Efficacy and safety of 4 kinds of hemocoagulases combined with proton pump inhibitor for nonvariceal upper gastrointestinal bleeding：a network meta-analysis / 中国药房

OBJECTIVE To systematically evaluate the difference of efficacy and safety of four kinds of commonly used haemocoagulases combined with proton pump inhibitor （PPI） for nonvariceal upper gastrointestinal bleeding （NVUGIB）， and to provide evidence-based basis for clinical decision-making. METHODS Retrieved from PubMed， Web of Science， Wanfang data， VIP and CNKI databases， randomized controlled trials （RCTs） or cohort studies about Hemocoagulase agkistrodon blomhoffii， Haemocoagulase agkistrodon， hemocoagulase and Hemocoagulase bothrops atrox combined with PPI were collected during the inception to Dec. 2021. Two researchers independently screened the literature， extracted data and evaluated the quality of included studies. ADDIS 1.16.8 software was used to conduct a Bayesian network meta-analysis. RESULTS A total of 33 studies were included， involving 3 602 patients. Results of network meta-analysis showed that： in terms of hemostatic efficacy， compared with PPI monotherapy， four kinds of haemocoagulases combined with PPI could significantly improve the hemostatic efficacy of patients （P＜0.05）； there was no statistical significance in the pairwise comparison of different hemocoagulases （P＞0.05）. The optimal probabilistic ranking of network meta-analysis was as follows： Hemocoagulase agkistrodon blomhoffii combined with PPI＞ Hemocoagulase bothrops atrox combined with PPI＞Haemocoagulase agkistrodon combined with PPI＞hemocoagulase combined with PPI＞PPI alone. In terms of the incidence of adverse drug reactions （ADR）， compared with PPI monotherapy， there was no statistical difference in the incidence of ADR among four kinds of haemocoagulases combined with PPI （P＞0.05）. There was no statistical significance in the pairwise 88325750。E-mail：fengyufei@126.com comparison of different hemocoagulases （P＞0.05）. The optimal probabilistic ranking of network meta-analysis was as follows： hemocoagulase combined with PPI＞Hemocoagulase bothrops atrox combined with PPI＞Hemocoagulase agkistrodon blomhoffii combined with PPI＞Haemocoagulase agkistrodon combined with PPI＞PPI alone. CONCLUSIONS Compared with PPI monotherapy， four different sources of hemocoagulases combined with PPI have better efficacy and similar safety in the treatment of NVUGIB. There is no significant difference in efficacy and safety among different hemocoagulases.

Application of four scoring systems on evaluation of the prognosis of acute nonvariceal upper gastrointestinal bleeding / 中华消化内镜杂志

Objective To evaluate the predictive value of Admission-Rockall Score (aRS), Full-Rockall Score ( fRS ), Glasgow-Blatchford Score ( GBS ) and AIMS65 scoring systems for rebleeding, mortality, transfusion and clinical intervention of patients with acute nonvariceal upper gastrointestinal bleeding ( ANVUGIB). Methods A retrospective study was performed on the data of 294 ANVUGIB inpatients in the Department of Gastroenterology of Tianjin Medical University General Hospital from January 2015 to September 2016. Each patient was graded using the four scoring systems. The area under the receiver-operating characteristic curve ( AUC) about rebleeding, mortality, blood transfusion and clinical intervention was calculated using each system. Results For predicting rebleeding, fRS (AUC＝0. 696) and GBS (AUC＝0. 697) were both superior to aRS (AUC＝0. 609, P＜0. 05) and AIMS65 (AUC＝0. 571, P＜0. 05), and there was no significant difference on AUC between fRS and GBS (P＞0. 05). For predicting mortality, the AUC of aRS, fRS, GBS and AIMS65 were 0. 755, 0. 791, 0. 818, and 0. 780, respectively, and there were no significant differences (P＞0. 05). There were no significant differences in the predicting transfusion among four scoring systems, and the AUC was 0. 625, 0. 626, 0. 697 and 0. 658, respectively. Regarding clinical intervention treatment, fRS (AUC＝0. 661) was superior than that of aRS (AUC＝0. 520, P＜0. 05) and AIMS65 (AUC＝0. 545, P＜0. 05), and the AUC of GBS and three other scoring systems had no significant differences (P＞0. 05). Conclusion The four scoring systems are all with good predicting value on mortality of patients with ANVUGIB, while not on other aspects including rebleeding, transfusion and clinical intervention. fRS has a slightly better value on prediction of rebleeding and clinical intervention, and GBS is slightly better on prediction of rebleeding.

