Thermal therapy for gastrointestinal bleeding

Thermal therapies were the initial forms of endoscopic treatment for GI bleeding more than 20 years ago. Other new technologies have emerged, but thermal treatment with multipolar coagulation or heat probe therapy remains as good as newer techniques. Initial hemostasis rates continue to be 90% or greater. However, rebleeding in about 15% remains a problem. The devices are safe and generally affordable.     

Endoscopic injection treatment of gastrointestinal bleeding in hemophiliacs

The aims of this prospective study were to determine the patterns of gastrointestinal (GI) bleeding in hemophiliacs and to assess the hemostatic effect of injection therapy with alcohol. During a 5-year period (1990-1994) 89 hemophiliacs were admitted to our department with acute GI bleeding. Among these patients duodenal ulcer was found endoscopically to be the most common (42.7%) cause of hemorrhage; gastric ulcer was the source of the bleeding in only three patients (3.4%). A group of 46 patients met the criteria of active or recent bleeding and underwent injection therapy with alcohol. The injected bleeding lesions were duodenal ulcer in 32 patients, duodenal erosion in 2, gastric ulcer in 3, and other gastric lesions (Mallory-Weiss tear, Dieulafoy lesion, stomal ulcer, erosions) in 9 patients. Initial hemostasis was achieved in 100% and permanent hemostasis in 82.6%. Rebleeding was observed in eight patients (17.4%), with five of them successfully treated by reinjections. Three patients (6.5%) required emergency surgery. The mortality rate in the group of injected patients was 2.2%. One patient died of stroke on day 10 after partial gastrectomy. All injected patients were given replacement therapy with factor VIII or IX for 2 days (29 patients) or 7 to 14 days (17 patients). Analysis of the hemostatic effect achieved in these two subgroups indicate that short-term replacement therapy (2 days) may be sufficient to ensure adequate hemostasis in hemophiliacs. The results of the present study indicate that injection therapy with alcohol is an effective, safe, proved method to control GI bleeding in hemophiliacs.     

Does endoscopic hemostasis effect the reduction of mortality in patients with hemorrhage from the digestive tract?

BACKGROUND/AIMS: Endoscopy is the method of choice for localizing the sites of hemorrhage and transendoscopic hemostatic procedures in patients with hemorrhage from the digestive tract. The aim of the study was to establish the efficacy of endoscopic hemostasis and to analyze the mortality of patients with upper digestive tract hemorrhage. METHODOLOGY: The retrospective analysis included those patients who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions with injection sclerotherapy, laser photocoagulation or electrocoagulation of the hemorrhaging spot in the period between January 1994 and May 1995. RESULTS: 1000 patients were examined, 638 men and 362 women. In only 312 patients (31.2%) the examination revealed signs of acute or recent hemorrhage. Hemostatic interventions were performed in 275 (27.5%) cases. During hospitalization at the medical wards, 14 (9/275, 5.1%) patients died. In 9 patients (9/275, 3%) with acute hemorrhage, endoscopic hemostasis did not prove successful, therefore after several unsuccessfully repeated endoscopic interventions (21 in all), the patients were treated operatively. During the postoperative period, 4 patients died due to complications. CONCLUSIONS: Despite the development of endoscopic instruments and improved methods of hemostasis, mortality due to hemorrhage from the digestive tract has not dramatically decreased. Numerous demanding endoscopic procedures are usually carried out in older patients which also suffer from other diseases. These diseases represent the risk factors for eventual surgical treatment and the ensuing complications.     

Laser therapy for gastrointestinal bleeding

Lasers are important in the development of endoscopic treatment of gastrointestinal bleeding. Laser therapy was the first endoscopic therapy for hemostasis to be assessed in large numbers of randomized controlled trials. The evidence for efficacy of laser treatment of bleeding is greater than for any other endoscopic treatment method. No other therapy for GI bleeding has been as rigorously tested.     

