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Background: Gastrointestinal bleeding is one of the consequences of COVID-19, which is associated with increased hospitalization and patient mortality. This study was conducted to determine the prevalence of endoscopic findings and the outcome of gastrointestinal bleeding in patients with COVID-19 who were hospitalized from September to December 2019 in Al-Zahra Hospital, Isfahan. Method(s): In this cross-sectional study, out of 5800 patients who were admitted to Al-Zahra Hospital in Isfahan from September to December 2019 due to COVID-19 (according to the positive PCR test result), 87 patients who underwent endoscopy due to upper gastrointestinal bleeding by a skilled gastroenterologist, were selected and studied. Demographic characteristics, underlying diseases, use of anticoagulants, and laboratory findings were studied and evaluated and finally, the disease was evaluated and compared based on endoscopic findings. Result(s): Based on the results obtained from this research, the patients with endoscopic lesions had higher average age (P=0.041), lower blood oxygen saturation percentage (P=0.028), and higher bleeding intensity (P=0.018). The frequency of using anticoagulant drugs in the group whose endoscopy results were abnormal was higher but insignificant. Hemoglobin, platelet, lymphocyte, and CRP levels were higher in the group whose endoscopy was normal, and NLR, LDH, and D-dimer levels were higher in the group whose endoscopy was abnormal (P<0.050). Three people (11.55%) from the group with normal endoscopy and 18 people (29.5%) from the group with abnormal endoscopy died, but the frequency of death was not significantly different between the two groups (P=0.070). Conclusion(s): The findings of the present study showed that the COVID patients with upper gastrointestinal bleeding who had endoscopic lesions had significant differences in some characteristics such as age, bleeding intensity, and blood oxygen saturation percentage with patients with normal endoscopy. Also, the frequency of death in patients with endoscopic lesions was relatively higher. Therefore, COVID patients with gastrointestinal bleeding should undergo endoscopy as soon as possible and necessary measures should be taken to control and prevent gastrointestinal bleeding.Copyright © 2022 Tabesh et al. Tehran University of Medical Sciences. Published by Tehran University of Medical Sciences.
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Introduction: Due to the COVID-19 outbreak, many chronic patients and elective surgical procedures have been postponed to create spaces for the hospitalization of COVID-19 patients, raising issues related to this change. The objective of this study is to assess the effect of the COVID-19 pandemic on the demand for blood products transfusion. Materials ant methods: The study presents the results of a retrospective study of blood transfusions in COVID-19 patients admitted to the Constanta County Emergency Clinical Hospital. The period of study was January-December 2021. We compared the transfusion requirement for each type of blood component in COVID 19 patients versus patients with non-COVID pathology. Results and discussions: During 2021, we transfused 282 COVID-19 patients;150 patients had only Covid pneumonia (of which 19 patients with severe forms needed intensive care in ICU-Covid), and 132 patients had various co-morbidities. The maximum blood requests was registered in the period February - April 2021, with a peak of 63 patients in April 2021. The main co-morbidities in patients with Covid 19 were: severe anemia in patients with malignant hemopathies. Anemia at admission in patients with Covid pneumonia is reported in more than 40% of patients. Moderate anemia (Hb <11 g/dL) is considered as an independent risk factor for the severe course of COVID-19 infection and mortality in these patients. The transfusion requirement in these patients was greater than 1.43 RBC (units/patient), 0.81 Plasma units/patient, 0.40 Platelets concentrate units + single donor platelet concentrate units/patient, in accordance with the associated pathology. Conclusion(s): The most requested product was packed red blood cells, the correction of anaemia being an important factor in preventing the severe course of the disease. The platelet requirement was 0.15 units/patient, thrombocytopenia being present in patients with severe evolution of the infection (hospitalized in ICU-COVID). The most requested blood groups were O+ and A+. COVID-19 transfusion data will help plan and prepare for the use of blood resources during the pandemic.Copyright © 2022 Sevigean Ali et al., published by Sciendo.
