-risk patients who might be suitable for outpatient management is useful. The full RS is helpful in predicting death. None of the systems accurately predict rebleeding with a low AUROC. (Clinical trial: cris.nih.go.kr/KCT0000514). [ABSTRACT FROM AUTHOR]

Background and Aim Upper gastrointestinal bleeding ( UGIB) leads to significant morbidity and mortality in chronic kidney disease ( CKD) patients. This study determined the efficacy of using a low-dose proton pump inhibitor ( PPI) to reduce the risk of non-variceal UGIB in CKD patients receiving aspirin. Methods We retrospectively reviewed the medical records of 500 CKD patients who received aspirin between January 2008 and March 2013. Cumulative incidence analysis using the Kaplan- Meier method was performed to analyze the rate of non-variceal UGIB and association with the administration of low-dose PPI. Results Of the 500 patients, 191 received low-dose PPI. Over the follow-up period, which lasted 1067 person-years, three patients in the low-dose PPI group (8.9 per 1000 person-years) and 19 patients in the non- PPI group (25.9 per 1000 person-years) developed non-variceal UGIB, respectively ( P = 0.113). Low-dose PPI use did not decrease the risk of UGIB in CKD patients, including patients who did not receive dialysis ( P = 0.127). However, according to the subgroup analysis of 230 patients who received dialysis, the low-dose PPI group (14.4 per 1000 person-years) demonstrated significantly reduced incidence and risk of non-variceal UGIB in comparison with the non- PPI group (53.8 per 1000 person-years) ( P = 0.032). Conclusion Prophylactic low-dose PPI can reduce the risk of non-variceal UGIB in dialysis patients receiving aspirin. [ABSTRACT FROM AUTHOR]

Objective To investigate the prevalence and risk factors of upper gastrointestinal bleeding ( UGIB) in patients with severe acute pancreatitis ( SAP). Methods Altogether 101 patients were admitted to the Department of Gastroenterology, Changhai Hospital, Second Medical Military Hospital from July 2006 to June 2010 due to SAP. Their prevalence and risk factors of UGIB were retrospectively analyzed. Results In total, 18 (17.8%) patients developed UGIB and 13 received endoscopic examination, which yielded six cases of acute gastric mucosal lesions ( AGML), five of peptic ulcers (PU) and two of pancreatic necrotic tissue invading the duodenal bulb and presenting as multilesion, honeycomb-like ulcer. The mortality rate of UGIB patients was much higher than that of non- UGIB patients (44.4% vs 10.8%, P = 0.0021). Univariate analysis revealed that the risk factors for UGIB included the Acute Physiology and Chronic Health Evaluation II ( APACHE II) score, computed tomography severity index (CTSI), Ranson score, arterial blood pH and PaO2, serum blood urea nitrogen and creatinine concentrations, platelet count, shock, sepsis and organ failure, mechanical ventilation, heparinized continuous renal replacement therapy and total parenteral nutrition. Multivariate logistic regression revealed that APACHE II score and CTSI were significant risk factors while PaO2 was the protective factor for UGIB in SAP. Conclusions UGIB is a common complication with poor prognosis due mainly to PU and AGML. Patients having SAP with high APACHE II scores and CTSI or low PaO2 should be considered to be at high risk for UGIB. [ABSTRACT FROM AUTHOR]

Background and Aim The present study aimed to clarify the features and management of non-variceal upper gastrointestinal bleeding ( UGIB) in Japanese patients taking antithrombotic agents. Methods We retrospectively investigated the medical records of 560 patients who underwent emergency endoscopy for UGIB from 2002 to 2013. The patients were divided into two groups: group A, antithrombotic agent use; and group NA, no antithrombotic agent use. We compared clinical characteristics, comorbidities, and causes of UGIB between the groups. We also investigated management with antithrombotics. Results Of 560 patients with UGIB, 27.5% were taking antithrombotics, and this proportion gradually increased during the study period. Mean hemoglobin levels on admission were significantly lower in group A (8.0 ± 1.7 g/dL) than in group NA (8.9 ± 2.9 g/dL) ( P < 0.001). Patients in group A developed more gastric ulcers and multiple ulcers than did patients in group NA. Incidence of Forrest Ia-type bleeding was lower in group A than in group NA ( P < 0.001), and the rate of endoscopic hemostasis was significantly higher in group A (98.7%) than in group NA (94.3%) ( P = 0.022). After the release of the 2012 Japan Gastroenterological Endoscopy Society guidelines, the antithrombotic agent cessation periods were significantly shortened ( P < 0.001). Conclusions Among patients with UGIB, those taking antithrombotics exhibited more severe clinical signs. However spurting hemorrhage was rare. Antithrombotics may be resumed early after endoscopic hemostasis. [ABSTRACT FROM AUTHOR]

