ABSTRACT
Background: Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency and carries a high morbidity and mortality. There are multiple risk factors for poorer outcomes, including malnutrition. Ascorbic acid is a water-soluble vitamin present in most plant foods. Dietary deficiency leads to scurvy, which may alter the natural history of UGIB through impaired tissue and mucosal integrity. Traditionally thought to be rare in developed countries, Vitamin C deficiency (VCD) is now well described in patients with pneumonia, sepsis and COVID-191, 2. There is a paucity of literature investigating the prevalence and clinical significance of VCD in UGIB;interim findings reported by our group suggested a prevalence of >30%. Aim: The aim of this study was to establish the prevalence of VCD in patients presenting with UGIB and its association with clinical outcomes. Methods: We conducted a prospective cohort study of adult patients presenting with UGIB to two metropolitan tertiary hospitals in Melbourne, Australia over a 12-month period (March 2020 to March 2021). Fasting Vitamin C levels were obtained on admission. Patients were risk stratified using the AIMS65 score and baseline demographic data and outcomes were recorded. The primary outcome was the prevalence of VCD (serum Vitamin C level <23mcmol/L) and severe VCD (<12mcmol/L). Secondary outcomes included a composite endpoint of adverse events (AE), comprising inpatient death, intensive care unit (ICU) admission, rebleeding, surgery, angioembolisation or massive transfusion (≥4 units of red cells). Multivariate logistic regression was used to determine the association between Vitamin C levels and the secondary endpoints. Subgroup analyses were performed in variceal and non-variceal UGIB and high- (AIMS65≥2) and low-risk (AIMS65 0-2) UGIB. Results: 227 patients were included. The mean age was 65±17 years, 145 (63.9%) were male and median AIMS65 score was 1 (IQR 1-2). The aetiology of UGIB was variceal bleeding in 20.3%, peptic ulcer disease (PUD) in 44.1% and other causes in 35.7%. The mean Vitamin C level was 40±26mcmol/L. In terms of patient outcomes, inpatient mortality was 4%, ICU admission occurred in 11.9% and mean length of stay (LOS) was 7.7±9.7 days. Red cell transfusion was required in 63.4% of patients with a mean requirement of 2.2±2.8 units. VCD was identified in 74 patients (32.6%) with severe deficiency in 32 (14.1%). VCD was associated with significantly higher in-hospital mortality (9.5% vs. 1.3%, p=0.01), prolonged LOS (10.8 vs. 6.2 days, p<0.01), rebleeding (17.6% vs. 7.88%, p=0.05) and a higher composite endpoint of AE (77% vs. 54.9%, p<0.01). At multivariate logistic regression, high-risk UGIB (OR 3.24, CI 1.42-7.42), VCD (OR 2.28, CI1.11-4.71) and chronic liver disease (OR 11.66, CI 2.92-46.64) were all independently associated with the composite endpoint of AE. At subgroup analysis, VCD was associated with a significantly increased composite endpoint of AE in patients with non-variceal (74% vs. 51%, p<0.01) and low-risk UGIB (66% vs. 44%, p=0.04). Conclusion: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding and LOS. Interventional studies are required to determine the impact of early Vitamin C supplementation on clinical outcomes.
ABSTRACT
BACKGROUND/OBJECTIVE: There is a paucity of data on the management of gastrointestinal (GI) bleeding in patients with Coronavirus disease -2019 (COVID-19) amid concerns about the risk of transmission during endoscopic procedures. We aimed to study the outcomes of conservative treatment for GI bleeding in patients with COVID-19. METHODS: In this retrospective analysis, 24 of 1342 (1.8%) patients with COVID-19, presenting with GI bleeding from 22nd April to 22nd July 2020, were included. RESULTS: The mean age of patients was 45.8 ± 12.7 years; 17 (70.8%) were males; upper GI (UGI) bleeding: lower GI (LGI) 23:1. Twenty-two (91.6%) patients had evidence of cirrhosis- 21 presented with UGI bleeding while one had bleeding from hemorrhoids. Two patients without cirrhosis were presumed to have non-variceal bleeding. The medical therapy for UGI bleeding included vasoconstrictors-somatostatin in 17 (73.9%) and terlipressin in 4 (17.4%) patients. All patients with UGI bleeding received proton pump inhibitors and antibiotics. Packed red blood cells (PRBCs), fresh frozen plasma (FFPs) and platelets were transfused in 14 (60.9%), 3 (13.0%) and 3 (13.0%), respectively. The median PRBCs transfused was 1 (0-3) unit(s). The initial control of UGI bleeding was achieved in all 23 patients and none required an emergency endoscopy. At 5-day follow-up, none rebled or died. Two patients later rebled, one had intermittent bleed due to gastric antral vascular ectasia, while another had rebleed 19 days after discharge. Three (12.5%) cirrhosis patients succumbed to acute hypoxemic respiratory failure during hospital stay. CONCLUSION: Conservative management strategies including pharmacotherapy, restrictive transfusion strategy, and close hemodynamic monitoring can successfully manage GI bleeding in COVID-19 patients and reduce need for urgent endoscopy. The decision for proceeding with endoscopy should be taken by a multidisciplinary team after consideration of the patient's condition, response to treatment, resources and the risks involved, on a case to case basis.