Factores asociados a la mortalidad por sangrado digestivo alto variceal / Factors associated with mortality from variceal upper gastrointestinal bleeding

Introducción: Las hemorragias digestivas altas por várices esofagogástricas constituyen un problema clínico-quirúrgico y aún mantienen una mortalidad excesivamente alta. Objetivo: Estimar la carga de mortalidad y sus causas relacionadas con la enfermedad, así como los factores asociados según variables seleccionadas. Material y Métodos: Estudio observacional, descriptivo y transversal de 39 pacientes ingresados con este diagnóstico en el servicio de Cirugía General del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba durante el cuatrienio 2013-2016. Resultados: Predominaron los pacientes masculinos, en las edades medias de la vida y con varios factores de riesgo asociados. La Clase B de Child-Pugh, así como las Clases de sangrado II y III fueron las más frecuentes. El diagnóstico fue eminentemente clínico. El tratamiento endoscópico se realizó en tres pacientes y la aplicación de la sonda de Sengstaken-Blakemore resultó infrecuente. Se operaron 7 enfermos, que representan 43,7 por ciento de los que fallecieron. La tasa de mortalidad osciló entre 22,2 por ciento en 2013 hasta 41,0 por ciento en 2016. Conclusiones: La persistencia del sangrado digestivo alto variceal obedece a la pobre utilización del tratamiento endoscópico y al no uso de los derivados de la somatostatina, asociado a niveles de mortalidad elevados y en íntima relación con un grado de insuficiencia hepática avanzada y las intervenciones urgentes; hubo correspondencia entre las causas directas de muerte y la enfermedad en análisis(AU)

Introduction: Variceal upper gastrointestinal bleeding constitutes a clinical surgical problem that still has an excessively high mortality. Objective: To estimate the burden of mortality and its causes related to the disease, as well as the associated factors according to selected variables. Material and Methods: An observational, descriptive, and cross-sectional study was conducted in 39 patients who were admitted with this diagnosis to the General Surgery Service of the Saturnino Lora Teaching Provincial Hospital of Santiago de Cuba during 2013-2016. Results: Middle-aged male patients with several associated risk factors predominated in the study. Child-Pugh Class B and Classes II and III bleedings were the most frequent ones. The diagnosis was eminently clinical. Endoscopic treatment was carried out in three patients and the application of the Sengstaken-Blakemore tube was infrequent. 7 patients received surgical treatment, who account for the 43,8 percent of those who died. Mortality rate ranged from 22,2 percent in 2013 to 41,0 percent in 2016. Conclusions: The persistence of variceal upper gastrointestinal bleeding responds to the poor use of endoscopic treatment and the non-use of somatostatin derivates. It is also associated with high levels of mortality, and in close relationship with a grade of advanced hepatic failure and urgent interventions. There was a correspondence between the direct causes of death and the disease under analysis(AU)

Razão da contagem de plaquetas ao quadrado/diâmetro do baço-aspartato aminotransferase: avaliação de um novo método não-invasivo para a predição de varizes esofágicas / Platelet count squared/spleen diameter-aspartate aminotransferase ratio: non-invasive method to predict esophageal varices

