DOCSLIB.ORG

Predictors of Non-Significant Endoscopic Findings in Patients with Suspected Upper Gastrointestinal Tract Hemorrhage

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Predictors of Non-Significant Endoscopic Findings in Patients with Suspected Upper Gastrointestinal Tract Hemorrhage Predictors of Non-Significant Endoscopic Findings in Patients with Suspected Upper Gastrointestinal Tract Hemorrhage Preeda Sumritpradit MD*, Suwat Tangkittimasak MD*, Panuwat Lertsithichai MD* * Department of Surgery, Ramathibodi Hospital and Medical School, Mahidol University Objectives: The objective of the present study was to determine pre-endoscopic predictive factors of non- significant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage (UGIH). Material and Method: Medical records of 187 patients admitted with the primary diagnosis of UGIH were reviewed. Non-significant endoscopic findings were defined as “normal”, “mild gastritis” or unspecified gastritis with a hospital stay of two days or less. Possible predictors of non-significant endoscopic findings included pertinent history, physical examination, nasogastric tube aspirate, routine laboratory findings, and units of infused packed red cells (PRC). Multiple logistic regression analysis was used to determine signifi- cant predictors. Results: Predictors of non-significant endoscopic findings included the absence of comorbid diseases (OR: 6.4; 95%CI: 3.0-13.6), higher platelet count (OR: 1.7 per 100,000 increase; 95%CI: 1.1-2.5) and less PRC infusion (OR: 1.9 per unit decrease; 95%CI: 1.3-2.7). Conclusion: Patients with UGIH who may have a negative EGD can be identified prior to endoscopy. Keywords: Predictors, Non-significant findings, Endoscopy, Upper gastrointestinal hemorrhage J Med Assoc Thai 2005; 88 (9): 1207-13 Full text. e-Journal: http://www.medassocthai.org/journal Acute upper gastrointestinal tract hemorrhage reducing hospitalization costs(6,12). For example, many (UGIH) remains a major cause of morbidity and mor- patients are hospitalized while awaiting EGD. The tality(1,2). Urgent esophagogastroduodenoscopy (EGD) ability to recognize patients who may or may not need is widely recommended for patients presenting with urgent EGD should reduce some of these costs(12). It acute UGIH in the emergency department. EGD can can be further proposed that a subgroup of these provide definitive diagnoses of the cause of UGIH as patients may not need EGD at all. These patients in- well as treatment for actively bleeding lesions(3,4). How- clude those diagnosed as having suspected UGIH but ever, 80% of UGIH patients have an uncomplicated with normal EGD findings or other “non-significant” course(5). If it is possible to identify these patients prior findings such as “mild gastritis” or “mild duodenitis”. to EGD, then a less costly or less risky level of care can The objective of the present study was to be provided without compromising outcome(6-8), for determine which pre-endoscopic predictive factors can example by foregoing urgent EGD. be used to distinguish between acute UGIH patients There is some evidence that 20% to 30% of who do not have significant EGD findings and those patients presenting with UGIH can be safely managed who do. in an outpatient setting(9-11). Studies have been con- ducted to identify such patients with the hope of Material and Method Medical charts of patients who were admitted Correspondence to : Lertsithichai P, Department of Surgery, to the authors’ hospital with the primary diagnosis of Ramathibodi Hospital and Medical School, Mahidol University, Bangkok 10400, Thailand. Phone: 0-2201-1315, Fax: 0-2201- UGIH during the period between May 2003 and July 1316, E-mail: [email protected] 2004 were reviewed. Patients were included if they J Med Assoc Thai Vol. 88 No.9 2005 1207 underwent urgent EGD (within 24 - 48 hrs after admis- deviation, 17.9 years). Potential predictive factors for sion). Patients were excluded if they were hospitalized non-significant EGD findings are presented in Table 1, for other illnesses, if they had severe cardiopulmonary separately for patients with non-significant EGD find- diseases, severe hematologic derangement and ings and for those with significant findings. Fifty-five advanced cancer. A total of 187 patients were enrolled. patients (29%) were found to have non-significant Data on pre-endoscopic predictive factors EGD findings. Details of the EGD findings are shown in potentially able to help discriminate between UGIH Table 2. The most common EGD finding was gastritis patients without significant EGD findings and those (38%). with such findings were abstracted. These factors On bivariable analysis, sex, history associated included age and sex, history associated with the cur- with current UGIH episode, history of previous UGIH rent bleeding episode, documented history of comorbid episodes and concomitant drug use, with the excep- diseases and medications used, results of pertinent tion of aspirin, were not associated with EGD findings. physical examination, results of nasogastric (NG) tube Younger age was, however, associated with non- aspirates, basic laboratory investigations, and units of significant findings. Almost all comorbid diseases were blood components infused. Details of these factors significantly associated with significant EGD findings. and their measures are presented in Table 1. A variable defined by the absence of any comorbid The primary outcome of the present study diseases was most significantly associated with non- was the EGD findings. These findings were abstracted significant EGD findings. from endoscopic report forms available both electroni- Interestingly, blood pressure at presentation cally and in the medical charts. “Non-significant” EGD was not associated with EGD findings although there findings were defined as either “normal” EGD findings, was a tendency for patients with non-significant EGD or findings of “mild gastritis”, “mild duodenitis”, “gas- findings to have higher blood pressure. Most of the tritis” along with a hospital stay no longer than 48 hrs. patients in the present study were hemodynamically Other EGD findings were considered “significant”. stable on presentation (66% and 60% of patients had “Bivariable” association between each pre- a systolic and diastolic blood pressure greater than dictive factor and the EGD finding of non-significant 100 and 60 mmHg, respectively). Physical findings of or significant lesions was tested using the t-test, chronic liver disease, anemia and melena were asso- Wilcoxon ranksum test, or chi-square test (including ciated with significant EGD findings, as was a bloody Fisher’s exact test) as appropriate(13). Factors found aspirate from the NG tube. to be significantly associated with EGD findings on Blood counts were not associated with EGD bivariable analysis were entered in a multiple logistic findings, with the exception of platelet counts. Bio- regression model. Factors remaining statistically sig- chemical renal function tests were not associated EGD nificant in the model were retained in the final model. findings, although abnormal liver function tests were The discriminatory ability of the final multiple logistic associated with significant EGD findings. Finally, the regression model was measured using the Area Under number of units of packed red cells (PRC) infused were the receiver operating characteristic Curve (AUC)(14). significantly associated with EGD findings. Cross-validity of the model was assessed using the On multivariable analysis, the only remaining jackknife method(13). Statistical significance was defined significant predictors of non-significant EGD findings as a test p-value of 0.05 or less. were the absence of comorbid diseases or conditions, A simple clinical prediction rule was created higher platelet counts and less PRC infusions (Table 3). based on the multiple logistic regression model, It is interesting to note that physical findings, NG tube emphasizing high specificity. This was because in aspirates, and other routine laboratory tests were no order not to perform an EGD, the clinician must be able longer significant in the multiple logistic regression to predict with near certainty that the EGD findings will model. The AUC of the model was 0.83, and the jack- be non-significant. Hence the prediction rule must be knife AUC was 0.81. highly specific. A simple clinical prediction rule was created, by which a clinician might exclude a UGIH patient from Results undergoing urgent EGD or not to undergo EGD at all. Data were available for all 187 patients iden- Based on the multiple logistic regression model, the tified. There were 118 men (63%) and 69 women (37%) simplest rule with the highest specificity was “the in the cohort. The mean age was 53.5 years (standard absence of comorbid diseases, with a platelet count 1208 J Med Assoc Thai Vol. 88 No.9 2005 Table 1. Predictive factors for “non-significant” EGD findings Predictive factors Total (n = 187) Significant EGD Non-significant EGD p-values findings (n = 132) findings (n = 55) Age (years): mean (sd) 53.5 (17.9) 57.3 (16.8) 44.2 (17.1) <0.001 a Sex (male): number (%) 118/187 (63) 86/132 (65) 32/55 (58) 0.368 b History Coffee ground emesis: number (%) 59/187 (32) 41/132 (31) 18/55 (33) 0.823 b Hematemesis: number (%) 53/187 (28) 37/132 (28) 16/55 (29) 0.883 b Melena: number (%) 129/187 (69) 95/132 (72) 34/55 (62) 0.171 b Syncope: number (%) 93/187 (50) 67/132 (51) 26/55 (47) 0.664 b Peptic ulcer disease: number (%) 66/187 (35) 45/132 (34) 21/55 (38) 0.594 b First bleeding episode (yes): number (%) 121/187 (65) 81/132 (62) 40/55 (73) 0.138 b Medications and substances NSAIDS use (yes): number (%) 42/187 (22) 27/132 (20) 16/55 (29) 0.161 b ASA use (yes): number (%) 31/187 (17) 27/132 (20) 4/55 (7) 0.027 b
