Hemorragia digestiva y enfermedad celíaca complicada en paciente anticoagulado / Gastrointestinal bleeding and complicated celiac disease in anticoagulated patient

Resumen La enfermedad celíaca tiene una considerable frecuencia en nuestro medio. La mayoría de los pacientes presenta mejoría clínica, serológica y endoscópica al poco tiempo de iniciada la dieta libre de gluten. Un muy bajo porcentaje puede presentar o desarrollar una "enfermedad celíaca complicada", entidad que comprende el esprue refractario, la yeyunitis ulcerativa y el linfoma intestinal, que conllevan pronósticos desfavorables, con requerimiento de tratamientos más radicales. Presentamos aquí el caso de un paciente de 77 años evaluado en nuestro centro, que ingresó para estudio de hemorragia digestiva aguda y se realizó finalmente diagnóstico de enfermedad celiaca complicada, requiriendo inicio de tratamiento con corticoides sistémicos y seguimiento estrecho ambulatorio.

Abstract Celiac disease is considerably frequent in our media. Gluten-free diet shows clinical, serological and endoscopic improvement in most patients shortly after its start. A few patients may present or develop a "complicated celiac disease", an entity that includes refractory sprue, ulcerative jejunitis and intestinal lymphoma, which carry unfavorable prognoses, requiring more radical treatments. We present here the case of a 77-year-old male patient evaluated in our center, who was admitted for study of acute gastrointestinal bleeding. Complicated celiac disease was diagnosed, systemic corticosteroids were started and a close follow-up was carried out.

Síndrome de Stevens-Johnson asociado al tratamiento con metotrexato de la leucemia linfoblástica aguda: a propósito de un caso / Stevens-Johnson Syndrome associated with methotrexate treatment for acute lymphoblastic leukemia: a case report

La necrólisis epidérmica tóxica y el síndrome de StevensJohnson son enfermedades mucocutáneas raras que están asociadas a una evolución prolongada y a un desenlace potencialmente mortal. Principalmente están inducidas por fármacos y las tasas de mortalidad son muy elevadas. Aunque la piel es la más comprometida, también pueden estar afectados múltiples aparatos o sistemas como el cardiovascular, pulmonar, gastrointestinal y urinario. En este artículo, describimos el caso de un paciente con síndrome de Stevens-Johnson asociado al tratamiento con metotrexato, quien desarrolló insuficiencia cardíaca aguda y hemorragia gastrointestinal además de las manifestaciones en la piel. El paciente recibió un tratamiento satisfactorio con metilprednisolona e inmunoglobulina por vía intravenosa y continuó la quimioterapia con metotrexato.

Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare mucocutaneous diseases which are associated with a prolonged course and potentially lethal outcome. They are mostly drug induced and mortality rates are very high. Although mostly skin is involved, multiple organ systems such as cardiovascular, pulmonary, gastrointestinal, and urinary systems may be affected. Here, we report a case of StevensJohnson Syndrome associated with methotrexate treatment who developed acute cardiac failure and gastrointestinal hemorrhage beside skin findings. He had been treated with intravenous immunglobulin and methylprednisolone succesfully and continued chemotherapy with methotrexate treatment again.

Evaluation of primary prophylaxis with propranolol and elastic band ligation in variceal bleeding in cirrhotic children and adolescents / Avaliação da profilaxia primária em crianças e adolescentes cirróticos com propranolol e ligadura elástica

