Clinical and Biochemical Differences in Patients Having Non-Variceal Upper Gastrointestinal Bleeding on NSAIDs, Oral Anticoagulants, and Antiplatelet Therapy.

Introduction: Upper gastrointestinal bleeding (UGIB) is among the most common causes of morbidity and mortality worldwide, accounting for major resource allocation and increasing incidence. This study aimed to evaluate the severity of non-variceal bleeding in patients at risk of bleeding through the use of NSAIDs, oral anticoagulants, and antiplatelet therapy. Material and Method: The study included 296 patients admitted in the Gastroenterology Department of the Municipal County Emergency University Hospital, Timisoara, between 01.01.2018 and 01.04.2020, and diagnosed via gastroscopy with non-variceal gastrointestinal bleeding. The patients were divided among four groups based on their use of different drugs known to induce UGIB, i.e., aspirin and clopidogrel, NOACs, NSAIDs, and anti-vitamin K drugs, respectively. Statistical analyses were performed based on ANOVA one-way tests for continuous variables and Chi-square tests for categorical variables with pairwise comparisons based on Bonferroni adjusted significance tests. Results: The results showed several parameters having statistical significance among the different groups of patients. Patients on NOACs had statistically significant lower hemoglobin levels, lower hematocrit values, lower erythrocytes, lower RDW and higher fibrinogen levels compared to patients on VKA. Discussion: Surprisingly, the results from our study suggest that the use of NOACs was associated with a higher risk of bleeding when compared to VKA, which differs from the existing literature. Conclusions: One of the important factors causing upper non-variceal bleeding can be iatrogenic, either due to antiplatelet drugs or anticoagulants, to which NSAID treatment is additionally associated for various reasons. In our study, the use of NOACs seemed to have a more severe bleeding spectrum with higher morbidity compared to VKA.

Gastric Antral Vascular Ectasia: Resolution of Bleeding and Stabilization of Hematocrit Following Orthotopic Liver Transplantation.

Gastric Antral Vascular Ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding and iron deficiency anemia in the geriatric population. It is often associated with cirrhosis of the liver and is hypothesized to result from synthetic liver dysfunction. Treatment options include argon plasma coagulation, endoscopic band ligation, and radiofrequency ablation. An orthotopic liver transplant may be effective for patients with advanced liver disease. In this case report, we describe a 60-year-old woman with a history of cirrhosis secondary to nonalcohol-related steatohepatitis (NASH) and GAVE syndrome who presented with abdominal pain and melena. She had multiple prior episodes of gastrointestinal bleeding, leading to long-term transfusion dependency. An urgent esophagogastroduodenoscopy revealed the presence of GAVE with active bleeding. The patient was supported with blood transfusions and transferred to a transplant center, where she underwent orthotopic liver transplantation. Following the transplantation, her hemoglobin levels improved and remained stable. She was no longer noted to require any further blood transfusions during outpatient follow-up visits. This case report substantiates the role of synthetic liver dysfunction in the development of GAVE. Also, it suggests that patients with advanced cirrhosis and refractory GAVE may benefit from liver transplantation as a potential treatment option.

Deep learning and capsule endoscopy: Automatic multi-brand and multi-device panendoscopic detection of vascular lesions.

Background and study aims Capsule endoscopy (CE) is commonly used as the initial exam for suspected mid-gastrointestinal bleeding after normal upper and lower endoscopy. Although the assessment of the small bowel is the primary focus of CE, detecting upstream or downstream vascular lesions may also be clinically significant. This study aimed to develop and test a convolutional neural network (CNN)-based model for panendoscopic automatic detection of vascular lesions during CE. Patients and methods A multicentric AI model development study was based on 1022 CE exams. Our group used 34655 frames from seven types of CE devices, of which 11091 were considered to have vascular lesions (angiectasia or varices) after triple validation. We divided data into a training and a validation set, and the latter was used to evaluate the model's performance. At the time of division, all frames from a given patient were assigned to the same dataset. Our primary outcome measures were sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and an area under the precision-recall curve (AUC-PR). Results Sensitivity and specificity were 86.4% and 98.3%, respectively. PPV was 95.2%, while the NPV was 95.0%. Overall accuracy was 95.0%. The AUC-PR value was 0.96. The CNN processed 115 frames per second. Conclusions This is the first proof-of-concept artificial intelligence deep learning model developed for pan-endoscopic automatic detection of vascular lesions during CE. The diagnostic performance of this CNN in multi-brand devices addresses an essential issue of technological interoperability, allowing it to be replicated in multiple technological settings.