Successful hemostasis during a major orthopedic operation by using recombinant activated factor VII in a patient with severe hemophilia A and a potent inhibitor

The treatment of bleeding episodes and the provision of perioperative hemostasis in patients with hemophilia in whom coagulation factor inhibitors have developed are a major therapeutic challenge because ordinary replacement therapy is usually ineffective. Herein we report the use of recombinant activated factor VII (rFVIIa) in providing successful hemostasis in a patient with hemophilia A and a high-titer inhibitor to factor VIII during a major orthopedic operation. rFVIIa (102 micrograms/kg) was administered intravenously every 2 to 3 hours for a total of 9 days. No excessive bleeding occurred intraoperatively or postoperatively, and no adverse effects attributable to rFVIIa were observed. This surgical procedure probably represented a greater hemostatic challenge than any previously reported operation in which rFVIIa was used. Thus, this article adds considerably to the growing body of literature that suggests the safety and efficacy of rFVIIa in providing perioperative hemostasis and treating severe bleeding episodes in patients with hemophilia and inhibitors refractory to other treatment modalities.     

Diabetic retinopathy should not be a contraindication to thrombolytic therapy for acute myocardial infarction: review of ocular hemorrhage incidence and location in the GUSTO-I trial. Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries

OBJECTIVES: This study sought to evaluate the incidence of ocular hemorrhage in patients with and without diabetes after thrombolytic therapy for acute myocardial infarction. BACKGROUND: Ocular hemorrhage after thrombolysis has been reported rarely. However, there is concern that the risk is increased in patients with diabetes. In fact, diabetic hemorrhagic retinopathy has been identified as a contraindication to thrombolytic therapy without clear evidence that these patients have an increased risk for ocular hemorrhage. METHODS: We identified all suspected ocular hemorrhages from bleeding complications reported in patients enrolled in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-I trial. Additional information was collected on a one-page data form. We compared the incidence and location of ocular hemorrhages in patients with and without diabetes. RESULTS: There were 40,899 patients (99.7%) with information about diabetic history and ocular bleeding. Twelve patients (0.03%) had an ocular hemorrhage. Intraocular hemorrhage was confirmed in only one patient. There were 6,011 patients (15%) with diabetes, of whom only 1 had an ocular hemorrhage (eyelid hematoma after a documented fall). The upper 95% confidence intervals for the incidence of intraocular hemorrhage in patients with and without diabetes were 0.05% and 0.006%, respectively. CONCLUSIONS: Ocular hemorrhage and, more important, intraocular hemorrhage after thrombolytic therapy for acute myocardial infarction is extremely uncommon. The calculated upper 95% confidence interval for the incidence of intraocular hemorrhage in patients with diabetes was only 0.05%. We conclude that diabetic retinopathy should not be considered a contraindication to thrombolysis in patients with an acute myocardial infarction.     

Effects of thyroid hormone replacement therapy on nocturnal apnea in elderly patients with hypothyroidism

BACKGROUND AND STUDY AIMS: Dieulafoy's disease is a rare cause of upper gastrointestinal tract hemorrhage. The aim of the study was to evaluate the efficacy of endoscopic hemostasis and to analyze the mortality of patients with hemorrhage due to Dieulafoy's disease. PATIENTS AND METHODS: The retrospective analysis included patients from our institution who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions in the period between January 1994 and December 1996. RESULTS: Twenty-five patients were examined (18 men and 7 women, average age 52.6, SD+/-15.3, range 25-78). In 20 patients endoscopic injection sclerotherapy was performed (diluted epinephrine 1:10,000 plus polidocanol 1%) and Nd:YAG laser photocoagulation in five patients. In all patients a total of 44 interventional endoscopies were carried out. Repeated endoscopic hemostasis did not prove successful in two patients (8%, 2 men), and they were treated operatively. During the postoperative period one patient died because of multiorgan failure. The total mortality rate of all patients in which endoscopic hemostasis was done was 16% (4/25). None of the 21 surviving patients had rebleeding on long-term follow-up (mean: 29.4 months). CONCLUSIONS: Endoscopic hemostasis is a major therapeutic advance in the management of Dieulafoy's disease hemorrhage. Interventional endoscopy has decreased the need for surgical management and significantly reduced mortality.     

