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Objective: Upper gastrointestinal bleeding (UGIB) is a frequent medical emergency and several scoring systems are developed to help risk-stratify patients. We aimed to investigate if elevated arterial lactate (AL) was associated with 30-day mortality, need for hospital-based intervention, or rebleeding. Furthermore, we compared the performance of AL with existing scoring systems and examined if incorporation of AL could improve their predictive ability., Materials and Methods: Retrospective cohort study of 331 consecutive patients admitted with UGIB during a one-year period. Multivariate analyses were performed to evaluate the association between AL and outcomes. Receiver operating characteristic curves were used to compare AL with existing scoring systems and to test if incorporation of AL could significantly increase their performance., Results: AL was significantly associated with mortality (p = .001), need for hospital-based intervention (p = .005), and rebleeding (p = .031). In predicting mortality and rebleeding, AL performed equally to existing scoring systems, however, inferior to all, in predicting need for intervention. Two of the scoring systems were marginally improved in predicting mortality if AL was included., Conclusions: AL is associated with adverse outcomes in patients with UGIB, but has only similar or inferior ability to predict relevant clinical outcomes compared to existing scoring systems. Although AL could enhance performance of two scorings systems in predicting mortality, it does not have an apparent clinical significance. Thus, our data does not support routine measurement of AL in patients with UGIB.

Objective: Dual antiplatelet therapy reduces the risk of ischemic complications after acute coronary syndrome, but increases the risk of bleeding including upper gastrointestinal bleeding (UGIB).The aim of this study was to examine the effect of screening for risk of UGIB and prophylactic proton pump inhibitor (PPI) treatment in dual-antiplatelet-treated patients at risk of UGIB and to assess the significance of dual antiplatelet therapy compliance for cardiovascular events., Patients and Methods: In a register-based randomized-controlled trial, 2009 patients were included at the time of first percutaneous coronary intervention and randomized to either screening or control. Screened high-risk patients were prescribed pantoprazole 40 mg during the 1-year after percutaneous coronary intervention., Results: The incidence of UGIB was 0.8 versus 1.3% in screened patients and controls, respectively (P=0.381).Significantly fewer screened patients (5.4%) than controls (8.0%) underwent upper gastrointestinal endoscopy (P=0.026). Screened patients (2.9%) had significantly fewer events of unstable angina pectoris than controls (4.7%) (P=0.036) and a higher compliance to dual antiplatelet therapy (88.3 vs. 85.0%) (P=0.035), but no statistically difference was observed in the incidences of myocardial infarction and all-cause mortality (1.0 vs. 1.5%) (P=0.422)., Conclusion: Screening for risk factors for UGIB and subsequent prophylactic PPI treatment did not significantly reduce the incidence of UGIB. Prescription of PPI was associated with a higher compliance with dual antiplatelet therapy and decreases the risk of recurrent cardiovascular events.

Introduction: Dual antiplatelet therapy is standard treatment following percutaneous coronary intervention (PCI) and stenting. However, such therapy increases the risk of upper gastrointestinal bleeding (UGIB). The risk factors of UGIB are well-documented and proton pump inhibitor (PPI) treatment reduces the risk. The aim was to describe the prevalence of risk factors of UGIB in dual antiplatelet-treated patients., Methods: A questionnaire was used to assess the prevalence of risk factors of upper gastrointestinal bleeding among dual antiplatelet-treated first-time PCI patients in Western Denmark. The following characteristics were considered risk factors: increasing age (age 60-69 years and ≥ 70 years); dyspepsia; previous peptic ulcer; use of non-steroidal anti-inflammatory drugs (NSAIDs) (weekly or daily), corticosteroids, selective serotonin reuptake inhibitors (SSRIs) and anticoagulants., Results: A total of 1,358 patients with a mean age of 64.1 years (range: 33-92 years) were included. The distribution of risk factors was as follows: dyspepsia: 681 patients (50.1%); previous ulcer: 110 (8.1%; 2.3% with bleeding); use of NSAIDs: 214 (15.8%); corticosteroids (2.9%), SSRIs (5.8%) and anticoagulants (6.3%). Defined high-risk patients: 886 (65.2%). PPI treatment prior to PCI was found in 248 (18.3%), of whom 86% were at high risk of UGIB., Conclusion: This study demonstrates a high prevalence of risk factors among PCI patients treated with dual antiplatelet therapy, many of whom were not in PPI treatment.