Background To date no incidence figures for upper gastrointestinal haemorrhage (UGIH) in New Zealand have been published. Aims To determine the incidence of UGIH in a demographically defined population, and to assess variation in incidence associated with demographic parameters. Methods Between 17 March 2001 and 12 October 2010, all patients presenting to Waikato Hospital with UGIH were prospectively ascertained, and clinical, epidemiological and laboratory data were collected. Incidence rates were calculated, and were age adjusted to the World Health Organization world standard population. Parameters associated with trends in incidence were examined. Results There were 1360 UGIH events, yielding a crude incidence of 59.2 per 100 000 adults (age ≥ 15 years) per year (all quoted incidence figures per 100 000 adults per year), and an age-adjusted incidence ( AAI) of 46.4. AAI was higher for Maori compared with New Zealand Europeans (91.3 vs 37.0, rate ratio ( RR) = 2.47, P < 0.001). Maori were more likely to have a gastric ulcer at endoscopy (odds ratio ( OR) = 2.21, P < 0.001). For those tested for H elicobacter pylori ( n = 702), Maori were more likely to be infected ( OR = 2.12, P < 0.001). AAI was higher for males (61.1 vs 33.6, RR = 1.82, P < 0.001). Males were more likely to have a duodenal ulcer at endoscopy ( OR = 1.79, P < 0.001). AAI incidence decreased from the first to the second half of the study period (53.6 vs 45.8, RR = 1.17, P < 0.001). Conclusion AAI of UGIH in the Waikato region was 46.4. This was significantly higher in Maori and in males, and decreased over the study period. These data will provide a comparison for future assessment of trends in UGIH. [ABSTRACT FROM AUTHOR]

Background Helicobacter pylori ( H. pylori) testing in patients with bleeding ulcers is recommended by society guidelines and considered a quality indicator. The aim of the study is to examine the proportion of patients with bleeding ulcers who had H. pylori testing and identify predictors associated with H. pylori testing. Materials and methods Consecutive hospitalized patients with bleeding ulcers documented endoscopically at a single center from 10/2004-5/2011 were identified retrospectively from an endoscopy database. The proportion of patients undergoing direct H. pylori testing (histology, rapid urease test, breath test or stool antigen) and any H. pylori testing (direct or serologic) were determined. Results Among 330 patients with bleeding ulcers, 105 (32%, 95% CI 27-37%) underwent direct testing and another 52 (16%, 95% CI 12-20%) had serologic testing during a median follow-up of 9 months (range, 0-86). H. pylori testing occurred at the index hospitalization in 146 (93%) of the 157 patients tested. Among the 105 patients who had direct H. pylori testing, 90 (86%) had biopsy-based testing during the initial endoscopy. On multivariate analysis, undergoing biopsy of a gastric ulcer was strongly associated with having direct H. pylori testing performed ( OR = 5.1, 95% CI 2.3-11.5; p < .0001). Conclusions Among patients hospitalized with bleeding ulcers, less than half received H. pylori testing and less than a third received the more accurate direct testing. Most of the direct H. pylori testing was biopsy-based with very few being tested after the index hospitalization. Efforts to increase H. pylori testing in patients with bleeding ulcers are needed to improve outcomes. [ABSTRACT FROM AUTHOR]