ABSTRACT Background The efficacy of nonselective β-blocker and endoscopic procedures, such as endoscopic variceal ligation, as primary prophylaxis of variceal hemorrhage in cirrhotic adults was demonstrated by numerous controlled trials, but in pediatric population, few are the number of studies. Objective The objective of this study is to evaluate the primary prophylaxis with β-blocker in cirrhotic children and adolescents with portal hypertension. Methods This is a cohort study encompassing 26 cirrhotic patients. β-blocker prophylaxis was performed with propranolol. When contraindicated the use of β-blocker, or if side effects presents, the patients were referred to endoscopic therapy with band ligation. Patients were evaluated by endoscopy, and those who had varicose veins of medium and large caliber or reddish spots, regardless of the caliber of varices, received primary prophylaxis. Results Of the 26 patients evaluated, 9 (34.6%) had contraindications to the use of propranolol and were referred for endoscopic prophylaxis. Six (35.3%) of the 17 patients who received β-blocker (propranolol), had bled after a median follow-up time of 1.9 years. β-blockage dosage varied from 1 mg/kg/day to 3.1 mg/kg/day and seven (41.2%) patients had the propranolol suspended due to fail of the β-blockage or adverse effects, such as drowsiness, bronchospasm and hypotension. Patients who received endoscopic prophylaxis (elastic bandage) had no bleeding during the follow-up period. Conclusion All of the patients that had upper gastroinstestinal bleeding in this study were under propranolol prophylaxis. The use of propranolol showed a high number of contraindications and side effects, requiring referral to endoscopic prophylaxis. The endoscopic prophylaxis was effective in reducing episodes of bleeding.

RESUMO Contexto A eficácia dos beta-bloqueadores e de procedimentos endoscópicos como a ligadura elástica endoscópica para profilaxia primária de ruptura de varizes de esôfago em adultos cirróticos já foram demonstrados por inúmeros ensaios clínicos na população adulta, porém poucos são os estudos envolvendo a faixa etária pediátrica. Objetivo Avaliar a profilaxia primária com β-bloqueador em crianças e adolescentes cirróticos com hipertensão porta. Métodos Estudo de coorte envolvendo 26 pacientes cirróticos. O propranolol foi o β-bloqueador utilizado para a profilaxia. Quando contraindicado o uso de β-bloqueador, ou se efeitos colaterais presentes, os pacientes eram encaminhados para profilaxia endoscópica com ligadura elástica. Os pacientes foram avaliados por endoscopia, e naqueles que foram observadas varizes de médio e/ou grosso calibre ou presença de manchas avermelhadas nas varizes, independentemente do calibre das varizes, a profilaxia primária foi indicada. Resultados Dos 26 pacientes avaliados, 9 (34,6%) tinham contraindicações para o uso de propranolol e foram encaminhados para a profilaxia endoscópica. Seis (35,3%) dos 17 pacientes que receberam β-bloqueador (propranolol) apresentaram sangramento após mediana de tempo de acompanhamento de 1,9 anos. A dose de β-bloqueio variou de 1 mg/kg/dia a 3,1mg/kg/dia e em sete (41,2%) pacientes o propranolol foi suspenso por falha em atingir β-bloqueio ou presença de efeitos adversos, tais como sonolência, broncoespasmo e hipotensão. No grupo de pacientes que receberam a profilaxia endoscópica (ligadura elástica) não foi observado nenhum episódio de hemorragia digestiva alta durante o período de acompanhamento. Conclusão Todos os pacientes que apresentaram hemorragia digestiva alta no presente estudo estavam recebendo profilaxia com propranolol. Foi observado, ainda, elevado número de contraindicações e efeitos colaterais, com consequente encaminhamento para profilaxia endoscópica. A profilaxia endoscópica foi eficaz na redução de episódios de hemorragia digestiva alta.

Gastrointestinal Bleeding with Dabigatran, a Comparative Study with Warfarin: A Multicenter Experience / 대한소화기학회지

BACKGROUND/AIMS: The risk of gastrointestinal (GI) bleeding with dabigatran when compared to warfarin has been controversial in the literature. The aim of our study was to assess this risk with the use of dabigatran. METHODS: We examined the medical records of patients who were started on dabigatran or warfarin from October 2010 to October 2012. The study was conducted in two hospitals. RESULTS: A total of 417 patients were included (208 dabigatran vs. 209 warfarin). GI bleeding occurred in 10 patients (4.8%) in the dabigatran group compared to 21 patients (10.1%) in the warfarin group (p=0.0375). Multivariate analysis showed that patients who were on dabigatran for 100 days (p=0.0007). The odds of GI bleeding in patients who were on dabigatran for 100 days. The incidence of GI bleeding in patients >65 years old was higher than in those 65 years, and a history of previous GI bleeding.