ABSTRACT BACKGROUND - Variceal bleeding has a high mortality among cirrhotics, and screening with endoscopy is indicated at the diagnosis of cirrhosis. Screening with endoscopy implies discomfort, risks and considerable costs. OBJECTIVE - To evaluate platelet count squared/spleen diameter-aspartate aminotransferase ratio (PS/SA), as a non-invasive predictor of esophageal varices in cirrhotics. METHODS - This cross-sectional study evaluated cirrhotics for PS/SA and presence of esophageal varices. Outpatient records of cirrhotic patients were reviewed for the abovementioned data. Sensitivity, specificity, negative and positive predictive values of PS/SA were calculated. After the univariate analysis, variables with P<0.10 were submitted to a logistic regression. RESULTS - The study included 164 cirrhotics, 59.70% male, with a mean age of 56.7 years. Hepatitis C was the most frequent cause of cirrhosis, being present in 90 patients. Patients were classified as Child-Pugh A in 52.44% and as Child-Pugh B or C in 47.56%. Esophageal varices were present in 72.56% of the patients at endoscopy. PS/SA, with a cutoff of 3x108, had a sensitivity of 95.80% (confidence interval of 95% - 95%CI=0.92-0.99), a specificity of 22.70% (95%CI=0.10-0.35), a positive predictive value of 77.20% (95%CI=0.70-0.84) and a negative predictive value of 66.70% (95%CI=0.42-0.91). In the logistic regression, only platelet count and Child-Pugh score were associated to esophageal varices (P<0.05). CONCLUSION - PS/SA has an excellent sensitivity to predict esophageal varices, allowing almost one fourth of patients without esophageal varices to spare endoscopy. Nevertheless, PS/SA is not independently associated to esophageal varices.

RESUMO CONTEXTO - A hemorragia varicosa tem elevada mortalidade entre cirróticos, e o rastreamento endoscópico de varizes está indicado no momento do diagnóstico da cirrose. O rastreamento endoscópico implica desconforto, riscos e custos consideráveis. OBJETIVO - Avaliar a razão da contagem de plaquetas ao quadrado/diâmetro do baço-aspartato aminotransferase (PQ/BA) como preditor não-invasivo de varizes esofágicas em cirróticos. MÉTODOS - Este estudo transversal avaliou cirróticos quanto ao PQ/BA e à presença de varizes esofágicas. Prontuários ambulatoriais de cirróticos foram revisados quanto a tais dados. Sensibilidade, especificidade e valores preditivos negativo e positivo do PQ/BA foram calculados. Após a análise univariada, variáveis com P<0,10 foram submetidas à regressão logística. RESULTADOS - O estudo incluiu 164 cirróticos, 59,70% masculinos, com média de idade de 56,7 anos. Hepatite C foi a mais frequente causa de cirrose, estando presente em 90 pacientes. Os pacientes foram classificados como Child-Pugh A em 52,44% e em Child-Pugh B ou C em 47,56%. As varizes esofágicas estiveram presentes à endoscopia em 72,56% dos pacientes. PQ/BA, com um ponto de corte de 3x108, teve sensibilidade de 95,80% (intervalo de confiança de 95% - IC95%=0,92-0,99), especificidade de 22,70% (IC95%=0,10-0,35), valor preditivo positivo de 77,20% (IC95%=0,70-0,84) e valor preditivo negativo de 66,70% (IC95%=0,42-0,91). Na regressão logística, apenas a contagem de plaquetas e o escore de Child-Pugh associaram-se às varizes esofágicas (P<0,05). CONCLUSÃO - PQ/BA apresentou excelente sensibilidade para predizer varizes esofágicas, permitido que cerca de um quarto dos pacientes sem varizes esofágicas evitasse a endoscopia. Entretanto, PQ/BA não se associou de maneira independente às varizes esofágicas.

Bleeding complications in critically ill patients with liver cirrhosis

BACKGROUND/AIMS: Patients with liver cirrhosis (LC) are at risk for critical events leading to Intensive Care Unit (ICU) admission. Coagulopathy in cirrhotic patients is complex and can lead to bleeding as well as thrombosis. The aim of this study was to investigate bleeding complications in critically ill patients with LC admitted to a medical ICU (MICU). METHODS: All adult patients admitted to our MICU with a diagnosis of LC from January 2006 to December 2012 were retrospectively assessed. Patients with major bleeding at the time of MICU admission were excluded from the analysis. RESULTS: A total of 205 patients were included in the analysis. The median patient age was 62 years, and 69.3% of the patients were male. The most common reason for MICU admission was acute respiratory failure (45.4%), followed by sepsis (27.3%). Major bleeding occurred in 25 patients (12.2%). The gastrointestinal tract was the most common site of bleeding (64%), followed by the respiratory tract (20%). In a multivariate analysis, a low platelet count at MICU admission (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.97 to 0.99) and sepsis (OR, 8.35; 95% CI, 1.04 to 67.05) were independent risk factors for major bleeding. The ICU fatality rate was significantly greater among patients with major bleeding (84.0% vs. 58.9%, respectively; p = 0.015). CONCLUSIONS: Major bleeding occurred in 12.2% of critically ill cirrhotic patients admitted to the MICU. A low platelet count at MICU admission and sepsis were associated with an increased risk of major bleeding during the MICU stay. Further study is needed to better understand hemostasis in critically ill patients with LC.