Interactive training with a novel simulation model for upper gastrointestinal endoscopic hemostasis improves trainee technique and confidence.

Background and study aims Endoscopic hemostasis is a life-saving procedure for gastrointestinal bleeding; however, training for it is often performed on real patients and during urgent situations that put patients at risk. Reports of simulation-based training models for endoscopic hemostasis are scarce. Herein, we developed a novel simulator called "Medical Rising STAR-Ulcer type" to practice endoscopic hemostasis with hemoclips and coagulation graspers. This study aimed to evaluate the reproducibility of the clinical difficulty of this model and the effectiveness of simulation-based training for clipping hemostasis. Patients and methods This was a prospective educational study. Fifty gastroenterology residents from Japan and Canada were recruited to participate in a simulation-based training program. The primary outcome was the success rate for clipping hemostasis. We measured differences in trainee subjective assessment scores and evaluated the co-occurrence network based on comments after training. Results The hemostasis success rate of the trainees significantly increased after instruction (64% vs. 86%, P < 0.05). The success rate for ulcers in the upper body of the stomach (59%), a high-difficulty site, was significantly lower than that for ulcers in the antrum, even after feedback and instruction. Trainee self-perceived proficiency and confidence significantly improved after simulation-based training ( P < 0.05). Co-occurrence network analysis showed that trainees valued a structured learning approach, acknowledged simulator limitations, and recognized the need for continuous skill refinement. Conclusions Our study demonstrates the potential of our simulation-based training model as a valuable tool for improving technical skills and confidence in trainees learning to perform endoscopic hemostasis.

Through-the-scope clip retention rates and performance in a porcine model.

Background and study aims Limited comparative data exist to guide optimal through-the-scope (TTS) clip selection. The aim of this study was to compare the efficacy, retention, and safety of three industry-leading TTS clips on tissue that mimics common clinical scenarios. Methods A survival study involving six domestic pigs was undertaken. Three commonly used clip models were selected: Assurance (STERIS, Mentor, Ohio, United States), Resolution (Boston Scientific, Boston, Massachusetts, United States), and SureClip (Micro-Tech, Ann Arbor, Michigan, United States). To mimic clinical practice, the following scenarios were assessed: (1) normal mucosa; (2) cold snare resection; and (3) hot mucosal resection simulating fibrotic ulcers. Deployment of clips was randomized to target sites. Repeat endoscopy was performed 2 weeks following placement. Endoscopists rated the ease of use of clip placement on a Likert scale of 1 to 5. Results Fifty-four clips (18 Assurance, 18 Resolution, and 18 SureClip) were placed in six pigs. Mucosal healing was noted at all sites on follow up. Overall retention was nine of 18 (50.0%) SureClip, 10 of 18 (55.6%) Assurance, and 13 of 18 (72.2%) Resolution ( P =0.369). There was no difference in clip retention on normal and cold snare resection sites; however, clip retention was significantly higher for Resolution clips on fibrotic ulcers (50.0% versus 0% for Assurance and 0% SureClip, P =0.03). No adverse events were reported. Ease of use was equivalent across all models. Conclusions All clips were equivalent in efficacy and safety with successful clip deployment and mucosal healing. Overall retention rate was low for fibrotic tissue, with an improved retention rate observed with Resolution clips.