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During the COVID-19 pandemic in 2020, most healthcare services, including inpatient and outpatient procedures, got delayed. We reviewed the effect of COVID-19 infection on the timing of esophagogastroduodenoscopy (EGD) in variceal bleeding patients and analyzed the complications of delayed EGD. Using the National Inpatient Sample (NIS) 2020, we identified patients admitted for variceal bleeding with COVID-19 infection. We performed a multivariable regression analysis and adjusted it for patient and hospital-related variables. The International Classification of Disease Tenth Revision (ICD-10) codes were used for patient selection. We measured the effect of COVID-19 on the timing of EGD and further analyzed the effect of delayed EGD on hospital-based outcomes. A total of 49,675 patients diagnosed with variceal upper gastrointestinal bleeding were analyzed, out of which 915 (1.84%) were COVID-19 positive. Variceal bleeding patients who were COVID-positive had a significantly lower rate of EGD performed within the first 24 h of admission (36.1% vs. 60.6% p = 0.001) compared to the patients who tested negative for COVID-19. The performance of EGD within 24 h of admission resulted in a decrease in all-cause mortality by 70% (adjusted odds ratio (AOR) 0.30, 95% CI 0.12-0.76, p = 0.01) compared to EGD after 24 h. A significant decrease was noted in the odds of ICU admission rate (AOR 0.37, 95% CI 0.14-0.97, p = 0.04) in patients who got EGD within the first 24 h of admission. No difference in odds of sepsis (AOR 0.44, 95% CI 0.15-1.30, p = 0.14) and vasopressor use (AOR 0.34, 95% CI 0.04-2.87, p = 0.32) was seen in COVID positive vs. COVID negative group. The hospital mean length of stay (2.14 days, 95% CI 4.35-0.06, p = 0.06), mean total charges ($51,936, 95% CI $106,688-$2816, p = 0.06), and total cost (11,489$, 95% CI 30,380$-7402$, p = 0.23) was similar in both COVID-positive and -negative groups. In our study, we found that the presence of COVID-19 infection in variceal bleeding patients resulted in a significant delay in EGD compared to COVID-negative patients. This delay in EGD resulted in increased all-cause mortality and intensive care unit admissions.
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Background and aim: In Veneto region, rates of hospitalization (2.4 per 10,000) and 30-day mortality (4.3%) for non-variceal upper gastrointestinal bleeding (NVUGIB) were stable during 2012-2019. The COVID-19 pandemic has caused a global health emergency and the aim of this study was to evaluate COVID-19 impact on hospitalizations and mortality for NVUGIB in Veneto region. Material(s) and Method(s): This is a retrospective study based on administrative databasescarried out to compare NVUGIB hospitalizations and 30-day mortality after hospital admission before (2018- 2019) and duringthe COVID-19 pandemic (2020-2021).The indicator proposed by the National Outcomes Evaluation Programme was adopted,includingall NVUGIB hospitalizations of patients over 18 years old, residing in Veneto, excluding conditions with indication of anticoagulant or antiplatelet therapy, trauma, cardiovascular surgeries, cancer, cirrhosis. The crude and standardized hospitalization rates (sHR,direct standardization method),and 30-day mortality were calculated. Chi-square, Mann Whitney test, ORand adjusted OR (aOR), estimated throughlogistic regression analysis were used to compare the two periods. Result(s): 3,436 eligible admissions for NVUGIB were identified, 1,872 before COVID-19and 1,564 during the pandemic: 815 in 2020 and 749 in 2021. The distribution by age and sex in the two periods was comparable: 42% females, above 60% patients aged >70 years;females were older (p<.0001) (median age: males 72 (IQR:57-81), females 81 (IQR:70-87)). sHR were significantly higher in the pre- COVID-19 period (2.34 per 10,000 population 95% CI 2.23-2.45 Vs. 1.90 95% CI 1.80-1.99) and comparable between 2020 and 2021 (1.99;95% CI:1.85-2.12Vs. 1.81;95% CI:1.68-1.94 p-value=0.0644). Rates increased with age and were higher for patients over 80. Rates were also higher among males for both periods and for all age groups. Crude 30-day mortality was significantly higher for females in both periods(F:M risk ratio: pre-COVID-19: 1.57 - p-value: 0.0355;during covid: 1.49 - p-value: 0.0316) and was higher during the pandemic both for males (3.75% vs 6.11%) and females (5.9%vs 9.12%) also after adjusting for age (aOR males: 1.71;95% CI:1.13-2.61;females: 1.56;95% CI:1.04-2.33). Conclusion(s): COVID-19 pandemic has caused a global reduction of access to care with an important decrease also of NVUGIB hospitalization rate (- 19%) and a concomitant rise of 30-day mortality (+58%).Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.