Preditores não invasivos de varizes esofágicas em crianças e adolescentes com hepatopatia crônica ou obstrução extra-hepática da veia porta / Non-invasive predictors of esophageous varices in children and adolescents with chronic liver disease or extrahepatic portal venous obstruction

OBJETIVO: Identificar preditores não invasivos de varizes esofágicas em crianças e adolescentes com hepatopatia crônica ou obstrução extra-hepática da veia porta. PACIENTES E MÉTODOS: Estudo transversal que incluiu 53 crianças e adolescentes com hepatopatia crônica ou obstrução extra-hepática da veia porta, sem antecedente de hemorragia digestiva ou tratamento de varizes esofágicas, com até 20 anos de idade. Dois grupos foram formados: grupo I (35 pacientes com hepatopatia crônica) e grupo II (18 com obstrução extra-hepática da veia porta). Foram realizados hemograma, razão normalizada internacional, albumina, bilirrubina total, ultrassonografia de abdome e endoscopia digestiva alta. O índice esplênico foi determinado dividindo a dimensão esplênica pelo valor do limite superior da normalidade. As variáveis foram comparadas quanto à presença ou não de varizes esofágicas através de análise univariada (testes qui-quadrado, exato de Fischer e de Wilcoxon) e multivariada (regressão logística). A acurácia foi determinada a partir da área sob a curva ROC. RESULTADOS: As varizes esofágicas foram observadas em 48,5% dos pacientes do grupo I e em 83,3% do grupo II. Plaquetopenia (p = 0,0015), esplenomegalia (p = 0,0003) e a razão plaquetas/índice esplênico (p = 0,0007) se mostraram indicadores preditivos de varizes esofágicas entre os pacientes do grupo I. Após análise multivariada, a plaquetopenia (odds ratio = 21,7) se manteve como um indicador independente da presença de varizes esofágicas entre os pacientes com hepatopatia crônica. CONCLUSÃO: O número de plaquetas, o índice esplênico e a razão plaquetas/índice esplênico se mostraram preditivos de varizes esofágicas em crianças e adolescentes com hepatopatia crônica. Não foram encontrados preditores de varizes esofágicas entre os pacientes com obstrução extra-hepática da veia porta.

OBJECTIVE: To identify non-invasive predictors of esophageal varices in children and adolescents with chronic liver disease or extrahepatic portal venous obstruction (EHPVO). METHODS: 53 patients younger than 20 years with chronic liver disease or EHPVO and no history of bleeding or prophylactic treatment of esophageal varices (EV) were assessed. They were divided into 2 groups: group I (35 with chronic liver disease) and group II (18 with EHPVO). Their blood count, international normalized ratio (INR), albumin, bilirubin, abdominal ultrasonography and upper endoscopy results were taken. A splenic index was determined by dividing the patients' spleen dimension by its uppermost limit according to their age. The variables were compared to EV presence or not. Univariate (chi-square test, Fischer's exact test and Wilcoxon exact test) and multivariate (logistic regression) analyses were performed. A receiver operating characteristic (ROC) curve was constructed and the area under the ROC curve was calculated. RESULTS: EV were observed in 48.5% of group I patients and in 83.3% of group II patients. Low platelet count (p = 0.0015), splenomegaly (p = 0.0003) and splenic index (p = 0.0007) were statistically significant predictors of EV among group I patients. The multivariate analysis showed low platelet count (odds = 21.7) as an independent predictor of EV in patients with chronic liver disease. CONCLUSION: Platelet count, splenic index and platelet-splenic index ratio were predictors of EV in children and adolescents with chronic liver disease. There were no EV predictors among group II patients.