Patterns of increased in vivo fundus autofluorescence in the junctional zone of geographic atrophy of the retinal pigment epithelium associated with age-related macular degeneration

BACKGROUND: The impact of upper endoscopy in patients with upper gastrointestinal hemorrhage treated in community practice is unknown. Thus we examined the effectiveness of endoscopy performed within 24 hours of admission (early endoscopy). METHODS: Medical records of 909 consecutive hospitalized patients with upper gastrointestinal hemorrhage who underwent endoscopy at 13 hospitals in a large metropolitan area were reviewed. We evaluated unadjusted and severity-adjusted associations of early endoscopy with recurrent bleeding or surgery to control hemorrhage, length of hospital stay, and associations of endoscopic therapy in patients with bleeding ulcers or varices. RESULTS: Early endoscopy was performed in 64% of patients and compared with delayed endoscopy and was associated with clinically significant reductions in adjusted risk of recurrent bleeding or surgery (odds ratio [OR] 0.70: 95% CI [0.44, 1.13]) and a 31% decrease in adjusted length of stay (95% CI: [24%, 37%]). In patients at high risk for recurrent bleeding, the use of early endoscopic therapy to control hemorrhage was associated with reductions in recurrent bleeding or surgery (OR 0.21: 95% CI [0.10, 0.47]) and length of stay (-31%: 95% CI [-44%, -14%). CONCLUSION: In this study of community-based practice, the routine use of endoscopy, and in selected cases endoscopic therapy, performed early in the clinical course of patients with upper gastrointestinal hemorrhage was associated with reductions in length of stay and, possibly, the risk of recurrent bleeding and surgery.     

Hiatal hernia with cameron ulcers and erosions

Cameron lesions are seen in 5.2% of patients with hiatal hernias who undergo EGD examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernia sac, with an increased prevalence the larger the hernia sac. In about two thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. Historically, Cameron lesions present clinically with chronic GI bleeding and associated iron deficiency anemia. With increased awareness of the existence of this lesion, however, it is now more frequently seen as an incidental finding during EGD. Cameron lesions can also present as acute upper GI bleeding, occasionally life-threatening, in up to one third of cases. Therefore, Cameron lesions should be considered in any patient in whom a hiatal hernia is noted during endoscopic examination. Concomitant acid-peptic diseases are seen in a majority of individuals, especially reflux esophagitis and its complications. Mechanical trauma, ischemia, and acid mucosal injury may play a role in the pathogenesis of Cameron lesions. The choice of therapy of Cameron lesions, medical or surgical, should be individualized for each patient. Of those patients who were treated with a spectrum of medical therapy and who have had long-term follow-up, about one third have had a recurrence of the lesion and 17% (8/48) have developed complications, most commonly either acute upper GI bleeding (6.3%) or persistent and recurrent iron deficiency anemia (8.3%).     

Efficiency of electro-hydrothermal coagulation in the management of non-variceal upper gastrointestinal bleeding

The data of 596 electro-hydrothermal coagulations in nonvariceal acute gastrointestinal bleeding were retrospectively evaluated and the results were compared to a previous period in which the endoscopic hemostasis was not regularly applied. Initial hemostasis was achieved in 96.1%, the rebleeding rate was 20.5%, perforation occurred in 0.5%. Comparing the two period the need of urgent surgery decreased from 9.2% to 3.4% (p < 0.05) and the mortality from 25.4% to 12% (p < 0.01). CONCLUSION: The electro-hydro-thermal coagulation is a safe and effective method in the treatment of nonvariceal gastrointestinal bleeding.     