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Upper gastrointestinal bleeding (UGIB) represents a major emergency, and patient management requires endoscopic assessment to ensure appropriate treatment. The impact of COVID-19 on patient mortality in UGIB may be related to the combination of respiratory failure and severe bleeding and indirectly to delayed admissions or a reduction in endoscopic procedures. METHODS: We conducted a retrospective study involving patients admitted between March 2020 and December 2021 with UGIB and confirmed. Our objective was to compare these types of patients with those negative for SARS-CoV-2 infection, as well as with a pre-pandemic group of patients admitted between May 2018 and December 2019. RESULTS: Thirty-nine patients (4.7%) with UGIB had an active COVID-19 infection. A higher mortality rate (58.97%) and a high risk of death (OR 9.04, p < 0.0001) were noted in the COVID-19 pandemic, mostly because of respiratory failure; endoscopy was not performed in half of the cases. Admissions for UGIB have decreased by 23.7% during the pandemic. CONCLUSIONS: COVID-19 infection in patients admitted for UGIB was associated with a higher mortality rate because of respiratory failure and possible delays in or contraindications of treatment.
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Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06-1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08-0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93-0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89-0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762-10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.
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SARS-COV 2 recently caused a global pandemic, with the first case being reported in Romania in February 2020. Important restrictive measures were imposed, so that the addressability of patients to medical services decreased. Upper gastrointestinal bleeding had more severe forms of evolution at the time of presentation, which required additional methods of diagnosis and treatment. This is a retrospective study performed on 268 patients, which aims to evaluate the type and effectiveness of different treatment methods for upper gastrointestinal bleeding during the COVID 19 pandemic. Severity assessment was performed by measuring the Rockall score and additional methods of diagnosis. The association of COVID-19 with upper gastrointestinal bleeding can lead to much more severe outcomes for the patient, so treatment must be sustained and fast established. If the initial therapeutic methods fail, the other available therapeutic measures should be introduced progressively and without delay to achieve the best possible outcomes.
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Introduction: During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding. Patients and Methods: We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017-December 2021) including Covid-19 pandemic period (March 2020-December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection. Results: A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion. Conclusion: Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.
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Objective: In the period of the coronavirus disease-19 (COVID-19) pandemic, upper gastrointestinal endoscopy was either postponed or canceled, except for emergencies, due to the high risk of transmission. Our study aimed to evaluate the effect of the COVID-19 pandemic on patients with upper gastrointestinal bleeding presenting to the emergency department and to compare it with the data before the pandemic. Material(s) and Method(s): In this single-center, retrospective study, patients were divided into 2 groups: pre-COVID-19 (pre-C) (March 2019-March 2020) and post-COVID-19 (post-C) (March 2020-March 2021). Patients who presented to the emergency department with upper gastrointestinal bleeding during these periods and underwent endoscopic examination were included in the study. Result(s): Endoscopy for upper gastrointestinal bleeding was urgently performed in 125 patients in the pre-C period and in 89 (29% decrease) patients in the post-C period. The Glasgow-Blatchford Score was higher in the pre-C period (p=0.02). Peptic ulcers were the most common cause of bleeding in both groups. High-risk peptic ulcer (forrest 1a/1b/2a/2b), and malignancy were observed more frequently in the post-C period (p=0.003, p=0.04;respectively). Endoscopic combined treatment rate was higher in the post-C group (p<0.001). Re-bleeding ratios were similar for both the groups (p=0.48). Conclusion(s): During the post-C period, the number of upper gastrointestinal bleeding cases admitted to the emergency department decreased significantly. However, the rate of high-risk peptic ulcer and malignancy in the etiology of upper gastrointestinal bleeding increased in the post-C period. Copyright © 2022 by Turkiye Klinikleri.