Ulcus péptico perforado: revisión de 102 casos en el Hospital Dr. "Domingo Luciani" / Perforated peptic ulcer: a review of 102 cases at the Hospital Dr. Domingo Luciani

Determinar los aspectos epidemiológicos y el tratamiento quirúrgico en los pacientes con ulcus péptico perforado atendidos en el Departamento de Cirugía General del Hospital Domingo Luciani. IVSS, Caracas. Estudio retrospectivo, transversal, descriptivo y observacional, realizado en el período correspondiente de julio de 1989 a julio de 2007, mediante la revisión de historias clínicas de pacientes intervenidos quirúrgicamente por ulcus péptico perforado. Un total de 102 pacientes fueron intervenidos por ulcus péptico perforado, en su mayoría hombres (90 por ciento), con edad promedio de 40 años. El principal síntoma fue el dolor. Los pacientes acudieron en las primeras 24 horas del inicio de los síntomas. Los antecedentes más importantes fueron el hábito tabáquico y alcohólico (62 por ciento y 56 por ciento). La localización más frecuente de la úlcera fue prepilórica (64 por ciento). La técnica de reparación quirúrgica más empleada fue la rafia de la úlcera más parche de epiplón (44 por ciento). La morbilidad fue de 27.5 por ciento y la mortalidad de 5 por ciento. El ulcus péptico perforado se presenta con mayor frecuencia en hombres fumadores. La raparación quirúrgica con rafia y parche de epiplón es segura.

Factors predicting in-hospital mortality in patients with cirrhosis hospitalized with gastro-esophageal variceal hemorrhage.

AIM : To identify factors at the time of admission that predict in-hospital mortality in patients with gastro-esophageal variceal hemorrhage. METHODS : Case records of patients admitted with gastro-esophageal variceal hemorrhage between January 1998 and October 2003 were retrospectively analyzed. Relevant clinical and laboratory parameters and their relationship to mortality, were studied. Clinical parameters assessed included Child-Pugh class, ascites, portosystemic encephalopathy (PSE) and occurrence of rebleed within 24 hours of esophago-gastroduodenoscopy. The laboratory parameters assessed were: hemoglobin, prothrombin time, serum bilirubin, creatinine and albumin. RESULTS : Of the 343 patients admitted during the study period, 30 (8.7%) died in hospital. Serum bilirubin (2.4 versus 1.6 mg/dL) and serum creatinine (2.1 vs 1.1 mg/dL) levels were higher among non-survivors than among survivors. Non-survivors were also more likely to suffer from PSE (53%) than survivors (17%), while re-bleeding within 24 hours of endoscopy occurred in 40% and 5% of these groups, respectively. On multivariate analysis, serum creatinine > 1.5 mg/dL at the time of admission (p < 0.001), serum bilirubin > 3 mg/dL (p < 0.001), presence of PSE (p = 0.003) and rebleed within 24 hours of endoscopy (p < 0.001) were significant predictors of mortality. CONCLUSION : Serum creatinine and bilirubin levels, presence of PSE and re-bleeding within 24 hours of initial endoscopy are independent predictors of mortality in patients with gastro-esophageal variceal bleeding.