Clinical Impact of Dual Antiplatelet Therapy on Peptic Ulcer Disease / 대한소화기학회지

BACKGROUND/AIMS: Increased incidence of coronary artery disease has led to the increased use of dual antiplatelet therapy composed of aspirin and clopidogrel. We investigated the incidence of gastrointestinal complications in patients who received single or dual antiplatelet therapy and analyzed their clinical characteristics in order to predict the prognostic factors. METHODS: Between January 2009 and December 2011, we retrospectively reviewed the medical records of patients who underwent coronary angiography at Chung-Ang University Hospital (Seoul, Korea). One hundred and ninety-four patients were classified into two groups: aspirin alone group and dual antiplatelet group. Clinical characteristics, past medical history, and presence of peptic ulcer were analyzed. RESULTS: During the follow-up period, 11 patients had duodenal ulcer; the event rate was 2.02% in the aspirin alone group and 9.47% in the dual antiplatelet group (hazard ratio [HR] 5.24, 95% CI 1.03-26.55, p<0.05). There was no significant difference in the rate of significant upper gastrointestinal bleeding: 0% vs. 4.2% (p=0.78). In patients who received proton pump inhibitor (PPI), 24 patients had gastric ulcer; the event rate was significantly different between the two groups: 4.87% vs. 22.98% (HR 3.40, 95% CI 1.02-11.27, p<0.05). CONCLUSIONS: Dual antiplatelet groups had a higher incidence of duodenal ulcers without significant bleeding compared with the aspirin alone group. In patients who received PPI, the dual antiplatelet therapy group had a higher incidence of gastric ulcers without significant bleeding compared with the aspirin alone group. Therefore, physicians must pay attention to high risk groups who receive dual antiplatelet therapy and aggressive diagnostic endoscopy should also be considered.

Antiagregantes y anticoagulantes: manejo en el contexto de hemorragia digestiva / Management of antiaggregants and anticoagulants in gastrointestinal bleeding

Currently the administration of antiplatelet and/or anticoagulant drugs for prophylaxis of thromboembolic events is frequent; thus increasing the risk of gastrointestinal bleeding. Approximately 10 percent of patients with gastrointestinal bleeding are on anticoagulation therapy. It is necessary to consider the indication for anticoagulation/antiplatelet therapy in patients with gastrointestinal bleeding, to decide on the importance of early reintroduction of such drugs, seeking a balance between the risk of recurrent bleeding and thromboembolic complications. Generally, in patients with gastrointestinal bleeding in anticoagulant therapy it is considered appropriate to make a quick correction of anticoagulation with intravenous vitamin K and fresh frozen plasma, prothrombin complex or recombinant factor VII, depending on the severity of the hemorrhage. The latter is considered only in life-threatening cases, where other methods have failed. The reduction of the internacional normalized ratio (INR) to 1.5 should be enough to control bleeding, and even with values < 2.5 there are no differences in bleeding control. Patients receiving aspirin should reintroduce it early. In patients with coronary stents placed uncoated < 1 month of the bleeding episode, or drug-eluting stents placed within < 1 year, no antiplatelet therapy should be withdrawn, and never without first consulting a cardiologist. Regardless of the value of INR, in most patients a lesion responsible for bleeding is identified at the time of endoscopy (often, this is a peptic lesion), therefore endoscopy should be performed even in patients with very high INR.

Actualmente, es frecuente la administración de fármacos antiagregantes y/o anticoagulantes para profilaxis de fenómenos tromboembólicos; con ello aumenta el riesgo de hemorragia digestiva. Aproximadamente 10 por ciento de los pacientes con hemorragia digestiva está en tratamiento anticoagulante. Es necesario considerar la indicación de la anticoagulación/ antiagregación en los pacientes con hemorragia digestiva, para poder decidir sobre la importancia de la reintroducción precoz de dichos fármacos, buscando un balance entre el riesgo de recidiva hemorrágica y de complicaciones tromboembólicas. En general, en los pacientes con hemorragia digestiva en terapia anticoagulante, se considera adecuado realizar una corrección rápida de la anticoagulación, con vitamina K endovenosa y plasma fresco congelado, complejo protrombínico, o factor VII recombinante, dependiendo de la gravedad de la hemorragia. El último se considerará sólo en casos de riesgo vital en que los otros métodos hayan fallado. La reducción del internacional normalized ratio (INR) hasta 1,5 debe ser suficiente para poder controlar la hemorragia, e incluso en valores < 2,5 no se observan diferencias en el control hemorrágico. Los pacientes que reciben aspirina deben reintroducirla precozmente; en pacientes con stents coronarios no recubiertos, colocados < 1 mes del episodio hemorrágico, o en stents liberadores de fármacos, colocados en un plazo de < 1 año, no debería retirarse la antiagregación, y en cualquier forma nunca sin antes consultar a un cardiólogo. Independientemente del valor de INR, en la mayoría de los pacientes se identifica en la endoscopia una lesión responsable del sangrado (con frecuencia se trata de una lesión péptica); por ello, no debe desestimarse la realización de una endoscopia incluso en pacientes con INR muy elevados.

