[Aute upper gastrointestinal bleeding--erosive gastropathy].

AIMS: Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologist. Our aim was to assess the frequency of erosive gastropathy as a cause of upper GI bleeding as well as its relation to age. gender and known risk factors. MATERIAL AND METHODS: We conducted retrospective observational analysis of emergency endoscopy reports from the files of Emergency Department of Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, during the period from 2000-2005. Data consisted of patients' demographics, endoscopic findings and potential risk factors. RESULTS: During the period 2000-2005. Three thousand-nine hundred and fifty four emergency tipper endoscopies were performed for acute bleeding. In one quarter of cases acute gastric erosions were the actual cause of bleeding. One half of them were associated with excessive consumption of salicilates and NSAIDs. In most of the examined cases bleeding stopped spontaneously, while in 7.6%) of the cases required endoscopic intervention. CONCLUSION: Erosive gastropathy represents significant cause of upper gastrointestinal bleeding count up to one quarter of all cases required emergency endoscopy during the 5-year period. Consumption of NSAIDs and salicilates was associated with erosive gastropathy in almost one half of cases (46%) leading us with a conclusion that we must explore other causes of erosive gastropathy more thoroughly.

[Role of Helicobacter pylori infection and use of NSAIDs in the etiopathogenesis of upper gastrointestinal bleeding].

INTRODUCTION: Non-steroid antiinflammatory drugs (NSAIDs) and Helicobacter pylori (Hp) infection are two most important independent risk factors involved in the etiopathogenesis of gastroduodenal mucosal injury with a clear and critical role in both uncomplicated and complicated peptic ulcer disease. It is estimated that upto 90% of all peptic ulcers result from the effect of one or both of these factors. AIM: To determine the frequency of NSAIDs use and Hp infection in patients with acute upper gastrointestinal bleeding. PATIENTS AND METHODS: Study evaluated data from 500 patients in whom esophagogastroduodenoscopy was performed following presentation in emergency unit with acute upper gastrointestinal bleeding. Anamnestic data was collected together with detailed information on previous salicilates and/or NSAIDs use. Hp status was determined and anatomic localisation of bleeding lesion was also registered. RESULTS: Acute upper GIT bleading was caused solely by NSAIDs in 55 (11%), by aspirin in 66 (13.2%), while combined NSAID/aspirin therapy was identified in 19 (3.8%) of patients. In total NSAID and/or aspirin use were diagnosed in 139 (27.8%). while in 122 (24.4%) only Hp infection was diagnosed. Both risk factors were identified in 144 (28.8%) patients (Hp+NSAIDs in 12.2%, Hp+aspirin in 10.8% and Hp+aspirin+NSAIDs in 5.8%). In 19.8% of the cases (14% of males and 27% of females) neither NSAID/aspirin use nor presence of Hp infection was noted. Out of 500 patients enrolled, 63% were mails. In females, bleeding lesion was most frequently localized in gastric mucosa, while males had equal chance of bleeding from either gastric or duodenal mucosa. Fortunatelly, only 5 to 7% of patients were bleeding from both gastric and duodenal lesion. CONCLUSION: Prevention of acute upper gastrointestinal bleeding can be achieved trough strict and limited use of aspirin and NSAIDs, eradication of Hp infection and use of gastroprotective therapy in well-defined risk patients that need chronic NSAIDs and/or aspirin therapy. In all patients starting long-term NSAID and/or aspirin therapy and all patients already on long-term aspirin therapy test and treat strategy for Hp infection should be used. On the other hand, only in high risk patients (more than 65 years, history of peptic ulcer disease, concomitant corticosteroid, aspirin, clopidogrel or warfarin therapy) already on chronic NSAID therapy long-term PPI therapy should be prescribed after testing and treating of Hp infection.

[Myeloproliferative diseases as causative agents of portal and hepatic veins thrombosis].