Arterial disease and thrombosis in the antiphospholipid syndrome: a pathogenic role for endothelin 1

PURPOSE: It has been proposed that inferior vena cava filter placement should be the initial treatment of deep venous thrombosis (DVT) or pulmonary embolus (PE) in patients with coexisting malignant disease. We have chosen instead to selectively place filters only in patients with either a contraindication to anticoagulation therapy or a subsequent complication from anticoagulation therapy. The treatment efficacy and mortality rates in patients with concomitant malignant disease and venous thromboembolism using this approach was determined. METHODS: We retrospectively reviewed all patients at our institution with malignant disease in whom venous thromboembolism developed between August 1991 through August 1996 and identified 166 patients with PE (n = 8), DVT (n = 147), and DVT/PE (n = 11). Of these patients, 138 (83.1%) were initially treated with anticoagulation therapy, and 28 (16.9%) had primary filter placement because of contraindications to anticoagulation therapy (10 for intracranial tumors, 11 for recent or upcoming operations, 6 for recent hemorrhage, and 1 for a malignant bloody pericardial effusion). RESULTS: Thirty-two (23%) of the 138 patients who initially underwent anticoagulation therapy subsequently required a filter for the following reasons: bleeding (n = 15, 10.9%); recurrent thromboembolism (n = 6, 4.3%); heparin-induced thrombocytopenia (n = 1, 0.7%); and perceived high risk for bleeding with continued anticoagulation therapy (n = 11, 8%). Both bleeding and recurrent thromboembolism developed in 1 patient. Sixty patients (36%) received filters. No major technical complications occurred from filter placement. Major recurrent thromboembolic complications developed in 10 patients: DVT (n = 6, 10%), PE (n = 2, 3.3%), inferior vena cava thrombosis and phlegmasia cerulea dolens (n = 1, 1.7%), superior vena cava thrombosis (n = 1, 1.7%). Venous gangrene developed in 1 patient with DVT. The 1-year actuarial survival rates for patients treated with filter and anticoagulation therapy were 35% and 38%, respectively (P = NS). CONCLUSION: In summary, our experience suggests that 64% of patients with malignant disease and venous thromboembolism are effectively treated with anticoagulation alone; 17% require primary filter placement for standard indications, and an additional 19% require subsequent filter placement because of complications (primarily bleeding) or failure of anticoagulation therapy. Although technical complications of filter placement are low, serious life-threatening or limb-threatening thromboembolic complications developed in 17% of patients. Survival was poor in all patients, regardless of treatment. These data support a conservative approach of routine anticoagulation therapy with selective filter placement.     

Recurrent source of bleeding in patients with esophageal varices]

During last 7 years were in Endoscopic Centre of Brno Traumatologic Hospital treated 824 patients (624 male, 200 female) with esophageal varices, indicated to endoscopic sclerotherapy, ligation, or tissue adhesive injection. For one or more episodes of bleeding were treated 659 patients and resting 165 received therapy prophylactically. Recurrent acute bleeding from upper GIT occurred from 1 January 1990 to 30 April 1997 in 212 of them. In patients with previously proved esophageal varices were investigated for repetitive acute bleeding in this period 212 of them. In 157 (74%) patients endoscopy confirmed expected repetitive bleeding from esophageal varices, but in 55 (26%) was found bleeding from other source of upper gastrointestinal tract. The bleeding from gastroduodenal ulcers in 18 (8%) patients, in 22 (10%) from apths, Mallory-Weiss syndrome was source of bleeding in 8 (4%) patients, and hemorrhagic gastropathy in 7 (3%) was found. The authors draw attention to the fact that, in their big group patients with esophageal varices, duplicity of source of bleeding occurred in 1/4 patients. They concluded, that in patients with previously proved esophageal varices in necessary to perform in case of recurrent bleeding emergency of urgent endoscopy not only of esophagus, but even of whole upper GIT. Therapeutic mistake can happen in 1/4 of patients, if repetitive bleeding from varices would be expected and automatically treated by balloon tube. The patients could be damaged by delay in the treatment of bleeding from other source.     