Upper gastrointestinal bleeding: a Jamaican perspective / La hemorragia digestiva alta: una perspectiva Jamaicana

BACKGROUND: Upper gastrointestinal bleeding (UGIB) remains one of the most common clinical lifethreatening emergencies which is associated with a high morbidity, mortality and medical care costs. OBJECTIVES: This study reviews the clinical features, management and outcomes ofpatients with UGIB seen at the University Hospital of the West Indies (UHWI), Jamaica, between January 2006 and December 2008. METHODS: Patients with UGIB admitted to the medical wards of the UHWI, Jamaica, between January 2006 and December 2008 were reviewed. Consecutive patients admitted with a confirmed diagnosis of UGIB were selected for analysis. Data collected included age, gender, presenting complaints, risk factors, clinical features and management. Endoscopic findings, treatment and outcomes were also reviewed. RESULTS: There were 104 patients, with a mean age of 55 years, admitted with UGIB. There were significantly more men than women (73 vs 31). Retching and vomiting were the most common presenting complaints followed by melaena and haemetemesis. Non-steroidal anti-inflammatory drug use was present in 28% of patients. Overall, 80% of patients had upper GI endoscopy (EGD) and 40% were done within 24 hours of admission. The median time for performing EGD was 24 hours (mean 46 hours). The leading causes of UGIB were duodenal ulcer (28%), erosive gastritis (20%) and gastric ulcer (13%). Proton pump inhibitors (PPI) were given to 95 (91%) patients intravenously. Blood transfusion was given to 40% ofpatients. The mortality was 5.7%, rebleeding occured in 4.8% of patients and 5% underwent surgery. The average duration ofhospital stay was 6.6 days. CONCLUSION: Upper gastrointestinal bleeding was more common in men ofmiddle age in this study. Proton pump inhibitors were used in most patients. The overall mortality of5.7% is similar to other series. Early EGD and use ofendoscopic therapy may lead to a decrease in mortality in high risk patients.

ANTECEDENTES: La hemorragia digestiva alta (HDA), o sangrado gastrointestinal alto (SGA) sigue siendo una de las emergencias clínicas serias más comunes, constituye un riesgo para la vida, y se halla asociada con alta morbosidad y mortalidad, así como altos costos de cuidado médico. OBJETIVOS: Este estudio examina las características clínicas, el tratamiento, y los resultados de pacientes con HDA vistos en el Hospital Universitario de West Indies (UHWI), Jamaica, de enero de 2006 a diciembre de 2008. MÉTODOS: Los pacientes con HDA ingresados en las salas de UHWI, Jamaica, de enero de 2006 a diciembre de 2008fueron sometidos a examen. Pacientes consecutivos ingresados con un diagnóstico confirmado de HDA, fueron seleccionados para análisis. Los datos recopilados incluyeron edad, género, dolencias, factores de riesgo, rasgos clínicos y tratamiento. Se examinaron los hallazgos endoscópicos, el tratamiento y los resultados. RESULTADOS: Hubo 104 pacientes, con una edad promedio de 55 años, ingresados con HDA. Había significativamente más hombres que mujeres (73 contra 31). Arcadas y vómitos fueron las dolencias más comunes, seguidas por melena y hematemesis. El uso de medicamentos antiinflamatorios no esteroidales estuvo presente en 28% de los pacientes. En general, al 80% de los pacientes les fue practicada endoscopia GI alta (EGD), el 40% de las cuales fueron realizadas dentro de las 24 horas tras del ingreso. El tiempo promedio de la realización del EGD fue 24 horas (46 horas promedio). Las causas principales de HDA fueron la úlcera duodenal (28%), la gastritis erosiva (20%) y la úlcera gástrica (13%). A 95 (91%) pacientes se les administró inhibidores de la bomba de protón (IBP) de forma intravenosa. Al 40% de los pacientes se les hizo una transfusión de sangre. La mortalidad fue de 5.7%. Se produjo resangrado en 4.8% de los pacientes y al 5% se les practicó cirugía. La duración promedio de estadía hospitalaria fue de 6.6 días. CONCLUSIÓN: La hemorragia digestiva alta fue más común en los hombres de mediana edad en este estudio. Se usaron inhibidores de bomba de protón en la mayoría de los pacientes. La mortalidad general de 5.7% es similar a otras series. La EGD temprana y el uso de la terapia endoscópica pueden llevar a una disminución de la mortalidad entre los pacientes de alto riesgo.