Review article: Advances in the management of lower gastrointestinal bleeding.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. AIMS: To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. RESULTS: The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. CONCLUSIONS: The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Utility of gastroscopy in the left lateral semi-recumbent position: A blood-free coup!

Background and study aims The utility of esophagogastroduodenoscopy (EGD) in the left lateral semi-recumbent position in the setting of acute upper gastrointestinal bleeding (UGIB) with a persistent fundal pool of blood for adequate visualization and effective endotherapy has not been studied. This study aimed to evaluate the feasibility, efficacy, and safety of this position in such settings. Patients and methods A prospective study of patients presenting with acute UGIB with an uncleared fundal pool of blood was conducted. All underwent EGD in the left lateral decubitus and secondary left lateral semi-recumbent positions. Outcomes in secondary position in terms of adequate visualization of the fundus, identification of new or additional sources of bleeding, and effectiveness of endotherapy were studied. Results We screened 860 patients and included 44 patients (5.11%) with a persistent fundal pool of blood. Endoscopy in the primary position revealed the source of bleeding in 37 of 44 patients (84%). The source of the bleeding was not identified in seven of 44 patients (16%). Endoscopy in the secondary position showed clearance of fundal pool in all 44 patients (100%). A new source of bleeding was identified in all seven patients (100%) and an additional source could be identified in another five patients (13.6%). Endotherapy was performed in the secondary position for all 44 patients with 100% technical success and 94% clinical success. Conclusions These data show that endotherapy in the left lateral semi-recumbent position is feasible, safe, and effective. It should be done when endoscopy in the left lateral decubitus position reveals a pool of blood in the fundus and there is inadequate visualization of the fundus.

Acute Upper Non-variceal and Lower Gastrointestinal Bleeding.

Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.

Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata.

BACKGROUND: Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS). METHODS: Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed. RESULTS: HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0-4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5-19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09-0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16-0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001). CONCLUSIONS: A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.

Prognosis of variceal and non-variceal upper gastrointestinal bleeding in already hospitalised patients: Results from a French prospective cohort.

OBJECTIVES: Patients who develop upper gastrointestinal bleeding (UGIB) while in hospital appear to have a poor prognosis. Our study aims at analysing the difference in outcome between in-patients (IPs) and out-patients presenting with variceal and non-variceal UGIB. METHODS: We conducted a multicentre prospective study by collecting data about variceal and non-variceal UGIB cases through 46 hospitals in France between November 2017 and October 2018. We then compared baseline demographic features, endoscopic findings and outcome between patients who developed variceal and non-variceal UGIB on admission (OPs) and those at least 24 h after hospitalisation (IPs). Our primary end-point was mortality and re-bleeding rates at 6 weeks of bleeding onset. RESULTS: A total of 2498 UGIB cases were identified, of whom 634 (25.4%) occurred in IPs. IPs were older than OPs (72.5 vs. 67.2 years old, p < 0.001) and had a higher rate of comorbidities (38.9% vs. 26.6%, p < 0.0001). Their bleeding was more severe with a Rockall score of >5 present in 40.9% (vs. 30.3% in OPs, p < 0.0001). The 6-week mortality rate was significantly higher in IPs when compared to OPs (21.7% vs. 8%, p < 0.0001). Prothrombin time <50% and rebleeding were the only independent predictors of mortality (p = 0.001 and 0.003, respectively). Six-week rebleeding occurred more frequently among IPs (18.6% vs. 14.4%, p = 0.015) and predictors included female sex, active bleeding upon endoscopy and a Blatchford score >11 (p = 0.017, 0.011 and 0.008, respectively). CONCLUSION: IPs who develop variceal and non-variceal UGIB are more likely to be elderly with more comorbidities. They have a higher rate of mortality and rebleeding. Independent predictors of mortality were underlying coagulopathy and bleeding recurrence. An optimal bleeding management and efficient rebleeding prevention may improve outcome in these patients.

Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS: This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS: A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION: Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

Pre-endoscopic intravenous proton pump inhibitors therapy for upper gastrointestinal bleeding: A prospective, multicentre study.

BACKGROUND/AIM: The indiscriminate use of high-dose, proton pump inhibitor (PPI) infusion in non-variceal upper gastrointestinal bleeding (UGIB) patients to reduce the rate of peptic ulcers with high-risk stigmata (HRS) has been questioned. We evaluated the prevalence of HRS on peptic ulcer and non-ulcer lesions in patients receiving or not receiving pre-endoscopic PPI therapy. METHODS: Data of consecutive UGIB patients observed in 50 Italian centres were analysed. The prevalence of both HRS on peptic ulcers and active bleeding on non-ulcer lesions between patients treated or not treated with PPI were compared. Multivariate analysis was performed. RESULTS: A total of 1,792 (69.8%) out of 2,566 patients received PPI therapy. Prevalence of HRS on ulcers was 51.8% and 53.4% (P = 0.58) in treated and not treated patients, respectively, and the rate of endoscopic therapy did not differ between groups. Prevalence of non-ulcer bleeding lesions was higher in patients treated than in those not treated with PPI (18.7% vs 10.6%; P = 0.023). At multivariate analysis, PPI therapy (OR: 1.16, 95% CI = 0.82-1.64; P = 0.4) was not an independent factor affecting HRS prevalence, which was inversely correlated with timing to endoscopy (OR: 0.85, 95% CI = 0.76-0.95; P = 0.005). CONCLUSIONS: Our data failed to detect a significant role of pre-endoscopic PPI therapy in decreasing prevalence of HRS and need for endoscopic treatment in bleeding patients with either peptic ulcer or non-ulcer lesions.

Patient's performance status should dictate transfusion strategy in nonvariceal acute upper gastrointestinal bleeding (NV-AUGIB): A prospective multicenter cohort study: Transfusion strategy in NV-AUGIB.

BACKGROUND: Non-variceal acute UGI bleeding (NV-AUGIB) is a frequent indication for transfusion, but the best hemoglobin threshold and target values for transfusion in relation to the patients' performance status are unknown. OBJECTIVE: To identify threshold and target hemoglobin levels for transfusion favoring survival of patients with NV-AUGIB stratified by ASA score. DESIGN: Prospective cohort study. SETTING: 50 hospitals of the Italian National Health Service. PARTICIPANTS: 2758 consecutive patients with NV-AUGIB admitted to 50 Italian hospitals from January 1st, 2014 to December 31st, 2015. Five hemoglobin cut-off values were evaluated. RESULTS: 30-days mortality: overall: 5.4%; ASA 1-2 patients: 2.5%; ASA 3-4 patients: 10.8%. Mortality was higher when hemoglobin at admission was ≤ 7 g/dL in ASA 1-2 patients, and when it was ≤ 8 g/dL in ASA 3-4 patients. The hemoglobin levels after transfusion favouring survival were ≥ 8 g/dL in ASA 1-2, p <0.0001 and 9-10 g/dL in ASA 3-4 patients; p = 0.0002. CONCLUSIONS: In patients with NV-AUGIB the physical performance status should dictate the transfusion strategy. In ASA 1-2 patients, admission hemoglobin values ≤ 7 g/dL should prompt transfusion, aiming at a target value of 8-9 g/dL; the corresponding figures for ASA 3-4 patients are: admission hemoglobin level ≤ 8 g/dL and target value of 9-10 g/dL.

Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis.

BACKGROUND: Recently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB. METHODS: Our primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures. RESULTS: A total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, I 2=52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, I 2=47.72%), compared to 87% (95%CI 75-94%, I 2=0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively. CONCLUSION: Hemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND: Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated. AIM: To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB. METHODS: This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups. RESULTS: A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2. CONCLUSION: In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Acute upper gastrointestinal bleeding: a guide for nurses.