Risk factors of recurrence in 157 MB/PNET patients treated in one institution

BACKGROUND: Epistaxis is one of the most common otolaryngological emergencies. In cases of bleeding from the anterior or the lower posterior part of the nose, epistaxis could usually be treated with cauterization and anterior or posterior nasal packing. More invasive methods of treatment are the endonasal coagulation of the sphenopalatine artery and the transantral ligation of the maxillary artery. Bleeding from the upper posterior part of the nose usually originates from the anterior and the posterior ethmoidal artery. In most cases a specific styptic treatment in the upper posterior part of the nose is not possible because of a diffuse bleeding from the ethmoidal arteries into the ethmoidal sinus and the lateral wall of the nasal cavity. In this study the endoscopic ethmoidectomy is presented as the therapy of epistaxis from the ethmoidal arteries. PATIENTS AND RESULTS: In the retrospective study the charts of twenty patients with intractable epistaxis from the upper posterior part of the nasal cavity were reviewed. In all cases the bleeding could not be controlled with anterior and posterior nasal packing. In seventeen patients the bleeding could be controlled with a unilateral or bilateral endoscopic ethmoidectomy (average follow-up: 36.5 months). Three patients who complained of a coagulopathy and an arterial hypertonia developed diffuse recurrent bleeding from multiple sources. In one case the recurrent bleeding was controlled by an unilateral transantral ligation of the maxillary artery and a bilateral revision of the ethmoidectomy. In two patients the recurrent bleeding was treated with bilateral posterior nasal packing. CONCLUSION: The endoscopic ethmoidectomy is an efficient therapy of intractable epistaxis from the ethmoidal arteries if systemic coagulopathy and arterial hypertonia are excluded. The ethmoidectomy can be performed by any head and neck surgeon who is familiar with endonasal surgery.     

The epidemiology of hemorrhage from the upper gastrointestinal tract in the mid-nineties--has anything changed?

BACKGROUND/AIMS: Gastrointestinal hemorrhage is a frequent medical problem and a significant cause of morbidity and mortality. The aim of this retrospective analysis, which was carried out at our institution, was to establish the causes of hemorrhage from the upper digestive tract during a 3-year period. METHODOLOGY: The retrospective study includes those patients in which urgent endoscopic investigations of the upper digestive tract were carried out between 1 January 1994 and 31 December 1996. RESULTS: 2150 patients were investigated: 797 women and 1353 men. The average age of our patients was 57 years (a 3-97 year span, SD+/-17). In 665 patients (35.8%), endoscopic investigation of the upper digestive tube revealed signs of acute hemorrhage or traces of previous hemorrhage. Endoscopic hemostasis was carried out in 577 cases (31.1%). Sequelae of ulcer disease were the cause of hemorrhage in 46.1% of investigated patients. Frequent causes of hemorrhage were also inflammatory, hemorrhagically-erosive changes of the gastric and duodenal mucosa (21.9%), ruptured esophageal varices (9.4%), and esophageal reflux disease (8.0%). In 13.6% of patients the cause of hemorrhage did not lie in the upper digestive tract. In 50.3% of cases the gastrointestinal hemorrhage manifested itself by the discharge of melenic feces, and in 33.1% by hematemesis. 47.2% of our patients were aged over 60. CONCLUSIONS: Also in our society sequelae of ulcer disease are the most significant cause of gastrointestinal hemorrhage. Hemorrhages are frequent in elderly patients who usually have accompanying diseases.     