Does Combination Therapy of Aspirin Plus Antiplatelet Therapy Increase the Risk of Upper Gastrointestinal Hemorrhage? / 대한소화기학회지

No abstract available.

The Effect of Aspirin Alone or Aspirin Plus Additional Antiplatelets Therapy on Upper Gastrointestinal Hemorrhage / 대한소화기학회지

BACKGROUND/AIMS: The increasing incidence of cardiovascular disease has led to an increase in the frequency of upper gastrointestinal (GI) hemorrhage due to the use of antiplatelet agents. This study examined the clinical characteristics of patients with upper GI hemorrhage who were administered aspirin alone or a combination treatment of antiplatelet agents. METHODS: A 656 patients who underwent drug-eluting coronary stenting at Ewha Mokdong Hospital in 2008 were divided into three groups according to the antiplatetlet agents used after the intervention; groups of aspirin alone, aspirin plus clopidogrel, and aspirin, and clopidogrel plus another antiplatelet agent, respectively. Patients admitted with GI hemorrhage in the same period without a medication history of antiplatelet or nonsteroidal anti-inflammatory drugs were used as the control hemorrhage group. The medical records were reviewed. RESULTS: Significant GI symptoms were observed in 21.1% of total patients, of whom 48.2% had ulcers. The upper GI hemorrhage rate was 3.8%. There was no significant difference in the hemorrhage rate between three groups. Compared to the control hemorrhage group, the endoscopic variables of the antiplatelet-related hemorrhage group were not significantly different. However, the Helicobacter pylori infection rate was lower, the admission period was longer, and the mortality rate was higher in the antiplatelet-related hemorrhage group (p<0.05, respectively). There was no direct association between restarting or discontinuance of antiplatelets after the hemorrhage event and mortality. CONCLUSIONS: Adding other antiplatelet agents to aspirin did not increase the hemorrhage rate. However, active diagnostic and therapeutic efforts are recommended in patients with GI symptoms during antiplatelet therapy.

Abdominal Compartment Syndrome Due to Spontaneous Retroperitoneal Hemorrhage in a Patient Undergoing Anticoagulation

Spontaneous retroperitoneal hemorrhage is one of the most serious and often lethal complications of anticoagulation therapy. The clinical symptoms vary from femoral neuropathy to abdominal compartment syndrome or fatal hypovolemic shock. Of these symptoms, abdominal compartment syndrome is the most serious of all, because it leads to anuria, worsening of renal failure, a decrease in cardiac output, respiratory failure, and intestinal ischemia. We report a case of a spontaneous retroperitoneal hemorrhage in a 48-year-old female who had been receiving warfarin and aspirin for her artificial aortic valve. She presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate. Computed tomography demonstrated a huge retroperitoneal hematoma and active bleeding from the right internal iliac artery. After achieving successful bleeding control with transcatheter arterial embolization, surgical decompression of the hematoma was performed for management of the femoral neuropathy and the abdominal compartment syndrome. She recovered without any complications. We suggest that initial hemostasis by transcatheter arterial embolization followed by surgical decompression of hematoma is a safe, effective treatment method for a spontaneous retroperitoneal hemorrhage complicated with intractable pain, femoral neuropathy, or abdominal compartment syndrome.