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SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Dieulafoy lesions are abnormally dilated submucosal vessels remain uncommon cause of upper gastrointestinal bleeding, accounting for approximately 1.5% of all GI bleeds [1]. Although the exact etiology remains unknown, multiple co-morbid conditions have been attributed to this condition, including heart diseases, hypertension, chronic kidney disease, diabetes, or excessive alcohol use [2].In our case, it was identified as a cause of lower GI bleed in a critically ill Covid patient. CASE PRESENTATION: A 49-year-old male with a history of diabetes, internal hemorrhoids, and diverticulosis was admitted to the hospital due to hypoxic respiratory failure from COVID pneumonia with characteristic CT findings of bilateral ground-glass opacification. On admission, the patient was afebrile, normotensive, tachypneic with a respiratory rate of 34.The physical examination was unremarkable except for coarse crackles in upper and middle lung zones. We treated patient with Dexamethasone and Remdesivir. His hypoxia deteriorated, and he was eventually intubated. On admission patient hemoglobin was within normal range. During the patient's hospital course, he had a significant drop in hemoglobin, requiring multiple blood transfusions. Blood clots were found on perianal examination. Flexible sigmoidoscopy revealed blood in the rectosigmoid colon. A visible vessel without apparent ulcer was seen in the rectum, which was actively oozing blood. It was determined to be a Dieulafoy lesion. The affected area was injected with epinephrine for hemostasis, and subsequently, hemostatic clips were placed. After the procedure patient did not have any repeat episodes of hematochezia or drop in hemoglobin. DISCUSSION: Dieulafoy lesions are an uncommon cause of GI bleeding and are usually present in the upper gastrointestinal tract. Furthermore, they caused hemodynamically significant bleeding from the lower gastrointestinal tract in our case. Dieulafoy lesions can be asymptomatic or may bleed intermittently to cause severe hemodynamic compromise. They may be missed on endoscopy due to the small size and intermittent bleeding [2]. In up to 9-40% of the cases, these lesions tend to rebleed. Therefore the patients need close monitoring [3]. In our case, after the intervention with the clips, the patient's bleeding stopped, and he had no further blood loss from the lesion. CONCLUSIONS: Dieulafoy's lesion is an infrequent cause of gastrointestinal bleeding, and it is challenging to diagnose [3]. It is a rare cause of GI bleeding, and even in those instances, it is found chiefly in upper GI bleed cases but can also be the cause of lower GI bleeding. Knowing that GI bleeding in Covid patients leads to worse outcomes, it is prudent to account for rare causes of GI bleed during the work-up. Reference #1: Van Zanten SV, Bartelsman J, Schipper M, Tytgat G. Recurrent massive haematemesis from Dieulafoy vascular malformations–a review of 101 cases. Gut. 1986;27(2):213. Reference #2: Shin HJ, Ju JS, Kim KD, et al. Risk factors for Dieulafoy lesions in the upper gastrointestinal tract. Clinical Endoscopy. 2015;48(3):228. Reference #3: Baettig B, Haecki W, Lammer F, Jost R. Dieulafoy's disease: endoscopic treatment and follow up. Gut. 1993;34(10):1418-1421. DISCLOSURES: No relevant relationships by Swe Swe Hlaing No relevant relationships by Joyann Kroser No relevant relationships by Hui Chong Lau No relevant relationships by Sze Jia Ng No relevant relationships by Subha Saeed No relevant relationships by Muhammad Moiz Tahir
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A 70-year-old man was diagnosed with coronavirus disease 2019 (COVID-19). The patient had suspected upper gastrointestinal bleeding during the course of the COVID-19 infection. Urgent esophagogastroduodenoscopy (EGD) was performed. However, because of mobility restrictions imposed as a COVID-19 countermeasure, EGD was done in a small hospital room. Hemostatic treatment was successful, but no sufficient close examination could be done. The patient, who was diagnosed as having alpha-fetoprotein-producing gastric cancer, died about three months later.
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Introduction Acute upper gastrointestinal bleeding (AUGIB) has an incidence between 84-172 per 100,000 people per year resulting in 50-70000 hospital admissions every year. Out -of-hours (OOH) endoscopy rotas for AUGIB are typically delivered by Consultant Gastroenterologists. Prior to the COVID-19 pandemic, the AUGIB OOH service was Specialty Registrar (SpR) led at Leeds Teaching Hospitals, and was felt to provide invaluable exposure and experience for SpRs in the endoscopic management of patients presenting with AUGIB. Following the start of the COVID pandemic, and subsequent redeployment of SpRs, the AUGIB OOH service has been a Consultant delivered one. The aim of this retrospective study was to compare the safety and efficacy of a SpR led OOH AUGIB service (2016 database) with a Consultant delivered service (2020-21 database) at the same trust. Methods We included adult patients (>16 years), presenting to LTHT between March and September 2016 with suspected AUGIB having an endoscopy procedure performed on a SpR led OOH rota and compared this with patients presenting with suspected AUGIB between September 2020 and March 2021 during which period the service was entirely consultant delivered. Baseline clinical, laboratory, admission Glasgow- Blatchford Score, demographic data, grade of endoscopist, place of endoscopy, findings of endoscopy and treatments applied were recorded. Primary outcome was 30-day mortality secondary to GI bleeding. Secondary outcomes included time to endoscopy and rebleed rate Results 177 patients from the 2016 database (62% male, median age 67, range 18-97) and 100 patients from the 2020-21 database (60% male, median age 63, range 18-96) were included in the study. 97.2% patients (2016) vs 93% (2020-21) had a GBS score ≥7. 30-day GI bleed related mortality was 2.89% (2016) vs 3% (2020-21) (p value 0.93). The median time to endoscopy was 16.3 hours (2016) vs 17.2 hours (2020-21). 8.9% (2016) vs 7% (2020-21) experienced a rebleed. Conclusions This study has shown that a Registrar led OOH AUGIB service has comparable outcomes to a Consultant delivered rota in important outcomes such as time to endoscopy and 30-day mortality. Where service configuration allows, a registrar led rota can aid in improving the standard of SpR training whilst also freeing up Consultants to undertake increased elective work and reduce the backlog created by the COVID-19 pandemic.