Portal hypertension: A surgical hepatologist's view of current management

Current strategies for management of acute esophageal variceal bleeding and for long-term treatment after an episode of variceal bleeding are outlined. Acute variceal bleeding is best managed by means of endoscopic therapy (sclerotherapy, band ligation, or "superglue"), whereas the role of pharmacologic agents remains controversial. In cases of failure of endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) procedure, an emergency shunt, or a transection operation should be performed. Patients who experience an acute variceal bleeding episode require long-term management to prevent recurrent bleeding. Endoscopic treatment is preferred using either sclerotherapy or banding. The principal alternative is long-term pharmacologic therapy with beta-adrenergic receptor blocking agents. Major surgical procedures should be reserved for failures of endoscopic or pharmacologic therapy. The distal splenorenal shunt or the new narrow-diameter polytetrafluoroethylene portacaval shunt is preferred. All patients who are first seen with acute variceal bleeding should be considered for a liver transplant, although few will ultimately become transplant candidates. Patients with end-stage liver disease who are not transplant candidates should be identified and major high-cost therapy discontinued. Prophylactic therapy prior to variceal bleeding should be considered in selected patients. At present, only pharmacologic therapy is justified. The major problem remains identification of those patients at high risk for a first episode of variceal bleeding.     

Endoscopic appearances of hemorrhagic peptic ulcers and efficacy of H2-receptor antagonists

BACKGROUND/AIMS: In this retrospective study, we compared the effects of histamine H2-receptor antagonists to those of antacids and anticholinergics in patients with hemorrhagic ulcers with various endoscopic appearances of bleeding. PATIENTS AND METHODS: Patients with hemorrhagic ulcers (n = 376) were examined by emergency endoscopy and were treated with 1) antacids and anticholinergic drugs or 2) H2-receptor antagonists. RESULTS: In ulcer patients with oozing or fresh red coagulation, H2-receptor antagonists ceased further hemorrhage more effectively (65.9% of the cases) than antacids and anticholinergic drugs (46.7%). In patients with projectile bleeding, both of the treatments failed to stop hemorrhage. There were no significant differences in favorable outcome in the patients only with old black coagulation between antacid and anticholinergic drugs-treated group and H2-receptor antagonists-treated group (94.4% and 93.8%, respectively). CONCLUSIONS: The results suggest that H2-receptor antagonists are more effective than antacids and anticholinergic drugs in patents with peptic ulcer with fresh coagulation or oozing, but not with projectile bleeding or old black coagulation. The results also indicate that endoscopic appearances of peptic ulcer bleeding are good predictors for the effects of medication.     

Injection of fibrin tissue adhesive versus laser photocoagulation in the treatment of high-risk bleeding peptic ulcers: a controlled randomized study

BACKGROUND AND STUDY AIMS: A controlled and randomized multicenter study was carried out in order to compare the efficacy of fibrin sealant and Nd:YAG laser photocoagulation in patients with high-risk arterial bleeding from peptic ulcers of the stomach and the small intestine. PATIENTS AND METHODS: In four teaching hospitals, 53 patients presenting with either active arterial ulcer bleeding (Forrest class 1 a) or a large visible vessel in the ulcer base (diameter over 2 mm, Forrest class 2 a) were treated with infiltration of epinephrine 1: 10,000 followed by the injection of fibrin tissue adhesive (n = 28), or with epinephrine plus laser photocoagulation (n = 25). Permanent hemostasis for at least seven days served as the principal end point; rebleeding, emergency surgery, and hospital mortality served as further end points. RESULTS: There were no significant differences between the study groups in terms of age, risk factors, initial hemoglobin values, number of patients showing signs of hemodynamic impairment, ulcer size and localization, or bleeding activity. Primary hemostasis was achieved in all patients. Rebleeding rates were seven of 28 and four of 25 among the patients treated with fibrin sealant and laser coagulation, respectively (not significant). There were no significant differences regarding the rates of ultimate hemostasis (24 of 28 vs. 24 of 25), emergency surgery (four of 28 vs. one of 25), or hospital mortality (0 vs. two of 25). No complications occurred with either form of treatment. Patients who had a visible vessel in the ulcer floor at the first control endoscopy had a significantly higher incidence of rebleeding, regardless of the type of endoscopic therapy. CONCLUSIONS: We conclude that both the injection of fibrin tissue adhesive and laser photocoagulation are effective methods of treating high-risk arterial peptic ulcer bleeding. As the number of high-risk patients necessary to reach significance are difficult to recruit within a reasonable period even in a multicenter study, a new meta-analysis of all studies now available should be considered.     

