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In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

In recent years there have been advances in the management of non-variceal upper gastrointestinal bleeding that have helped reduce rebleeding and mortality. This document positioning of the Catalan Society of Digestologia is an update of evidence-based recommendations on management of gastrointestinal bleeding peptic ulcer.

(1) Background: Although a meta-analysis reported that the sensitivity of CD3+ TCRγδ+ cells for coeliac disease diagnosis was &gt, 93%, a recent study has suggested that sensitivity decreased to 65% in elderly patients. (2) Aim: To evaluate whether the sensitivity of intraepithelial lymphocyte cytometric patterns for coeliac disease diagnosis changes with advanced age. (3) Methods: We performed a multicentre study including 127 coeliac disease patients ≥ 50 years: 87 with baseline cytometry (45 aged 50–59 years, 23 aged 60–69 years, 19 aged ≥ 70 years), 16 also with a follow-up cytometry (on a gluten-free diet), and 40 with only follow-up cytometry. (4) Results: In Marsh 3 patients, a sensitivity of 94.7%, 88.9% and 86.7% was observed for each age group using a cut-off value of TCRγδ+ &gt, 10% (p = 0.27), and a sensitivity of 84.2%, 83.4% and 53.3% for a cut-off value &gt, 14% (p = 0.02, 50–69 vs. ≥70 years), with difference between applying a cut-off of 10% or 14% (p = 0.008). The TCRγδ+ count in the ≥70 years group was lower than in the other groups (p = 0.014). (5) Conclusion: In coeliac patients ≥ 70 years, the TCRγδ+ count decreases and the cut-off point of &gt, 10% is more accurate than &gt, 14%.

Resumen Introduccion Se desconoce la incidencia de anemia ferropenica (AF) tras un episodio de hemorragia digestiva no asociada a hipertension portal (HDA). Objetivos El objetivo principal fue estudiar la incidencia de AF tras una HDA, y los secundarios describir los factores predictivos de AF y elaborar modelos que permitan detectar aquellos pacientes que se beneficiarian de ferroterapia. Material y metodo Desde abril de 2007 hasta mayo de 2009 se valoraron de forma prospectiva 391 pacientes con HDA. Se excluyeron todas las hemorragias secundarias a hipertension portal y pacientes con condiciones clinicas y/o biologicas que pudieran artefactuar el patron ferrocinetico. Se practico una analitica con parametros ferricos al ingreso, al 5.° y al 30.° dia de la HDA. Se utilizo un modelo de regresion logistica multiple y un modelo de arboles de decision. Resultados De los 124 pacientes incluidos 76 (61,3%) presentaron AF a los 30 dias de la HDA. Las variables predictoras de AF: edad > 75 anos (p = 0,037; OR 3,9; IC 95%: 1,3-11,6), urea inicial > 80 mg/dl (p = 0,027; OR 2,9; IC 95%: 1,1-7,6), ferritina inicial ≤ 65 ng/dl (p = 0,002; OR 7,6; IC 95%: 2,9-18,5), Hb inicial ≤ 100 g/l (p = 0,003; OR 3,2; IC 95%: 1,3-8,0), Hb al 5.° dia ≤ 100 g/l (p Conclusiones La mayoria de pacientes con HDA presentan AF a los 30 dias del episodio hemorragico. La identificacion de los factores predictivos de la misma permite establecer una indicacion de ferroterapia tras la HDA.

SummaryLow-grade chronic inflammation plays a pathogenic role in cardiovascular disease. An increase in the ratio of circulating neutrophils to lymphocytes (N/L ratio) may serve as a marker of cardiovascular risk in adults. It was the study objective to study whether N/L ratio associates with vascular parameters in children. Subjects were 501 prepubertal and early pubertal Caucasian children (mean age 8.0 years; mean body mass index (BMI) Z-score 0.2 ± 0.9; 266 boys and 235 girls) recruited within an ongoing population-based study. The subjects were stratified into three groups according to age. Neutrophil, lymphocyte, BMI, waist circumference, systolic blood pressure (SBP) and carotid intima-media thickness (cIMT), assessed in all children. The N/L ratio, derived from the absolute neutrophil and lymphocyte counts. In children aged < 7 years (n=190, all prepubertal), no associations were observed between N/L ratio and either anthropometric or cardiovascular parameters. In children aged 7–9 years (n=171, 1.7 % early pubertal), higher N/L ratio associated with higher BMI Z-score and waist circumference (p=0.008 to p< 0.0001). In children aged > 9 years (n=140, 29.2 % early pubertal), N/L ratio associated again with BMI Z-score and waist circumference and also positively with SBP and cIMT (all p=0.008 to p< 0.0001). These associations remained significant in linear regression models following adjustment for possible confounding variables such as age, gender, fasting triglycerides, C-reactive protein and puberty (and for SBP and cIMT, adjustment also for BMI). In conclusion, our results provide the first evidence that a higher N/L ratio is associated with a less favourable cardiovascular profile in children and delineate the development of these associations from late childhood onwards.