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The proceedings contain 374 papers. The topics discussed include: optical biopsy with linked color imaging accurately predicts inflammation in ulcerative colitis;predicting use of opiates in patients with inoperable pancreatic cancer: a retrospective cohort study;unbiased clustering of breath signature in NAFLD identifies disease progression high-risk patient phenotype - 5 year study;prevalence of malnutrition screening;the association between IBD and mental ill health: a retrospective primary care cohort study;the interleukin 22//neutrophil axis is associated with treatment resistance in ulcerative colitis;neuromuscular dysfunction in patients with nausea and vomiting syndrome defined by body surface gastric mapping;two-tiered liver fibrosis assessment in primary care annual diabetic screening 3 year follow up;can an algorithm help in the difficult dilemma of upper gastrointestinal bleed and anticoagulant COVID-19 pandemic and alcohol-specific hospital admissions;and upper gastrointestinal hemorrhages and COVID-19: a nationwide cohort study of the pandemic's impact on hospitalizations.
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Background and aims: Malnutrition is a common comorbidity in cirrhotic patients and confers a poorer prognosis. Vitamin C (VC) is a micronutrient essential for human health. Vitamin C deficiency (VCD) can lead to scurvy and may impair immune and liver functions. Although previously thought to be rare in developed countries, VCD is now well described in patients with pneumonia, COVID19 and upper gastrointestinal bleeding (UGIB). The prevalence and clinical significance of VCD in cirrhosis remains poorly studied. Method: Patients with cirrhosis admitted to 3 metropolitan tertiary centres in Australia were prospectively included over a 10-month period in 2021. Fasting VC levels were collected on admission and we recorded demographic data and clinical outcomes. The primary outcomes were the prevalence of VCD (defined as VC level <23 mcmol/L) and severe VCD (SVCD), defined as <11 mcmol/L. Secondary outcomes included mortality, intensive care admission, length of stay (LOS) and rate of infection. Results: 117 patients were included. Mean age was 57.1 ± 13.9 years, 59.0% were male and 23.9% belonged to the lowest socioeconomic decile. The most common aetiologies of cirrhosis were alcohol (62.4%), viral hepatitis (24.0%) and non-alcoholic fatty liver disease (18.8%). Median MELD scorewas 29 (IQR 22–36) and Child Pugh (CP) grades were 12.8% A, 46.2% B and 41.0% C. Most patients (74.4%) were hospitalised with complications of decompensated cirrhosis, including ascites (59.0%), encephalopathy (31.6%) and variceal bleeding (11.1%). Median VC level was 34mcmol/L (IQR 16–55) and did not differ with age, gender, or aetiology of cirrhosis. Increasing CP grade correlated with significantly lower median VC levels (CP-A 46.0 mcmol/L vs. CPB 36.5 mcmol/L and CP-C 20.5 mcmol/L, p = 0.026). The prevalence of VCD and SVCD were 39.3% and 17.1% respectively. SVCD was more prevalent in patients with a body mass index <25 (28.3% vs 13.0%, p = 0.036). In-hospital mortality was 12.8% and did not differ by VCD status, however in the subgroup of patients presenting with UGIB, SVCD correlated with significantly higher mortality (50% vs 4.1%, p = 0.045). Bacteraemia was more frequent in patients with VCD (13.3% vs. 1.4%, p = 0.014) and SVCD (26.3% vs 2.1%, p < 0.001), which remained significant at multivariate analysis (OR for every 1mcmol/L increase in VC, 0.91 (95% CI: 0.83–0.99), p = 0.037). Overall infection rateswere higher in patients with SVCD (40.0% vs. 27.8%) although thiswas nonsignificant (p = 0.279). Median hospital LOS was 10 (IQR 6–18) days and did not differ by VCD status. (Figure Presented) Conclusion: VCD is common in hospitalised cirrhotic patients and prevalence increases with severity of liver disease. VCD increases the risk of infective complications and higher mortality was observed in patients with UGIB and SVCD. Further studies are required to assess the significance of VCD in cirrhosis and the impacts of VC replacement.