Aortoduodenal fistula is a rare cause of life‐threatening upper gastrointestinal bleeding. Accurate diagnosis is essential to initiate definitive treatment because endoscopic hemostasis, which is the usual initial intervention for upper gastrointestinal bleeding, may be ineffective. This case underscores timely intervention using endovascular treatment for achieving hemostasis in aortoduodenal fistula. [ABSTRACT FROM AUTHOR]

Background and Aim The Blatchford score is based on clinical and laboratory variables to predict the need for clinical interventions in upper gastrointestinal bleeding ( UGIB). The primary object was to evaluate the Blatchford score with clinical and full Rockall scores in patients with active cancer presenting to the emergency department with UGIB. The secondary object was to assess the accuracy of the Blatchford score at different source of UGIB; cancer bleeding versus non-malignant lesions. Methods We reviewed and extracted data from electronic medical record on patients with active cancer presenting to the emergency department from January 2009 to December 2011. Clinical interventions included blood transfusion, therapeutic endoscopy, angiographic intervention, and surgery. Results Of the 225 patients included, 197 (87.6%) received interventions. Comparing the area under receiver-operator curves, the Blatchford score (0.86, 95% confidence interval [ CI] 0.77-0.95) was superior to clinical Rockall (0.67, 95% CI 0.55-0.79) and full Rockall score (0.72, 95% CI 0.61-0.83) in predicting interventions. When the score of 2 or less is counted as negative, sensitivity of 0.99 and specificity of 0.54 were calculated. When the patients were separated according to the source of UGIB, sensitivity and specificity were not changed. Conclusions The Blatchford score outperformed both Rockall scoring system in predicting intervention in patients with active cancer. The source of bleeding was not important factor in the score performance. The Blatchford score has a very good sensitivity. However, suboptimal specificity limits its role as sole means of decision making in cancer patient with UGIB. [ABSTRACT FROM AUTHOR]

Monbaliu D, Vandersmissen J, De Hertogh G, Van Assche G, Hoffman I, Knops N, Debbaut C, Heye S, Pirenne J, Maleux G. Portal hypertension after combined liver and intestinal transplantation, a diagnostic and therapeutic challenge? Pediatr Transplantation 2012: 00: 000-000. © 2012 John Wiley & Sons A/S. Abstract: A widely accepted technique to transplant the liver-bowel bloc is first to perform a piggyback anastomosis of the donor suprahepatic vena cava to the recipient vena cava; second to restore the arterial blood supply through an aortic interposition graft; and third to ensure venous drainage of the native foregut. The venous drainage of the native foregut can be restored through an end-to-end portocaval anastomosis between the donor infrahepatic vena cava and the recipient portal vein. Stenosis of this anastomosis can lead to portal hypertension presenting with upper GI congestion, bleeding, and hypersplenism. We report the successful treatment of this complication using an e-PTFE-covered stent inserted following balloon angioplasty. [ABSTRACT FROM AUTHOR]

Endoscopic hemostasis is widely performed for nonvariceal upper gastrointestinal (UGI) bleeding. As the aged Japanese population rapidly increases, the number of patients experiencing complications increases. The aim of this study was to evaluate the recent results of endoscopic hemostasis for nonvariceal UGI bleeding. A retrospective analysis of patients who underwent endoscopic procedures for nonvariceal UGI bleeding was performed. We performed 223 endoscopic procedures on 217 patients between January 1995 and July 2000, and 238 endoscopic procedures on 236 patients between January 2006 and September 2009 at the Kyoto Second Red Cross Hospital. We divided the patients into the 1995–2000 group and the 2006–2009 group. Patient characteristics, hemostasis methods chosen, rates of temporary hemostasis and rebleeding, and mortality were analyzed. There were many serious and actively bleeding cases in the 2006–2009 group ( P < 0.001). The endoclip method and intravenous proton pump inhibitor were mainly used in the 2006–2009 group compared with the drug-injection method and intravenous H2 receptor antagonist in the 1995–2000 group ( P < 0.001). Through these treatments, the two groups were able to obtain similar treatment outcomes. Through the progress of endoscopic management we obtained similar satisfactory results in the 2006–2009 group, which had multiple complicated cases, compared to the 1995–2000 group. [ABSTRACT FROM AUTHOR]