Fibrinolytic Activities and Their Relations to Esophageal Variceal Bleeding in Patients with Liver Cirrhosis / 대한소화기학회지

BACKGROUND/AIMS: Esophageal variceal bleeding in liver cirrhosis is a major complication and has high mortality rate. We tried to find fibrinolytic parameters, which correlated with variceal bleeding in cirrhotic patients. METHODS: We divided the cirrhotic patients into two groups: bleeding group (group A, n=15) and non-bleeding group (Group B, n=17). Fibrinolytic parameters (fibrinogen, D-dimer, plasminogen, tissue plasminogen activator [t-PA], fibrin degradation product [FDP], and plasminogen activator inhibitor type-1 [PAI-1]) were compared between two groups. In the group A, serial samplings were taken at the initial period, 3 days, 8 days, 15 days and 6 weeks after the bleeding onset. RESULTS: Plasma levels of FDP and D-dimer in the group A were significantly higher than the group B (1.7 +/- 1.16 vs. 0.95 +/- 1.27 mg/L and 10.96 +/- 6.58 vs. 4.99 +/- 3.50 micro gram/mL, respectively, p value<0.05). The clinical, biochemical, and coagulation parameters didn't show significant differences in both groups. The fibrinolytic parameters were improved along with the hemodynamic stabilization in group A. CONCLUSIONS: Cirrhotic patients with increased fibrinolytic activity were at higher risk of bleeding. Thus, the measurement of these parameters would be useful to identify patients at higher risk of esophageal variceal bleeding.

Discriminatory value of blood urea:creatinine ratio in upper gastrointestinal bleeding with and without cirrhosis of liver.

AIM: To evaluate the discriminatory ability of blood urea:creatinine ratio in upper gastro-intestinal bleeding (UGIB) with and without cirrhosis of liver. METHODS: Blood urea:creatinine (BU/CR) ratio in 160 adult patients of UGIB were studied after excluding clinically overt cirrhosis of liver, renal failure and hematochezia. All were subjected to ultrasonography of abdomen. Only those showing cirrhosis and portal hypertension (n=76) were taken up for liver biopsy to confirm the diagnosis. BU/CR ratio was compared to UGIB cases without cirrhosis of liver (n=84). RESULTS: The mean (+/- SD) blood urea creatinine ratio was significantly lower in the group with cirrhosis than without cirrhosis of liver (22.49 +/- 6.13 vs. 38.07 +/- 8.08, Z value 13.91). CONCLUSION: In absence of renal failure, the blood urea/creatinine ratio may differentiate UGIB with associated cirrhosis of liver from those without. Being simple, cheap and readily available, it can be of some value in those patients with cirrhosis of liver clinically not associated with gross findings of cirrhosis. In our study it was also noted that, an arbitrary cut-off value of 30 showed considerable overlap between the two groups; hence this ratio may not always differentiate between the cirrhotics and non-cirrhotics. Therefore, reproducibility of these results needs further studies, taking into account other factors which can modify the BU level in our population.

Hemorragia digestiva superior por divertículos esofágicos: a propósito de un caso / Upper gastrointestinal bleeding by esophageal diverticulums: a purpose of a case

Se describe el caso de hemorragía digestiva superior por divertículos en el tercio medio del esófago en un paciente masculino con antecedentes de dispepsia de 8 años de evolución, tratado con analgésico no esteroideo por presentar patología urinaria, consulta por episodio de hematemesis y melena líquida cediendo con terapéutica endoscópica e insuflación de balón gástrico (sonda de Sengstaken-Blakemore). Podemos concluir que el manejo médico fue una alternativa de tratamiento en este paciente con inestabilidad hemodinámica y patología asociada que aumentaban la morbi-mortalidad

Ulcera de ciego como causa de hemorragia digestiva inferior en paciente con insuficiencia renal crónica: reporte de un caso: revisión de la literatura / Lower digestive bleeding due to cecum ulceration: report of a case: literature revision

Se presenta un caso de hemorragia digestiva inferior e inestabilidad hemodinámica en un paciente con insuficiencia renal crónica, en cuya colonoscópia se evidenció una úlcera en ciego, con signos de sangramiento reciente, (vaso visible). La literatura sobre úlceras en ciego del paciente con insuficiencia renal crónica es revisada

Detección de hemorragia gastrointestinal mediante gammagrafía: estudio de 21 pacientes en el servicio de Medicina Nuclear de Solca