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Background: Gastrointestinal (GI) bleeding is one of the impactful complications in patients hospitalized from Covid-19 infection. The previous study showed the risk factors of overall (upper and lower) GI bleeding in patients with Covid-19 infection but no study focused on patients with upper GI bleeding (UGIB). This study aimed to identify the risk factors and outcomes of patients who were hospitalized from Covid-19 infection and developed UGIB. Methods: This is a retrospective in university-hospital which enrolled patients who were admitted due to Covid-19 infection and developed UGIB between April and October 2021. The primary outcome was the associated factors of high risk UGIB defined by having hematemesis or fresh blood from NG tube or hematochezia plus hemodynamic instability. The secondary outcomes were etiologies of high risk UGIB and mortality in those patients. Results: Of 7,214 patients hospitalized though the period, 49 patients (0.7%) had evidence of UGIB. The majority were male (63.3%) with mean ages of 70+12 years. Twenty-seven from 49 patients (55.1%) had mechanical ventilator, 40 patients (81.6%) received systemic corticosteroids, and 13 patients (26.5%) received anticoagulants for venous thromboembolic prophylaxis. Seven from 49 patients (14%) had high risk UGIB;5 hematemesis (71.4%), 1 fresh blood from NG tube (14.3%), and 1 hematochezia (14.3%). There was no significant difference in term of number of patient taking antiplatelets, anticoagulants, or steroids and severity of COVID-19 infection (e.g. Mechanical ventilator needed) between two groups. The emergency endoscopy was performed in 6/7 (85.7%) patients and showed 5 peptic ulcer with non-bleeding visible vessel and 1 gastric lymphoma with blood oozing (Table 1). All 6 patients underwent endoscopic hemostasis including adrenaline injection, bipolar coaptation, clipping, Hemospray®, and over-the-scope clip. There was a robust result when conducting uni- (p=0.005) and multi-variate analysis (OR 6.38;95%CI 1.04-38.92;p= 0.045) that an absence of proton-pump inhibitor (PPI) use was the significant risk factor of high risk UGIB in targeted patients (Table 2). The overall mortality rate in patients with UGIB was 20/49 (40.8%) and 1 from 20 patients (5.0%) expired from UGIB due to moribund condition and unsuitable for endoscopy. None of patients with high risk UGIB and underwent therapeutic endoscopy expired during admission. Conclusion: Our study demonstrated that the absence of PPI use was a sole significant risk factor for high risk UGIB which required therapeutic endoscopy in patients with COVID-19 infection. We suggest that PPI prophylaxis should be prescribed in those patients once they need hospitalization regardless of the severity of COVID-19 infection and anticoagulant usage to minimize the severity of UGIB.(Table Presented)
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Background: In the wake of the Coronavirus pandemic, there was a drastic decline in healthcare resource utilization for preventive, elective, and emergency care. It is unclear how this affected gastrointestinal (GI) outcomes. As such, we sought to investigate the impact of the Covid-19 pandemic and subsequent lockdowns on inpatient GI outcomes and endoscopy utilization in California. Methods: Using the all-payer California State Inpatient Database for 2018-2020, we explored year-to-year and 2020 month-to-month trends in hospitalizations, length of stay, and inpatient mortality (all-cause&viral pneumonia-specific) for common inpatient GI diagnoses including acute pancreatitis, diverticulitis, cholelithiasis, noninfectious gastroenteritis, upper and lower GI bleeding, Clostridium difficile, viral gastroenteritis, inflammatory bowel disease, and acute cholangitis using joinpoint, linear, and logistic regression modeling. We also investigated endoscopy utilization for GI emergencies during the pandemic. Results: For all 12 GI conditions studied, there was a 