Possible pathogenic role of IL-16 on SLE: with reference to HIV-1 infection]

PURPOSE: To evaluate percutaneous embolotherapy in the treatment of lower gastrointestinal hemorrhage. MATERIALS AND METHODS: Twenty-one patients who underwent attempted percutaneous embolization for acute lower gastrointestinal bleeding between 1982 and 1997 were retrospectively studied. Hemorrhagic sites included jejunum (n = 4), ileum (n = 4), cecum (n = 4), and the remaining colon (n = 9). RESULTS: Embolization was not technically possible in four patients (19%). Hemostasis was achieved in 15 patients (71%) with prolonged hemostasis in 10 (48%). All embolizations distal to the cecum resulted in prolonged hemostasis. Three of four patients with jejunal bleeding had recurrent bleeding after apparent successful embolization. Only one of four cecal embolizations achieved prolonged cessation of bleeding. No ischemic complications were identified. CONCLUSION: Based on these data, it would appear that the risk of bowel ischemia/infarction in the lower gastrointestinal tract may not be as high as has been suggested. Two regions (cecum and proximal jejunum) were associated with poor results, suggesting these areas may not be as responsive to embolotherapy as other sites in the lower gastrointestinal tract.     

Stigmata of hemorrhage in bleeding ulcers

Models for predicting rebleeding after upper GI bleeding, and practice guidelines to determine management of these patients, must include not only endoscopic findings but clinical variables, such as severity of blood loss and the age and comorbidity of the patient. The importance of these variables in determining rebleeding risk, and the high degree of interobserver variability in identifying stigmata of hemorrhage, suggest that management strategies based too heavily on stigmata result in inappropriate discharge of some patients. The validity of various management strategies incorporating stigmata of hemorrhage needs to be prospectively assessed.     

Timing waveform analysis

PURPOSE: To determine the diagnostic yield of routine admission chest radiographs in patients with acute gastrointestinal (GI) hemorrhage and clinical predictors of radiographic abnormalities. PATIENTS AND METHODS: The study was a retrospective series of 202 adult patients with GI hemorrhage admitted to intensive care units at an academic medical center. Routine admission chest radiographs were obtained in 161 patients. These radiographs were reviewed by a study radiologist blinded to the study purpose. The radiologist scored radiographic abnormalities into categories of "minor" or "major," "new" or "previously known," and "with an intervention" or "without an intervention." Nominal logistic regression explored the data for clinical features that identified patients with major new radiographic abnormalities with or without an intervention. RESULTS: Minor radiographic abnormalities were noted in 23 (14.3%) patients, of whom 17 (10.6%) patients had "new" (previously unknown) abnormalities. No minor abnormality prompted a therapeutic or diagnostic intervention. Major radiographic abnormalities were detected in 21 (13.0%) patients, of whom 19 (11.8%) had new findings. Major new findings prompted interventions in only 9 (5.6%) of patients. A history of lung disease and an abnormal lung physical examination predicted major new radiographic findings (P = 0.0001, sensitivity 79%, negative predictive value 96%). These variables also identified major new abnormalities that prompted interventions (P = 0.007, sensitivity 89%, negative predictive value 99%). Use of the logistic regression model to select patients for admission chest radiographs decreased charges from $1,068 to $580 for each detected major new radiographic abnormality and from $2,254 to $1,087 for major new radiographic abnormalities that prompted an intervention. CONCLUSION: These data indicate that routine chest radiographs have a low yield in detecting major new radiographic abnormalities in patients with acute GI hemorrhage. Clinical criteria, available at the time of admission, may be useful for selecting patients for chest radiographic evaluations.