Evaluation of individual risk in nonvariceal gastrointestinal bleeding patients with NSAID administration: a multicenter study in Japan.

BACKGROUNDS: Gastrointestinal (GI) toxicity is an undesirable effect of nonsteroidal anti-inflammatory drugs (NSAIDs). We conducted a multicenter study in Japan to clarify the GI risk grade in patients with NSAID-induced GI bleeding. METHODS: Patients with emergent endoscopic hemostasis by nonvariceal bleeding were registered from 36 hospitals in Hiroshima. In cases with NSAID use, the GI risk grade (low, moderate, or high) was evaluated, and concomitant drugs were investigated. We asked 79 gastroenterologists and 234 orthopedists what concomitant drugs they would prescribe to 3 simulated patients. RESULTS: A total of 1,350 patients were registered. NSAIDs were used in 278 cases (21%). Concerning the risk grade in each patient, the largest group was the moderate-risk group (203 patients; 73%), while the high-risk group comprised 10% of all NSAID users with bleeding. A proton pump inhibitor (PPI) or misoprostol was administrated to only 20 patients (7%). A small number of the gastroenterologists and orthopedists who responded to the questionnaire would prescribe PPI or misoprostol to simulated patients with short-term loxoprofen use. CONCLUSIONS: In NSAID users with GI bleeding, the moderate-risk group was the largest group for GI toxicity in Japan. In these cases, PPI or misoprostol was not commonly medicated in clinical practice.

Continuous proton pump inhibitor treatment decreases upper gastrointestinal bleeding and related death in rural area in Japan.

BACKGROUND AND AIMS: Proton pump inhibitors (PPI) have been rarely used for prevention of upper gastrointestinal bleeding (UGIB) induced by non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin in Japan. The increased incidence of UGIB in the aged society is becoming a serious problem. The aim of this study was to retrospectively evaluate whether PPI can prevent UGIB. METHODS: We examined records of 2367 patients (aged 67.9 ± 15.1 years, male 1271) attending the only hospital serving the rural area, with little population movement. We investigated the correlation between the frequency of usage of medicine (PPI, histamine 2 receptor antagonists [H2RA], NSAIDs, aspirin) and incidence of UGIB over 12 years. UGIB was defined as cases with hematemesis and/or melena and definite bleeding at upper gastrointestinal endoscopy. The annual incidence of UGIB of inhabitants (16,065 ± 375.3 persons/year) was evaluated. The frequency of usage of medicine was compared with the total number of patients prescribed any medication (1080 ± 33.2 persons/year). RESULTS: The frequency of PPI usage has increased significantly 4.6%→30.8% (P < 0.05). NSAIDs and aspirin usage increased significantly in the latter half of the survey period (P < 0.05). The annual incidence of UGIB significantly decreased 160.8 →23.6/100,000 inhabitants per annum (P ≤ 0.05) due to widespread use of PPI. No patients died due to UGIB after 2006. The incidence of UGIB and the prevalence of PPI usage were found to have a negative correlation (r = -0.804, P = 0.0016). CONCLUSIONS: By widespread use of PPI, UGIB and related death has declined significantly. This survey showed that continuous PPI treatment decreases UGIB and related death in community medicine.

Endoscopic hemostasis of gastric ulcer bleeding by hemostatic forceps coagulation.

Endoscopic submucosal dissection (ESD) for early gastric carcinoma has been widely performed in Japan. In this technique, when hemorrhaging from vessels is observed, the bleeding point is coagulated using hemostatic forceps with the soft coagulation. There have been reports that using hemostatic forceps with soft coagulation is a safe and effective method of controlling upper gastrointestinal ulcer bleeding. However, there have been no reports regarding the comparative effectiveness of hemostatic forceps and clipping in upper gastrointestinal ulcer bleeding. Between April 2003 and December 2008, a total of 124 patients with gastric ulcer bleeding causing melena or hematochezia were treated with endoscopic hemostasis in our hospital. Two endoscopic hemostatic methods were used for different groups of patients: coagulation with hemostatic forceps was used for Group A and clipping was used for Group B. The rate of additional treatment required after the initial procedure was 28.6% (8/28) for Group A and 79.2% (76/96) for Group B, indicating a significantly lower rate for Group A than that for Group B (P < 0.01). Additional treatment consists of a hypertonic saline epinephrine injection. The rebleeding rate was 3.6% (1/28) for Group A and 8.3% (8/96) for Group B, again indicating a lower rate for Group A than for Group B. Finally, successful endoscopic hemostasis was 100% in both groups. Using the soft coagulation mode of hemostatic forceps is shown to be a safe, easy and effective method of controlling gastric ulcer bleeding in relation to clipping.

[A case of Henoch-Schölein purpura with acute pancreatitis].

We report a 11-year-old girl who had abdominal pain, hematemesis and melena. On admission, endoscopy revealed multiple duodenal ulcers and abdominal computed tomography showed dilatation and wall thickness of the jejunum. Because she showed purpura on the lower extremities and a decreased serum level of the XIII factor, she was diagnosed as having Henoch-Schönlein purpura (HSP). On the clinical course, she had acute pancreatitis. Following administration of XIII factor, nafamostal mesilate and predonisolone, the abdominal pain disappeared. Eventually the acute pancreatitis was improved with improvement of purpura. According to this course, this acute pancreatitis was associated with HSP.