15% hospitalization rate reduction in 2020 compared to prior years (173,535 in 2018, 174,827 in 2019, and 148,762 in 2020). A significant decrease in disease-specific hospitalizations (ptrend< 0.0001) was observed except in nonvariceal upper GI bleeding, lower GI bleeding, and ulcerative colitis (UC) admissions [Table 1]. Compared to 2019, all-cause inpatient mortality in 2020 was higher in hospitalizations for acute pancreatitis (0.5% vs. 0.6%, p= 0.029), diverticulitis (0.4% vs 0.6%, p=0.04), nonvariceal upper GI bleeding (1.8% vs 2.1%, p=0.003), and Crohn's disease (1.7% vs 2.2%, p=0.004) [Table 1]. The 2020 month-tomonth trend analysis showed the lowest hospitalization rates in April, November, and December 2020, coinciding with the peaks of the pandemic. Fortunately, despite these nadirs in GI hospitalizations, the month-to-month inpatient mortality trend analysis did not show a significant increase, except in UC hospitalizations (p-trend=0.048). There was also a significant increase in viral pneumonia (p<0.001) and viral pneumonia complicated by respiratory failure (p<0.001) among GI hospitalizations. For all GI emergencies (upper/lower GI bleeding, acute cholangitis, and food impactions), endoscopy utilization within the first 24 hours was comparable between 2019 & 2020, except for acute nonvariceal GI bleeding (32.5% in 2019 vs 30.3% in 2020, p<0.001). Conclusions: Our findings suggest that the Covid-19 pandemic resulted in a significant decline in hospitalization rates for common GI conditions in California particularly in April, November and December 2020. All-cause mortality rates were significantly higher among acute pancreatitis, diverticulitis, nonvariceal upper GI bleeding, and Crohn's disease hospitalizations. However, 2020 emergency endoscopy rates were mostly comparable with 2019. (Figure Presented) Figure 1: Trends in number of hospitalizations, total hospital stay in days, and allcause inpatient mortality of selected GI diseases in California from 2018 to 2020. (Figure Presented) Figure 2: Endoscopy utilization rates for GI emergencies in California from 2018 to 2020
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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
This study aims to investigate the effects of COVID-19 on clinical outcomes of non-COVID-19 patients hospitalized for upper gastrointestinal bleeding (UGIB) during the pandemic. A retrospective review is conducted. We recruited patients with UGIB admitted during the pandemic's first wave (April 2020 to June 2020), and the year before the pandemic. The outcomes between the two groups were compared using propensity score matching (PSM). In total, 60 patients (pandemic group) and 460 patients (prepandemic group) are included. Patients admitted during the pandemic (mean age of 67 ± 14 years) had a mean Glasgow-Blatchford score of 10.8 ± 3.9. They were older (p = 0.045) with more underlying malignancies (p = 0.028), had less history of NSAID use (p = 0.010), had a lower platelet count (p = 0.007), and had lower serum albumin levels (p = 0.047) compared to those admitted before the pandemic. Esophagogastroduodenoscopy (EGD) was performed less frequently during the pandemic (43.3% vs. 95.4%, p < 0.001). Furthermore, the procedure was less likely to be performed within 24 h after admission (p < 0.001). After PSM, admissions during the pandemic were significantly associated with decreased chances of receiving an endoscopy (adjusted odds Ratio (OR), 0.02; 95% CI, 0.003-0.06, p < 0.001) and longer hospital stay (adjusted OR, 2.17; 95% CI, 1.13-3.20, p < 0.001). Additionally, there was a slight increase in 30-day mortality without statistical significance (adjusted OR, 1.92; 95% CI, 0.71-5.19, p = 0.199) and a marginally higher rebleeding rate (adjusted OR, 1.34; 95% CI, 0.44-4.03, p = 0.605). During the pandemic, the number of EGDs performed in non-COVID-19 patients with UGIB decreased with a subsequent prolonged hospitalization and potentially increased 30-day mortality and rebleeding rate.