Background & Aims: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification., Methods: We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk., Results: There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%)., Conclusions: A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Risk scoring systems are used increasingly to assess patients with upper gastrointestinal hemorrhage (UGIH). There have been comparative studies to identify the best system, but most have been retrospective and included small sample sizes, few patients with severe bleeding and with low mortality. We aimed to identify the optimal scoring system., Methods: We performed a prospective study to compare the accuracy of the Glasgow Blatchford score (GBS), an age-extended GBS (EGBS), the Rockall score, the Baylor bleeding score, and the Cedars-Sinai Medical Center predictive index in predicting patients' (1) need for hospital-based intervention or 30-day mortality, (2) suitability for early discharge, (3) likelihood of rebleeding, and (4) mortality. We analyzed the area under receiver operating characteristic (AUROC) curve, sensitivity, specificity, and positive and negative predictive values for each system. The study included 831 consecutive patients admitted with UGIH during a 2-year period., Results: The GBS and EGBS better predicted patients' need for hospital-based intervention or 30-day mortality than the other systems (AUROC, 0.93; P < .001) and were also better in identifying low-risk patients (sensitivity values, 0.27-0.38; specificity values, 0.099-1). The EGBS identified a significantly higher proportion of low-risk patients than the GBS (P = .006). None of the systems accurately predicted which patients would have rebleeding or patients' 30-day mortality, on the basis of low AUROC and specificity values., Conclusions: The GBS accurately identifies patients with UGIH most likely to need hospital-based intervention and also those best suited for outpatient care. The EGBS seems promising but must be validated externally. No scoring system seems to accurately predict patients' 30-day mortality or rebleeding. ClinicalTrials.gov number, NCT01589250., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: A number of studies have reported a possible association between use of selective serotonin reuptake inhibitors (SSRIs) and serious upper gastrointestinal bleeding (UGB). We conducted this case-control study to assess if Helicobacter pylori (H. pylori) potentiates the risk of serious UGB in SSRI users., Material and Methods: A population-based case-control study was conducted in the county of Funen, Denmark. Cases were 53 SSRI users with serious UGB whose H. pylori status on their bleeding date could be established. Controls (n = 723) were selected among subjects who participated in a population H. pylori screening study, and who were users of SSRIs. Data on drug exposure and medical history were retrieved from a prescription database and the county's patient register. Confounders were controlled for by unconditional logistic regression., Results: H. pylori infection increased the risk of serious UGB in patients using SSRI with an adjusted odds ratio (OR) of 2.73 (95% confidence interval (CI), 1.17-6.36). The adjusted OR for serious UGB among users of non-steroidal anti-inflammatory drugs (NSAIDs) and acetylsalicylic acid (ASA) were 3.91 (95% CI, 2.03-7.52) and 3.00 (95% CI, 0.94-9.54), respectively., Conclusion: H. pylori infection increases the risk of SSRI-related serious UGB.

Background & Aims: In vitro studies have shown that selective serotonin reuptake inhibitors (SSRIs) inhibit platelet aggregation. It is controversial whether use of SSRIs is a cause of clinically important bleeding; results from observational studies have been equivocal., Methods: A population-based case-control study was conducted in Denmark. The 3652 cases all had a first discharge diagnosis of serious upper gastrointestinal bleeding (UGB) from 1995 to 2006. Controls (n = 36,502), matched for age and sex, were selected by risk-set sampling. Data on drug exposure and medical history were retrieved from a prescription database and the county's patient register. Confounders were controlled for by conditional logistic regression and the case-crossover design., Results: The adjusted odds ratio (OR) of UGB among current, recent, and past users of SSRIs was 1.67 (95% confidence interval [CI], 1.46-1.92), 1.88 (95% CI, 1.42-2.5), and 1.22 (95% CI, 1.07-1.39). The adjusted OR for concurrent use of SSRI and nonsteroidal anti-inflammatory drugs (NSAIDs) was 8.0 (95% CI, 4.8-13). The adjusted OR for the concurrent use of NSAID, aspirin, and SSRI was 28 (95% CI, 7.6-103). Of the UGB cases, 377 were current users of SSRI; the adjusted OR for UGB in the case crossover analysis was 2.8 (95% CI, 2.2-3.6). The adjusted OR among users of proton pump inhibitors was 0.96 (95% CI, 0.50-1.82)., Conclusions: Use of SSRI was associated with UGB, consistent with its antiplatelet effects. SSRIs should be prescribed with caution for patients at high risk for UGB.

Objective. In 5-10% of patients with peptic ulcer bleeding (PUB) it is impossible to achieve endoscopic hemostasis because of severe bleeding. These patients have traditionally been treated surgically. Transcatheter arterial embolization (TAE) may, however, be associated with a better outcome because of the less-invasive nature of the procedure. The aim of the present study was to identify the treatment of choice in endoscopy-refractory PUB. Materials and methods. A retrospective study. Consecutive patients treated with surgery or TAE for endoscopy-refractory PUB during a period of 16 years at a university hospital were included. Primary hemostasis, rebleeding rate, mortality, and complications were assessed. Mortality was compared between groups after adjustment for age, comorbidity, and anemia using logistic regression analyses. Comorbidity was quantified using the Charlson comorbidity index (CCI). Results. One hundred and eighteen patients were included. Patients treated with TAE had a higher CCI (mean: 2.33 vs 1.42; p = .003), and more severe anemia (mean: 6.8 vs 7.9 g/dl; p = .007) compared with patients treated with surgery. Surgery was associated with a higher rate of primary hemostasis (100% vs 91%; p = .007), lower rate of rebleeding (15% vs 40%; p = .004) but also higher rate of complications (60% vs 38%; p = .02) than TAE. Surgery was associated with an increased mortality (Odds ratio: 3.05; p = .033) when adjusting for confounding factors and excluding patients ( n = 3) who were not candidates for both interventions. Conclusions. We propose use of TAE as first-line therapy in these patients as it may be associated with lower mortality and lower rate of complications compared with surgery. [ABSTRACT FROM AUTHOR]