GastrointentinaI bleed with clopidogrel and aspirin.

Anti-platelet drugs have been used to prevent thrombosis of systemic to pulmonary artery shunts. Aspirin has traditionally been used. Clopidogrel is being studied as an alternative and in combination with aspirin for shunt patients. We report a near fatal gastro-intestinal bleed in a patient with shunt and on aspirin and clopidogrel. This combination has been known to produce similar bleeds. The authors recommend caution in combining them. Prospective studies currently underway should evaluate this aspect of the antiplatelet drugs.

Sangramento durante a anticoagulação oral: alerta sobre um mal maior / Sangrado durante la anticoagulación oral: alerta sobre un mal mayor / Bleeding during oral anticoagulant therapy: warning against a greater hazard

FUNDAMENTO: Sangramento é uma das grandes preocupações em pacientes sob anticoagulação oral. OBJETIVO: Investigar causas determinantes do sangramento em usuários de anticoagulante oral. MÉTODOS: Foram acompanhados prospectivamente, por 48 ± 7,2 meses, 360 pacientes com fibrilação atrial (FA), todos em uso de anticoagulante oral (ACo) com INR-alvo de 2,0-3,5, avaliados em média a cada 30 dias. Os pacientes foram investigados quanto à presença de patologia associada que levasse a sangramento. RESULTADOS: Participaram deste estudo 338 pacientes. Desses, 210 (62,13 por cento) eram do sexo feminino. A estenose mitral estava presente em 218 pacientes (64,4 por cento), a prótese biológica mitral em 64 (18,9 por cento) e a insuficiência da valva mitral em 56 (16,5 por cento). O sangramento ocorreu em 65 pacientes (19,2 por cento) e de forma grave em 7 (10 por cento). Em 38/65 pacientes (58,5 por cento), identificou-se nova doença associada, facilitadora do sangramento. Em 100 por cento dos pacientes com sangramento na faixa terapêutica, foi encontrada doença associada, contra 49,05 por cento de diagnóstico de doenças associadas naqueles com INR > 3,5 (p = 0,001). CONCLUSÃO: O diagnóstico de doença local associada ao sangramento foi frequente entre os medicados com anticoagulante oral (58,5 por cento). Houve associação entre sangramento com INR na faixa terapêutica (INR 2,0-3,5) e diagnóstico de patologia predisponente a sangramento (p < 0,001). Em pacientes em uso de anticoagulante oral que apresentam sangramento, é mandatória a investigação da causa, sobretudo se a INR estiver na faixa terapêutica.

BACKGROUND: Bleeding is one of the main concerns in patients undergoing oral anticoagulation therapy. OBJECTIVE: To investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy. METHODS: A total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 ± 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding. RESULTS: A total of 338 patients participated in the present study. Of these, 210 (62.13 percent) were females. Mitral stenosis was present in 218 patients (64.4 percent), a mitral biological prosthesis in 64 (18.9 percent) and mitral valve failure in 56 (16.5 percent) patients. Bleeding occurred in 65 patients (19.2 percent), being severe in 7 (10 percent) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100 percent of the patients with bleeding within the therapeutic range, against 49.05 percent of associated disease diagnosis in those with an INR > 3.5 (p=0.001). CONCLUSION: The diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5 percent). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.