ABSTRACT
Introduction: Phosphorus is an essential component of many macromolecules found in bone, lipid membranes, and DNA. It circulates in serum as phosphate. Phosphate level is mainly determined by kidney function. Other factors such as 1, 25 vitamin D3, thyroid hormone and low phosphorous intake can increase renal absorption of phosphate. Hyperphosphatemia presents when serum phosphate is above 4.5 mg/dl (1.45 mmol/L). The phosphate target for hemodialysis (HD) patients is 5.5 mg/dl (1.77 mmol/L) or less. Serum phosphate is commonly measured through the colorimetric method and can also be measured isotopically. Depending on the method used to measure the serum phosphate, many factors have been reported to produce falsely elevated levels. Methods: 52-year-old female with past medical history of end stage renal disease on HD, heart failure with severely reduced ejection fraction secondary to ischemic cardiomyopathy status post left ventricular assist device (LVAD), type 2 diabetes, hypertension, upper gastrointestinal bleeding, anemia, was admitted at a rehabilitation center after a hospital stay due to COVID-19 infection and E. faecium bacteremia secondary to a drive-line infection of the LVAD which was treated with daptomycin. On admission, the patient was found to have a phosphorus level of 6.3 mg/dl, PTH 265 pg/mL, corrected calcium 10 mg/dl, and hemoglobin 9.1 g/dL. Results: Patient was started on oral Sevelamer tablets 800 mg every 8 hours and underwent regular full HD sessions. However, the hyperphosphatemia persisted. Sevelamer was increased to 1600 mg every 8 hours, and she was maintained on a strict low phosphorous renal diet. Four days later while on the new regimen, the phosphorous increased to 12.2 mg/dl. She remained asymptomatic. Hemolysis and hyperbilirubinemia were excluded. A serum protein electrophoresis revealed a monoclonal spike in the gamma region with gamma % of 38.5 (normal range 11-20), gamma globulin 3.0 g/dL (normal range 0.6 – 1.6 g/dL), and quantification of the abnormal protein of 0.41 g/dL (5.3% total). Serum immunofixation showed a probable IgG Lambda monoclonal band. A serum free light chain assay demonstrated a Kappa light chain free serum of 548.9 mg/L (normal range 3.3 – 19.4 mg/L) and Lambda light chain free serum 549.7 mg/L (normal range 5.7 – 26.3 mg/L). Patient was diagnosed with a monoclonal gammopathy, and the elevated phosphorus deemed to be pseudohyperphosphatemia secondary to paraproteinemia. Conclusions: Colorimetric assay with phosphomolybdate ultraviolet (UV) is commonly used for measurement of serum phosphate. The ammonium molybdate reacts with the phosphate to form a cloudy complex, UV absorbance is measured at a specific wavelength. Several factors have been reported to cause falsely high phosphate such as hyperlipidemia, hyperbilirubinemia, hemolysis, liposomal amphotericin B, recombinant tissue plasminogen activator, heparin sulfate, and gammopathies. The paraproteinemia present in monoclonal gammopathies creates a cloudier sample which increases the absorbance of UV light leading to spurious elevation of serum phosphate. Although hyperphosphatemia is a common finding in dialysis patients, the presence of persisting or worsening hyperphosphatemia in a compliant patient taking phosphorous binders and adhering to a low phosphorus diet should raise concern for pseudohyperphosphatemia. No conflict of interest
ABSTRACT
Background and Objective: With the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, various aspects of health care have been affected;however, there has been an unknown effect on hospital admissions for gastrointestinal (GI) diseases and the potential consequences on specific illnesses. Our study aims to characterize the rates of GI disease hospitalizations during the pandemic as compared to prior and any differences between specific gastrointestinal diseases throughout this period. This will be important in highlighting any gaps of care as related to gastroenterology during COVID-19.Methods: We conducted a retrospective, cross-sectional study between the months of January to May from the years 2016-2020 in a regional integrated health care system. January –May 2020 was delineated as the COVID-19 period. ICD-10 codes were used to identify principal diagnoses related to the most common GI hospitalizations in the United States (upper GI hemorrhage, pancreatitis, liver disease, diverticular disease, cholelithiasis). Rates of hospitalization were then calculated per 100,000 members for each calendar month and each respective year. Rates for the 5 most identified GI diseases were then calculated using a similar method from 2019 as compared to 2020. The rate of percent change for each month for these diseases were then analyzed during the pandemic year of 2020 versus the preceding year of 2019.Results: A total of 4589 (rate of 19.57 per 100,000) hospitalizations for GI related diseases occurred between January – May 2020 as opposed to 5328 (rate of 23.10 per 100,000) hospitalizations from January – May 2019 (p=0.03). The median age in 2020 was 59.1 (p= 0.27 compared to 2019) with a 51% female to male ratio. 38% of patients were White, 42% Hispanic, 10% Black, 8% Asian (p=0.58 compared to 2019 for all ethnicities). There was a decrease in the rate of hospitalization in each month from January – April 2020 compared to 2019 with a subsequent rise in May. There was a 2.86 increase in rate of hospitalization (p<0.01) from April to May 2020. There were only significant differences (p<0.05) in hospitalization rates between the months of March – May from 2020 versus 2019. Of the 5 most common GI diseases, upper gastrointestinal hemorrhage showed the highest average rate change of -20% from 2020 to 2019. Cholelithiasis had a change of -15%, pancreatitis with a change of -14%, diverticular disease with a change of -11%, and liver disease with a change of -9%.Conclusion: GI related hospitalizations decreased during the COVID-19 pandemic as com-pared to the previous year. Upper gastrointestinal hemorrhage showed the most average rate change of the GI diseases. Further studies highlighting the implications of these findings, such as mortality and severity of illness during the pandemic, need to be completed to assess the impact COVID-19 on GI disease.(Figure presented)(Table Presented)