This article outlines latest evidence-based care for patients with acute upper gastrointestinal (GI) bleeding. It aims to help gastroenterology and general medical ward nurses plan nursing interventions and understand the diagnostic treatment options available. Acute upper GI bleeding can present as variceal or non-variceal bleeding and has a high death rate. Endoscopy is used for diagnosis and to provide therapy, prior to which the patient should be adequately resuscitated and assessed. Various therapies can be initiated at endoscopy, depending on the source of bleeding. If bleeding continues in spite of these therapies, further interventions such as the Sengstaken tube, oesophageal stents, radiological or surgical treatments may be required. After endoscopy, it is important to have a plan for ongoing treatment. Patients may require acid suppression treatment or eradication of Helicobacter pylori as part of their treatment plan. They may in additional require correction of their haemoglobin levels and follow-up endoscopy. It is essential that nurses caring for such patients are aware of the current UK guidance and help patients to adhere to agreed treatment plans.

Diagnostic and therapeutic approach to upper gastrointestinal bleeding.

BACKGROUND: There is a lack of clarity about the approach to and management of upper gastrointestinal (UGI) bleeding in children. AIM: To examine the recent literature on UGI bleeding in children in order to outline the diagnostic approach and management. METHODS: The English language literature was searched for articles on UGI bleeding in children. Special attention was paid to its prevalence, risk factors, clinical approach and management. RESULTS: Although UGI bleeding is a common complication (10%) in paediatric intensive care units (PICU), clinically significant UGI bleeding (haemodynamic instability, fall in haemoglobin by 2 g/dL and/or a requirement for blood transfusion) is less common (1.6%). In low- and middle-income countries, clinically significant UGI bleeding is commonly owing to variceal bleeding whereas non-variceal aetiologies (e.g. peptic ulcer disease) are common in high-income countries. The fundamental clinical principles of managing UGI bleeding are immediate assessment of severity, detecting possible causes and stabilising the haemodynamic status. In suspected cases of variceal bleeding, intravenous octreotide and, in non-variceal bleeding, administration of a proton pump inhibitor (PPI) should be commenced immediately. UGI endoscopy plays a vital role in diagnosis and management. Over-transfusion should be avoided (target haemoglobin 7-9 g/dL). Stress ulcer prophylaxis is recommended in a select group of patients in PICUs (e.g. respiratory failure, coagulopathy and paediatric risk of mortality score ≥10). CONCLUSIONS: In clinically significant UGI bleeding, the primary goal is to restore the haemodynamic status, followed by early endoscopy. Intravenous octreotide in suspected variceal and PPI in non-variceal bleeding should be administered early. Stress ulcer prophylaxis should be restricted to high-risk children only.

What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?

OPINION STATEMENT: PURPOSE OF REVIEW: Upper non-variceal gastrointestinal bleeding (UNVGIB) remains an important clinical challenge for endoscopists, requiring skill and expertise for correct management. In this paper, we suggest the best strategy for an effective treatment of this complex category of patients. RECENT FINDINGS: Early endoscopic examination, the increasingly widespread use of endoscopic hemostasis methods, and the most powerful antisecretory agents that induce clot stabilization have radically modified the clinical scenario for treating this pathology. While hospitalization for digestive hemorrhage is decreasing, the incidence of bleeding seems to be increasing, especially in the elderly for whom a greater use of gastrolesive drugs and the presence of comorbidities are more common. A multidisciplinary approach for initial patient evaluation and hemodynamic resuscitation prior to endoscopic treatment is crucial for correct management, prevention of rebleeding, and reduction of morbidity and mortality rates and hospital stays. Appropriate operator technical expertise, together with the availability of a wide range of endoscopes and devices, is mandatory. Newer endoscopic techniques may improve patient outcomes for difficult-to-treat lesions. Today, endoscopic hemostasis can be achieved in over 95% of patients.