Thrombosis of portal and hepatic veins is one of the most severe complications and most important causes of death of patients with chronic myeloproliferative diseases. Based on results of the past studies, myeloproliferative diseases were the causes of hepatic veins thrombosis in 30% and portal vein thrombosis in 20% of patients. The study presented 4 patients with myeloproliferative diseases complicated by thrombosis of splanchnic veins, aiming at the illustration of issue complexity in diagnostics and therapy. Two patients with portal vein thrombosis and recurring hemorrhage from esophageal varicosity were described. The first case was planned for shunting, while another case sustained bleeding on what account his anticoagulant therapy was discontinued, but it caused mesenterial thrombosis resulting in lethal outcome. Another two patients had hepatic veins thrombosis. Due to frequent, life-threatening bleeding from the esophageal and gastric varices, a patient with chronic Budd-Chiari syndrome and lineal vein thrombosis underwent mesocaval shunting. An immediate postoperative period was manifested by multiple thrombosis and hemorrhages that ended in his death. A patient with the acute Budd-Chiari syndrome was administered myelosuppressants and anticoagulants on time so reperfusion was restored. In myeloproliferative diseases, thrombosis of portal and hepatic veins gives rise to excessive portal hypertension with profuse hemorrhage from the esophageal and gastric varicosity which is difficult to manage because of complex coagulation disorders.

[Acute upper gastrointestinal nonvariceal bleeding--how to determine low risk patients for rebleeding and mortality after endoscopic sclerotherapy?].

INTRODUCTION: Successful endoscopic sclerotherapy is effective in securing hemostasis for bleeding lesions and remains the first line and only needed therapy for most of the patients (pts), but bleeding reoccurs in 10% to 30% pts, and 4% to 14% of the pts die after acute nonvariceal upper gastrointestinal bleeding (UGIB). The need for hospitalization and its duration for all the bleeding pts is still a controversial question. AIM: To create the simple scoring system able to determine low risk pts for rebleeding and mortality by establishing the relative importance of risk factors for rebleeding and mortality after successful endoscopic sclerotherapy of acute nonvariceal UGIB. PATIENTS AND METHODS: Prospective study included 3 15 pts who where admitted to hospital because of acute nonvariceal UGIB. All of them underwent gastroscopy with successful sclerotherapy within 12 hours after the admission. We investigated the episode of rebleeding and death during the initial hospitalization, and analyzed the following parameters: age, gender, drug intake, shock, bleeding stigmata, location of bleeding lesion and comorbidity. RESULTS: Rebleeding occurred in 53 pts (16.8%) and was determined by shock, bleeding stigmata and comorbidity. Eleven pts (3.5%) died and shock, rebleeding and comorbidity were all independent, statistically significant predictors of pts' mortality. The numerical scores for determination of pts with different risk levels for rebleeding and mortality have been developed using the significant predictors of rebleeding and death. The score values for rebleeding ranged from 3 to 9 and pts with values < or = 4 had low risk of rebleeding. We identified 59 pts (18.7% of all) with score for rebleeding < or = 4. Score values for mortality risk ranged from 3 to 8 and the values < 5 revealed negligible risk of death. In our group we found 290 pts (92.1% of all) with low mortality score values. CONCLUSION: Following the successful initial endoscopic sclerotherapy, these scores can help to identify pts with low risk of rebleeding and negligible risk of death, so they can be treated as outpatients.

[Bleeding oesophageal varices--therapeutic options].

INTRODUCTION: Emergency endoscopy plays the most important role in diagnosis and treatment of patients with esophageal variceal bleeding. Endoscopic sclerotherapy (EST), placement of esophageal band ligatures (EVL), medicamentous treatment using somatostatin and its derivatives and balloon tamponade are the methods most frequently applied in treatment of the bleeding esophageal varices. PATIENTS AND METHODS: Endoscopic reports on the patients with bleeding esophageal and gastric varices were retrospectively analyzed in the emergency unit of the Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia over the five-year period--since January 2001 till December 2005. RESULTS: The total of approximately 3, 954 emergency upper endoscopies were performed due to the upper gastrointestinal tract bleeding. Out of the total number of patients, bleeding was diagnosed in 324 (8.2%) patients due to the esophageal varices. In the group of patients with bleeding esophageal varices, the total of 252 (77.8%) males and 72 (22.2%) females averagely aged 56.8 + 7.5 years (range 24 - 80 years) were examined. The primary sclerosant therapy with absolute alcohol was applied in 118 (36.4%) patients, while Blakemore probe tamponade was performed in 145 (44.8%) patients with bleeding esophageal varices. The total of 240 (74.1%) patientswere treated with vasoactive substances (somatostatin and its analogues), as additional therapy and control of the primary hemostasis. It was evidenced that out of 118 patients intra and paravariceally treated with the sclerosant agent (absolute alcohol) hemostasis was achieved in 47 (39.8%). Out of 145 patients subjected to Blakemore probe placement, bleeding was successfully arrested in 117 (80.7%) patients. Somatostatin and its analogues as primary and only treatment of the bleeding esophageal varices were applied in 71 (29.6%) patients, while in the remaining 169 (70.4%) patients, they were applied as additional therapy to the endoscopic sclerotherapy and mechanical treatment of bleeding. Out of 71 patients treated with somatostatin preparations as the only therapeutic option, 45 (63.4%) responded positively by arrest of bleeding for 72 hours. CONCLUSION: Treatment of the acute bleeding esophageal varices is focused on the arrest of bleeding, prevention of early recurrent bleeding and reduction of mortality. Based on the most recent studies, efficacy of the modern endoscopic therapy in the form of sclerotherapy and band ligature placement, as well as application of vasoactive substances reaches up to 90%. Our results evidence minimal efficacy of the sclerotherapy (approximately 40%), which indicates the need of better preparation of patients for the intervention itself and additional education of the personnel.