Load more

Recommended publications
  • Safety of Heparin Bridging Therapy for Transrectal Ultrasound-Guided Prostate Biopsy in Patients Requiring Temporary Discontinua
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Springer - Publisher Connector Hamano et al. SpringerPlus (2016) 5:1917 DOI 10.1186/s40064-016-3610-6 RESEARCH Open Access Safety of heparin bridging therapy for transrectal ultrasound‑guided prostate biopsy in patients requiring temporary discontinuation of antithrombotic agents Itsuto Hamano1, Shingo Hatakeyama1* , Tohru Yoneyama2, Yuki Tobisawa1, Osamu Soma1, Teppei Matsumoto1, Hayato Yamamoto1, Atsushi Imai2, Takahiro Yoneyama2, Yasuhiro Hashimoto2, Takuya Koie1 and Chikara Ohyama1,2 Abstract Background: Safety of heparin bridging therapy for transrectal ultrasound-guided prostate (TRUS) biopsy in patients requiring temporary discontinuation of antithrombotic therapy is unknown. This study aimed to assess the relation- ship between heparin bridging therapy and the incidence of complications after TRUS biopsy. Methods: From January 2005 to November 2015, we performed 1307 consecutive TRUS biopsies on 1134 patients in our hospital. The patients were assigned to two groups: those without heparin bridging (the control group) and those with temporary discontinuation of antithrombotic agents with heparin bridging therapy (the bridging group). A 10–12-core TRUS biopsy was performed; the patients were evaluated for bleeding-related complications. Results: Of 1134 patients, 1109 (1281 biopsies) and 25 (26 biopsies) were assigned to the control and bridging group, respectively. Patient background did not significantly differ between the control and bridging groups, except for age, history of diabetes, cardiovascular diseases, and CHADS2 scores. Compared with the control group, the bridg- ing group showed a significantly higher rate of complication for any complication (35 vs. 8.3%, P < 0.001), bleeding- related complications (27 vs.
    [Show full text]
  • Predictive Score for Positive Upper Endoscopies Outcomes in Children with Upper Gastrointestinal Bleeding. Score Prédictif De L
    Predictive score for positive upper endoscopies outcomes in children with upper gastrointestinal bleeding. score prédictif de la présence de lésions endoscopiques dans l’hémorragie digestive haute de l’enfant Sonia Mazigh 1, Rania Ben Rabeh 1, Salem Yahiaoui 1, Béchir Zouari 2, Samir Boukthir 1, Azza Sammoud 1 1- Service de médecine C Hôpital d'enfants Béchir Hamza de Tunis- Université de Tunis El Manar, Faculté de Médecine de Tunis 2- Département d'épidémiologie et de médecine préventive - Université Tunis El Manar, Faculté de Médecine de Tunis, résumé summary Prérequis: L'hémorragie digestive haute (HDH) est une urgence Background: Upper gastrointestinal bleeding (UGIB) is a common fréquente en pédiatrie. L'endoscopie digestive haute (EDH) est pediatric emergency. Esophago-gastro-duodenoscopy (EGD) is the l'examen de choix pour identifier l’origine du saignement. first line diagnostic procedure to identify the source of bleeding. Néanmoins l’étiologie demeure inconnue dans 20% des cas. En However etiology of UGIB remains unknown in 20% of cases. outre, l'endoscopie d'urgence n'est pas disponible dans de Furthermore, emergency endoscopy is unavailable in many hospitals nombreux hôpitaux dans notre pays . in our country. Objectifs: Décrire les lésions endoscopiques retrouvées chez Aims: Identify clinical predictors of positive upper endoscopy l'enfant dans l'HDH, identifier les facteurs prédictifs de la présence outcomes and develop a clinical prediction rule from these de ces lésions et élaborer un score clinique à partir de ces parameters. paramètres. Methods: Retrospective study of EGDs performed in children with Méthodes: Etude rétrospective des EDH réalisées chez les enfants first episode of UGIB, in the endoscopic unit of Children's Hospital of présentant un premier épisode d'HDH, à l'unité d'endoscopie Tunis, during a period of six years.