Lactate Parameters Predict Clinical Outcomes in Patients with Nonvariceal Upper Gastrointestinal Bleeding

The predictive role of lactate in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) has been suggested. This study evaluated several lactate parameters in terms of predicting outcomes of bleeding patients and sought to establish a new scoring model by combining lactate parameters and the AIMS65 score. A total of 114 patients with NVUGIB who underwent serum lactate level testing at least twice and endoscopic hemostasis within 24 hours after admission were retrospectively analyzed. The associations between five lactate parameters and clinical outcomes were evaluated and the predictive power of lactate parameter combined AIMS65s (L-AIMS65s) and AIMS56 scoring was compared. The most common cause of bleeding was gastric ulcer (48.2%). Lactate clearance rate (LCR) was associated with 30-day rebleeding (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.872–0.994; P = 0.033). Initial lactate (OR, 1.313; 95% CI, 1.050–1.643; P = 0.017), maximal lactate (OR, 1.277; 95% CI, 1.037–1.573; P = 0.021), and average lactate (OR, 1.535; 95% CI, 1.137–2.072; P = 0.005) levels were associated with 30-day mortality. Initial lactate (OR, 1.213; 95% CI, 1.027–1.432; P = 0.023), maximal lactate (OR, 1.271; 95% CI, 1.074–1.504; P = 0.005), and average lactate (OR, 1.501; 95% CI, 1.150–1.959; P = 0.003) levels were associated with admission over 7 days. Although L-AIMS65s showed the highest area under the curve for prediction of each outcome, differences between L-AIMS65s and AIMS65 did not reach statistical significance. In conclusion, lactate parameters have a prognostic role in patients with NVUGIB. However, they do not increase the predictive power of AIMS65 when combined.

Pharmacologic Management of Nonvariceal Upper Gastrointestinal Bleeding

Acute non-variceal upper gastrointestinal bleeding, the most common etiology of which is peptic ulcer disease, remains a persistent challenge despite a reduction in both its incidence and mortality. Both pharmacologic and endoscopic techniques have been developed to achieve hemostasis, with varying degrees of success. Among the pharmacologic therapies, proton pump inhibitor (PPI) remains the mainstay of treatment with potent acid suppression. Maintenance of the intragastric pH level above 6 by the administration of PPI prevents hemolysis caused by acid or pepsin and thereby promotes aggregation of platelets. Intragastric acid suppression can be achieved more effectively with continuous intravenous infusion of PPI after intravenous bolus injection. A high dose intravenous PPI is effective in reducing the risk of rebleeding, the need for surgery and repeated endoscopy. However, data regarding non-high dose intravenous PPIs are limited. In the future, novel PPIs and potassium-competitove acid blocker are in the area of interest. Combination therapy with the use of endoscopic hemostatic treatment and intravenous PPI administration is known to result in the best outcome for non-variceal upper gastrointestinal bleeding.

Comparison of AIMS65 Score and Other Scoring Systems for Predicting Clinical Outcomes in Koreans with Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND/AIMS: The AIMS65 score has not been sufficiently validated in Korea. The objective of this study was to compare the AIMS65 and other scoring systems for the prediction of various clinical outcomes in Korean patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB). METHODS: The AIMS65 score, clinical and full Rockall scores (cRS and fRS) and Glasgow-Blatchford (GBS) score were calculated in patients with NVUGIB in a single center retrospectively. The performance of these scores for predicting mortality, rebleeding, transfusion requirement, and endoscopic intervention was assessed by calculating the area under the receiver-operating characteristic curve. RESULTS: Of the 523 patients, 3.4% died within 30 days, 2.5% experienced rebleeding, 40.0% required endoscopic intervention, and 75.7% needed transfusion. The AIMS65 score was useful for predicting the 30-day mortality, the need for endoscopic intervention and for transfusion. The fRS was superior to the AIMS65, GBS, and cRS for predicting endoscopic intervention and the GBS was superior to the AIMS65, fRS, and cRS for predicting the transfusion requirement. CONCLUSIONS: The AIMS65 score was useful for predicting the 30-day mortality, transfusion requirement, and endoscopic intervention in Korean patients with acute NVUGIB. However, it was inferior to the GBS and fRS for predicting the transfusion requirement and endoscopic intervention, respectively.