[Endoscopic haemostasis of bleeding duodenal ulcer].

INTRODUCTION: Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologists. It manifests like: haematemesis, melaena or haemochezia. Diagnostic endoscopy accurately defining the cause of haemorrhage, while therapeutic endoscopy improves prognosis in patients who present with severe bleeding. Endoscopic therapies can be classified as those based on injection, application of heat, or mechanical clips. PATIENTS AND METHODS: This investigation was conducted in Department of endoscopic haemostasis, Clinic for gastroenterology and hepatology, CCS, using retrospective analysis of patients with acute upper gastrointestinal bleeding during the last five years. The aim of this study was to establish the number of upper gastrointestinal bleeding in our hospital during the last five years, and distribution of income according to type, difficulty, cause factors and risk factors of gastrointestinal bleeding and method of haemostasis. RESULTS: In Department of endoscopic haemostasis 3954 patients with upper gastrointestinal bleeding were endoscoped, and 33.4% of them had bleeding duodenal ulcer. Male patients were statistically significant more present than female patients in group with duodenal ulcer 71.8%: 28.2%). 79.7% patients with duodenal ulcer had only haematemesis, while 14.4% patients had haematemesis and melaena. 59.1% patients with bleeding duodenal ulcer consumed salicylates and/or non-steroidal anti-inflammatory drugs (NSAIDS) (statistical significant differences chi2 test; p = 0.007). Only endoscopic injection was used: in 36.8% of patients used injection of adrenaline solutions, while in 5.9% of patients used injection of adrenaline and absolute alcohol solutions. CONCLUSION: Using of therapeutic endoscopy improves better prognosis in patients who present with severe acute upper gastrointestinal bleeding. Endoscopist's experience is an important independent prognostic factor for acute upper gastrointestinal bleeding.

[Non-surgical approach to bleeding gastric ulcer].

Bleeding gastric ulcers is a common reason for emergency upper endoscopy in Emergency Center of Clinical Center of Serbia. Randomized controlled trials have shown that endoscopic hemostasis is beneficial for patients with a bleeding peptic ulcer. Aim of this study was to analyze the frequency, etiological factors and localization of bleeding gastric ulcer. At the same time we were evaluated a degree of bleeding activity according to Forrest's classification and modality of performed endoscopic hemostasis. All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding gastric ulcer in Emergency Center (January 2001 - December 2005.) were identified from an endoscopy database and the clinical records were reviewed retrospectivel. A total of 3954 patients underwent UGI endoscopy for presumed acute UGI hemorrhage. More than thirty % of them (31.1)-1230 had an endoscopic diagnosis of bleeding gastric ulcer. We observed 1230 bleeding patients (60% male and 40% female) with a mean age of 64.3. The commonest localization of bleeding gastric ulcers was antrum (54 - 15%). Percentage of patients who received non-steroidal anti-inflammatory drugs (NSAIDs) and/or salicilates before bleeding was 54 6%. The main symptom was melaena, which was observed in 82, 44% of patients with bleeding gastric ulcer. According to Forrest's classification of bleeding activity, the most of patients had F IB and F III degree (23, 41% and 22, 76%). Injection endoscopic hemostasis was performed in 26.34% patients, which had active bleeding (F IA, F IB) Hemostasis was initially obtained in 96% of bleeding patients. Bleeding gastric ulcer is one of the commonest endoscopic diagnosis in Emergency Center of Clinical Center of Serbia. The most frequent etiology factor was no--steroid antinflammatory drugs and/or salicilates. Injection endoscopic hemostasis is a safe procedure with a low cost, and, if successful, substantially reduces the need for emergency surgery.