Background: Guidelines recommend using prognostic scales for risk stratification in patients with non-variceal upper gastrointestinal bleeding. It remains unclear whether risk scores offer greater accuracy than clinical evaluation. Objective: Compare the diagnostic accuracy of the endoscopist&rsquo, s judgment against different risk-scoring systems (Rockall, Glasgow&ndash, Blatchford, Baylor and the Cedars&ndash, Sinai scores) for predicting outcomes in peptic ulcer bleeding (PUB). Methods: Between February 2006 and April 2010 we prospectively recruited 401 patients with peptic ulcer bleeding, 225 received endoscopic treatment. The endoscopist recorded his/her subjective assessment (&ldquo, endoscopist judgment&rdquo, ) of the risk of rebleeding and death immediately after endoscopy for each patient. Independent evaluators calculated the different scores. Area under the receiver-operating-characteristics (ROC) curve, sensitivity, specificity, positive and negative predictive values were calculated for rebleeding and mortality. Results: The areas under ROC curve of the endoscopist&rsquo, s clinical judgment for rebleeding (0.67&ndash, 0.75) and mortality (0.84&ndash, 0.9) were similar or even superior to the different risk scores in both the whole group and in patients receiving endoscopic therapy. Conclusions: The accuracy of the currently available risk scores for predicting rebleeding and mortality in PUB patients was moderate and not superior to the endoscopist&rsquo, s judgment. More precise prognostic scales are needed.

The presence of cirrhosis increases the mortality of patients with peptic ulcer bleeding (PUB). Both acute variceal bleeding (AVB) and PUB are associated with substantial mortality in cirrhosis. This multicenter cohort study was performed to assess whether the mortality of patients with cirrhosis with PUB is different from that of those with AVB. Patients with cirrhosis and acute gastrointestinal bleeding were consecutively included and treated with somatostatin and proton pump inhibitor infusion from admission and with antibiotic prophylaxis. Emergency endoscopy with endoscopic therapy was performed within the first 6 hours. 646 patients with AVB and 144 with PUB were included. There were baseline differences between groups, such as use of gastroerosive drugs or β-blockers. Child-Pugh and Model for End-Stage Liver Disease MELD scores were similar. Further bleeding was more frequent in the AVB group than those in the PUB group (18% vs. 10%; odds ratio [OR] = 0.50; 95% confidence interval [CI] = 0.29-0.88). However, mortality risk at 45 days was similar in both groups (19% in the AVB group vs. 17% in the PUB group; OR = 0.85; 95% CI = 0.55-1.33; P = 0.48). Different parameters, such as Child-Pugh score, acute kidney injury, acute on chronic liver failure, or presence of shock or bacterial infection, but not the cause of bleeding, were related to the risk of death. Only 2% of the PUB group versus 3% of the AVB group died with uncontrolled bleeding (P = 0.39), whereas the majority of patients in either group died from liver failure or attributed to other comorbidities. Conclusion Using current first-line therapy, patients with cirrhosis and acute peptic ulcer bleeding have a similar survival than those with variceal bleeding. The risk of further bleeding is higher in patients with variceal hemorrhage. However, few patients in both groups died from uncontrolled bleeding, rather the cause of death was usually related to liver failure or comorbidities. (Hepatology 2018;67:1458-1471).