Endoscopy for Nonvariceal Upper Gastrointestinal Bleeding

Endoscopy for acute nonvariceal upper gastrointestinal bleeding plays an important role in primary diagnosis and management, particularly with respect to identification of high-risk stigmata lesions and to providing endoscopic hemostasis to reduce the risk of rebleeding and mortality. Early endoscopy, defined as endoscopy within the first 24 hours after presentation, improves patient outcome and reduces the length of hospitalization when compared with delayed endoscopy. Various endoscopic hemostatic methods are available, including injection therapy, mechanical therapy, and thermal coagulation. Either single treatment with mechanical or thermal therapy or a treatment that combines more than one type of therapy are effective and safe for peptic ulcer bleeding. Newly developed methods, such as Hemospray powder and over-the-scope clips, may provide additional options. Appropriate decisions and specific treatment are needed depending upon the conditions.

The Clinical Features and Prognostic Factors of Nonvariceal Upper Gastrointestinal Bleeding in the Patients with Liver Cirrhosis

BACKGROUND/AIMS: Variceal rupture is the most common cause of upper gastrointestinal bleeding (UGIB) in cirrhotic patients and is well investigated. However, there are few documented studies on nonvariceal UGIB (NVUGIB) in these patients. This study was conducted to evaluate clinical features, in-hospital mortality rate and factors associated with mortality in cirrhotic patients with NVUGIB. MATERIALS AND METHODS: Among 399 cirrhotic patients who presented UGIB at Gyeongsang National University Hospital during 5 years since January 2007, patients with NVUGIB were selected by retrospective review of medical records. The patients' clinical and endoscopic findings, treatment outcomes, in-hospital mortality rates and its risk factors were investigated. RESULTS: NVUGIB was documented in 83 patients (20.8%). Mean age was 60.7+/-9.7 years, 85.5% was male. Child-Pugh class was A or B in 88%. Initial hemodynamic instability was reported in 25.3%, and 65.1% required blood transfusions. The major bleeding source was peptic ulcer 95.2% (79/83), and 44.6% (37/83) had endoscopic high risk bleeding stigmata and required endoscopic hemostasis. Rebleeding rate was 7.2% and in-hospital mortality rate was 8.4%. Hemodynamic instability (71.4% vs. 22.4%, P=0.013) and rebleeding (57.1% vs. 2.6%, P=0.000) were more frequent in the mortality group compared to the survival group. Hemodynamic instability was the risk factor for mortality at univariate and multivariate analyses. CONCLUSIONS: NVUGIB accounted for 20.8% of UGIB in liver cirrhosis and its development was not related to liver function. Peptic ulcer was the major cause and 45% required endoscopic hemostasis. It's in-hospital mortality rate was 8.4%, and hemodynamic instability was an independent risk factor of mortality in NVUGIB.

The Clinical Features and Prognostic Factors of Nonvariceal Upper Gastrointestinal Bleeding in the Patients with Liver Cirrhosis

BACKGROUND/AIMS: Variceal rupture is the most common cause of upper gastrointestinal bleeding (UGIB) in cirrhotic patients and is well investigated. However, there are few documented studies on nonvariceal UGIB (NVUGIB) in these patients. This study was conducted to evaluate clinical features, in-hospital mortality rate and factors associated with mortality in cirrhotic patients with NVUGIB. MATERIALS AND METHODS: Among 399 cirrhotic patients who presented UGIB at Gyeongsang National University Hospital during 5 years since January 2007, patients with NVUGIB were selected by retrospective review of medical records. The patients' clinical and endoscopic findings, treatment outcomes, in-hospital mortality rates and its risk factors were investigated. RESULTS: NVUGIB was documented in 83 patients (20.8%). Mean age was 60.7+/-9.7 years, 85.5% was male. Child-Pugh class was A or B in 88%. Initial hemodynamic instability was reported in 25.3%, and 65.1% required blood transfusions. The major bleeding source was peptic ulcer 95.2% (79/83), and 44.6% (37/83) had endoscopic high risk bleeding stigmata and required endoscopic hemostasis. Rebleeding rate was 7.2% and in-hospital mortality rate was 8.4%. Hemodynamic instability (71.4% vs. 22.4%, P=0.013) and rebleeding (57.1% vs. 2.6%, P=0.000) were more frequent in the mortality group compared to the survival group. Hemodynamic instability was the risk factor for mortality at univariate and multivariate analyses. CONCLUSIONS: NVUGIB accounted for 20.8% of UGIB in liver cirrhosis and its development was not related to liver function. Peptic ulcer was the major cause and 45% required endoscopic hemostasis. It's in-hospital mortality rate was 8.4%, and hemodynamic instability was an independent risk factor of mortality in NVUGIB.