FUNDAMENTO: El sangrado es una de las grandes preocupaciones en pacientes bajo anticoagulación oral. OBJETIVO: Investigar causas determinantes del sangrado en usuarios de anticoagulante oral. MÉTODOS: Se realizó el seguimiento, prospectivamente, por 48 ± 7,2 meses, de 360 pacientes con fibrilación atrial (FA), todos en uso de anticoagulante oral (ACo) con INR-objetivo de 2,0-3,5, evaluados en promedio cada 30 días. Los pacientes se investigaron sobre la presencia de patología asociada que llevara al sangrado. RESULTADOS: Participaron en este estudio 338 pacientes. De ellos, 210 (62,13 por ciento) eran del sexo femenino. La estenosis mitral estaba presente en 218 pacientes (64,4 por ciento), la prótesis biológica mitral en 64 (18,9 por ciento) y la insuficiencia de la válvula mitral en 56 (16,5 por ciento). El sangrado ocurrió en 65 pacientes (19,2 por ciento) y de forma grave en 7 (10 por ciento). En 38/65 pacientes (58,5 por ciento), se identificó nueva enfermedad asociada, facilitadora del sangrado. En el 100 por ciento de los pacientes con sangrado en el intervalo terapéutico, se encontró enfermedad asociada, contra el 49,05 por ciento de diagnóstico de enfermedades asociadas en aquellos con INR > 3,5 (p = 0,001). CONCLUSIÓN: El diagnóstico de enfermedad local asociada al sangrado fue frecuente entre los medicados con anticoagulante oral (58,5 por ciento). Hubo asociación entre sangrado con INR en el intervalo terapéutico (INR 2,0-3,5) y diagnóstico de patología predisponente a sangrado (p < 0,001). En pacientes en uso de anticoagulante oral que presentan sangrado, es indispensable la investigación de la causa, sobre todo si la INR está en el intervalo terapéutico.

Anticoagulant-induced intramural intestinal hematoma: report of three cases and literature review.

Spontaneous intestinal hematoma is a rare complication of anticoagulant therapy. The authors reported three cases of intramural and submucosal small bowel hematoma resulting from warfarin administration. The first patient presented with abdominal pain, had intramural hematoma at jejunum, the most common site of intramural small bowel hematoma. Another patient who had submucosal duodenal hematoma presented with massive upper gastrointestinal bleeding, a rare manifestation of small bowel hematoma. The third patient presented with intramural ileal hematoma that caused abdominal pain and palpable mass after a short period of warfarin therapy. Typical findings on abdominal computerized tomography yielded the diagnosis. All patients rapidly improved after conservative treatment. The history of anticoagulant use with prolonged INR value in patients presented with abdominal pain should alert physicians to search for this entity. It is extremely important to recognize this syndrome in order to avoid an unnecessary operation since the outcome is usually excellent after conservative treatment.

Prediction of UGIB event in NSAID users: a model development.

The purpose of this study was to create a predicting tool for UGIB event in NSAID users. The patients of this case-control study were NSAID users who had received NSAIDs for at least 3 days and were gastroscoped The patients with a history of gastrointestinal varices, gastrointestinal cancer, chronic renal failure, coagulopathy, or Mallory-Weiss tear were excluded. The data was collected between July 2001 and January 2002 by patient interviewing and medical record reviewing. One hundred and fifty four NSAID users were identified (89 in the UGIB group, 65 in the non-bleeding group). Most patients were elderly (mean age +/- SD: 60.9 +/- 12.6 years). Age and the number of current NSAID users were significantly higher in UGIB patients than in non-bleeding patients (p < 0.05 and p < 0.01, respectively). The number of antiulceration drug users in non-bleeding patients was higher than in UGIB patients (p < 0. 01). An equation for prediction of UGIB probability in NSAID users was generated by using enter logistic regression. The best model of predicting the risk of UGIB event in NSAID users was logit (UGIB) = 0.33 + 2.09 Multiple NSAID use + 1.43 H. pylori infection + 0.34 Current NSAID use + 0.12 (Age x Sex) - 8.53 Sex - 2.41 Antiulceration drugs - 0. 000048 Age. The model had 80.2% of the overall rate of correct classification. The positive and negative predictive values were 80.8% and 78.9% respectively. The probability of UGIB = e((logit(UGIB)) /1 + e(logit(UGlB)). If the value of the probability of UGIB is more than 0. 5, the patient has a high risk of UGIB. Multiple NSAID use is the strongest factor that affects the probability of UGIB in NSAID users. H. pylori infection is another strong risk factor of NSAID-related UGIB. Antiulceration drug usage reduced the risk of UGIB in this group of patients. The developed model can be used as a guide for pharmacotherapeutic planning in clinical practices.