High dose of somatostatin infusion achieves a greater reduction of hepatic venous pressure gradient (HVPG) than the usual dose, and terlipressin decreases HVPG through mechanisms other than somatostatin. Our aim was to assess the hemodynamic effects of terlipressin and high somatostatin dose during acute variceal bleeding in nonresponders to the usual somatostatin dose.Hemodynamic studies were performed in 80 patients with cirrhosis and variceal bleeding during the first 3 days of admission. After baseline measurements, somatostatin was administered (250 microg/h with an initial bolus of 250 microg). Patients were considered responders when the HVPG decreased by10% from baseline (n = 31). Nonresponders were randomized under double-blind conditions to a control group (n = 7), or to receive terlipressin (2 mg IV bolus, n = 22), or high dose of somatostatin (500 microg/h, n = 20). Final measurements were obtained 30 min later.Terlipressin caused a decrease in HVPG (from 22.2 +/- 5 to 19.1 +/- 5.2, p0.01) and heart rate (p0.01), while mean arterial pressure increased (p0.01). High somatostatin dose also reduced HVPG (from 21.8 +/- 3.4 to 19.6 +/- 3.1, p0.01), although this decrease was more pronounced with terlipressin (15%+/- 9%vs 10%+/- 6% from baseline, p= 0.05). Both terlipressin and high somatostatin dose achieved a significantly higher rate of response than that in the control group. A decrease in HVPG20% was observed in 36% of cases with terlipressin versus 5% with high somatostatin dose (p= 0.02).In nonresponders to usual somatostatin dose, both terlipressin and high-dose of somatostatin infusion significantly decreased HVPG and increased the rate of hemodynamic responders. Such effects were greater with terlipressin. Both treatments may be an alternative when standard somatostatin fails.

Paracentesis-induced circulatory dysfunction (PICD) is a recently described complication that can be prevented with the administration of plasma expanders. The aim of this study was to compare the efficacy of saline versus albumin in the prevention of PICD. Patients were randomized to receive albumin or saline after total paracentesis. Patients readmitted as a consequence of a second episode of tense ascites were treated with total paracentesis and the alternative plasma expander. After randomization, 35 patients received saline and 37 received albumin. Twenty-one patients were readmitted for tense ascites and treated with the alternative expander. Significant increases in plasma renin activity (PRA) were found 24 hours and 6 days after paracentesis when saline was used (baseline, 5.6 +/- 5.7; 24 hours, 7.6 +/- 6.9; 6 days, 8.5 +/- 8.0 ng x mL(-1). hr(-1); P

Portal hypertensive gastropathy (PHG) is a rare but relevant cause of gastrointestinal bleeding for which few options of medical therapy are available. Argon plasma coagulation (APC) is an endoscopic method of non-contact electrocoagulation which can be delivered by tangential application and has only limited deep of penetration. Subsequently, APC appeal for treating widespread vascular disorders such as PHG. The aim of this study was to assess the efficacy of APC for the treatment of chronic bleeding from PHG which did not respond to the pharmacological therapy of portal hypertension. METHODS: 9 patients with cirrhosis (Pugh class A/B in 3/6 and posthepatitic etiology in 6) were included. All had PHG with recurrent bleeding despite iron therapy plus isosorbide mononitrate alone (in 4 cases with intolerance to β-blockers) or combined with nadolol (3 cases) while 2 patients had no previous treatment. APC was delivered by multiple and brief pulses applied over wide areas of visible angioectasias. Sessions were performed every 2 to 3 weeks. PHG was diffuse in 4 cases and mainly antral in 5. RESULTS: a median of 6 sessions of APC were performed (range 4 to 12) during a mean period of 6±4 months. The mean follow-up was of 28±12 months. Hemoglobin value significantly improved after APC (from 76±13 to 106±19 G/L, P= 0.006) although iron therapy could be discontinued only in 1 case. Transfusional requirements decreased from a median of 4 (range 2 to 13) Units of Red Cells in the 12 months before APC to 0 (0 to 4) during the 12 months after starting APC (P=0.001). The endoscopic severity of PHG (graded from 1 for mild, to 3 for severe) also improved (from 2.9±0.3 to 2±0.5, P=0.002). There were no serious complications due to APC (3 patients complained of transient pain). Only 1 patient died 18 months after APC due to liver failure. CONCLUSIONS: endoscopic therapy with APC is a safe and effective treatment for PHG which do not respond to the pharmacological therapy of portal hypertension. In these patients APC should be considered before more aggressive approaches