Chronic Kidney Disease, Hemodynamic Instability, and Endoscopic High-Risk Appearance Are Associated with 30-Day Rebleeding in Patients with Non-Variceal Upper Gastrointestinal Bleeding

The results of studies that evaluated predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are inconsistent. The aim of this study was to investigate predictive factors for 30-day rebleeding in these patients. A consecutive 312 patients presenting symptoms and signs of gastrointestinal bleeding were enrolled in this prospective, observational study. Clinical and demographic characteristics and endoscopic findings were evaluated for potential factors associated with 30-day rebleeding using logistic regression analysis. Overall, 176 patients were included (male, 80.1%; mean age, 59.7+/-16.0 yr). Rebleeding within 7 and 30 days occurred in 21 (11.9%) and 27 (15.3%) patients, respectively. We found that chronic kidney disease (CKD) (OR, 10.29; 95% CI, 2.84-37.33; P100 beats/min) during the admission (OR, 3.79; 95% CI, 1.25-11.49; P=0.019), and Forrest classes I, IIa, and IIb (OR, 6.14; 95% CI, 1.36-27.66; P=0.018) were significant independent predictive factors for 30-day rebleeding. However, neither Rockall nor Blatchford scores showed statistically significant relationships with 30-day rebleeding in a multivariate analysis. CKD, hemodynamic instability during hospitalization, and an endoscopic high-risk appearance are significantly independent predictors of 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding. These factors may be useful for clinical management of such patients.

Clinical research of risk assessment of acute nonvariceal upper gastrointestinal bleeding / 中华消化杂志

Objective To investigate the accuracy of prognosis risk assessment and clinical applicability of Rockall (RS) and Blatchford scoring system (BRS) for acute nonvariceal upper gastrointestinal bleeding (ANVUGIB). Methods From January 2009 to December 2009, the clinical date 195 ANVUGIB patients who met the standards with complete information and treated in The First Affiliated Hospital of Anhui Medical University were recorded. Each patient's scores of RS and BRS were calculated for risk stratification. Patients were followed up for 30 days after discharged.Death or the prognosis of disease in 30 days after discharged was considered as clinical study endpoints.Checked prognostic capacity of these two scoring system. Results In the 195 patients, there were 150 years, mean age was 53.97±18.34 years. 90 patients' age was over sixty (elderly group), 105 less than sixty (non-elderly group). 182 patients survived (93.3%), while 13 dead (6.7%). In survival patients, 11were re-bleeding (5.6 %). Mortality ( 12.2 %, 11/90), the percentage of patients with comorbidities (43.3%, 39/90) and taking aspirin (24. 4%, 22/90) were higher in elderly patients than non-elderly patients (1.9%, 2/105; 16.2%, 17/105; 11.4%, 12/105 respectively)(P＜0.05).The AUC of RS in predicting risk of death was 0.742 (P=0.004) and re-bleeding was 0.469 (P=0.101). For BRS score system, the AUC of predicting risk of death was 0. 493 (P= 0. 067)and rebleeding was 0.341(P=0.092). The RS score was positively correlated with length of hospital stay,however there was no statistically significant between BRS score and length of hospital stay.Conclusion RS score system was good at predicting the risk of death, and the score was positively correlated with length of hospital stay. While it was poor in predicting the risk of re-bleeding. BRS performed poorly in predicting the risk of both death and re-bleeding, so it was not suitable for predicting the risk of hospitalized patients.