La gammagrafía utilizando glóbulos rojos radiomarcados ha sido un método empleado con éxito en la identificación del sitio y la intensidad del sangramiento digestivo. En casos pediátricos con diagnostico presuntivo de mucosa gástrica ectópica (diverticulo de Meckel), como causa de sangramiento digestivo, el uso de la gammagrafía también ha rendido resultados importantes. En este trabajo se reporta el estudio de 21 pacientes (grupo 1: nueve años con diagnostico presuntivo de divertículo de Meckel; Grupo II: 12 adultos con sangramiento digestivo) mediante gammagrafía con glóbulos rojos radiomarcados o con 99 mTC-pertecnetato. En tres de los nueve niños estudiados el método gammagráfico identificó la mucosa gástrica ectópica. En los restantes seis casos el diagnostico final no pudo ser establecido por lo que la negatividad de la gammagrafía no pudo ser tomada como evidencia de falsos negativos. En nueve de los 12 casos adultos con sangramiento digestivo, la gammagrafía mediante glóbulos rojos marcados evidencio el sitio y la intensidad del sangramiento, cuatro de estos casos fueron sometidos a cirugía debido a su patología de base, y en todos ellos la gammagrafía fue decisiva para la orientación quirurgica. Se concluye que este método gammagráfico para la identificación del sitio e intensidad del sangramiento digestivo debería ser indicado tempranamente en casos adultos con pérdida digestiva de sangre, o en niños en los que se sospeche fundamentalmente divertículo de Meckel.

Decreased antithrombin III: is it a cause or a result of oesophageal varices bleeding in endemic hepatic schistosomiasis

Chronic liver disease is often associated with many hemostatic abnormalities including decreased level of antithrombin 3 [AT3]. However, the involvement of AT3, in esophageal varices bleeding has not been demonstrated before. The aim of this study is to demonstrate the hemostatic abnormalities especially the disturbance in AT3 level in patients with bleeding esophageal varices. Forty subjects were studied including 10 normal control cases, 15 cases with bleeding esophageal varices [group 1] and 15 cases with silent varices [group 2]. All cases were subjected to the following hemostatic tests: Prothrombin time [PT], partial thromboplastin time [PTT], antithrombin 3 level, fibrinogen [F] and fibrin degradation products [FDP]. All these tests were done to patients of group 1, the first during the bleeding episode [la] and the second after control of bleeding by two weeks [lb]. There was significant deterioration in all the hemostatic parameters studied in both groups 1 and 2 compared to control. Further significant impairment in some of these parameters namely PT, AT3, FDP and platelet count occurred in patients of group 1 during active bleeding [la] compared to silent varices patients [group 2]. Most of these test differences disappeared after control of bleeding by two weeks with the exception of AT3, which was still significantly lower in group 1b compared with group 2 [p <0.005]. It was concluded that AT3 might be of great value to predict hepatic patients prone to bleed through their esophageal varices. Further prospective studies are needed

Hemostatic profile in septicemic neonates with and without bleeding.

Hemostatic profile was studied in 25 full term, non-asphyxiated neonates with blood culture-proven septicemia. Nine (36%) of these neonates manifested bleeding. Detailed coagulation tests and platelet studies were deranged in 24 (96%) of neonates with septicemia. Abnormalities in coagulation tests did not differ in those with and without bleeding. Only platelet aggregation with ADP was deranged to a significantly greater extent in those with bleeding as compared with those without bleeding.

Coagulation studies in leptospirosis.

Coagulation and serum F.D.P. studies in 10 leptospirosis patients (5, L. bataviae, 2, L. autumnalis, 2, L. australis, and 1, L. akiyami A.)showed prolongation of prothrombin time, partial thromboplastin time and thrombin clotting time, slight low platelet count, depletion of factor V and slightly high serum F.D.P. in only four cases. Four cases had bleeding and one case died because of severe haemorrhage but with only slight changes in coagulation factors and slightly high serum F.D.P. These findings suggested that the damage of capillary endothelium was more pronounced than the coagulopathy which may be due to liver cell damage.