    [Show full text]
  • Colorectal Cancer Health Services Research Study Protocol: the CCR-CARESS Observational Prospective Cohort Project José M
    Quintana et al. BMC Cancer (2016) 16:435 DOI 10.1186/s12885-016-2475-y STUDYPROTOCOL Open Access Colorectal cancer health services research study protocol: the CCR-CARESS observational prospective cohort project José M. Quintana1,8* , Nerea Gonzalez1,8, Ane Anton-Ladislao1,8, Maximino Redondo2,8, Marisa Bare3,8, Nerea Fernandez de Larrea4,8, Eduardo Briones5, Antonio Escobar6,8, Cristina Sarasqueta7,8, Susana Garcia-Gutierrez1,8, Urko Aguirre1,8 and for the REDISSEC-CARESS/CCR group Abstract Background: Colorectal cancers are one of the most common forms of malignancy worldwide. But two significant areas of research less studied deserve attention: health services use and development of patient stratification risk tools for these patients. Methods: Design: a prospective multicenter cohort study with a follow up period of up to 5 years after surgical intervention. Participant centers: 22 hospitals representing six autonomous communities of Spain. Participants/Study population: Patients diagnosed with colorectal cancer that have undergone surgical intervention and have consented to participate in the study between June 2010 and December 2012. Variables collected include pre-intervention background, sociodemographic parameters, hospital admission records, biological and clinical parameters, treatment information, and outcomes up to 5 years after surgical intervention. Patients completed the following questionnaires prior to surgery and in the follow up period: EuroQol-5D, EORTC QLQ-C30 (The European Organization for Research and Treatment of Cancer quality of life questionnaire) and QLQ-CR29 (module for colorectal cancer), the Duke Functional Social Support Questionnaire, the Hospital Anxiety and Depression Scale, and the Barthel Index. The main endpoints of the study are mortality, tumor recurrence, major complications, readmissions, and changes in health-related quality of life at 30 days and at 1, 2, 3 and 5 years after surgical intervention.
    [Show full text]
  • Cals Provider Manual the First 30 Minutes Edition 15 2019
    COMPREHENSIVE ADVANCED LIFE SUPPORT CALS PROVIDER MANUAL THE FIRST 30 MINUTES EDITION 15 2019 DIRECTOR: DARRELL CARTER, MD EDUCATION MANAGER: Ann Gihl, RN Comprehensive Advanced Life Support © January 2019 All Rights Reserved www.calsprogram.org NOTE TO USERS The CALS course was developed for rural and other healthcare providers who work in an environment with limited resources, but who are also responsible for the emergency care in their often geographically isolated communities. Based on needs assessment and ongoing provider participant feedback, the CALS course endorses practical evaluation and treatment recommendations that reflect broad consensus and time-tested approaches. The organization of the CALS Provider Manual reflects the CALS Universal Approach. The FIRST THIRTY MINUTES (previously known as Volume 1) of patient care. ACUTE CARE ALGORITHMS/ TREATMENT PLANS/AND ACRONYMS provide critical care tools and are designed for quick access. The STEPS describe a system to diagnose and treat emergent patients. The FOCUSED CLINICAL PATHWAYS provide a brief review of most conditions encountered in the emergency setting. Supplement to the First Thirty Minutes (previously known as Volume 2) is composed of RESUSCITATION PROCEDURES divided into appropriate areas of clinical expertise, which illustrate hands-on techniques. Reference material for the First thirty Minutes (previously known as Volume 3) is composed of DIAGNOSIS, TREATMENT, AND TRANSITION TO DEFINITIVE CARE PORTALS, is also divided into appropriate areas of clinical expertise. In conjunction with the FOCUSED CLINICAL PATHWAYS, these detail further specialized guidelines on many conditions. Recommendations in the CALS course manual are aligned with those from organizations such as the American Heart Association, American College of Surgeons, American Academy of Family Physicians, American College of Emergency Physicians, American Academy of Neurology, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, National Institutes of Health, and Centers for Disease Control.
    [Show full text]
  • Acute Lower Gastrointestinal Bleeding
    The new england journal of medicine Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Acute Lower Gastrointestinal Bleeding Ian M. Gralnek, M.D., M.S.H.S., Ziv Neeman, M.D., and Lisa L. Strate, M.D., M.P.H.​​ This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors’ clinical recommendations. From the Institute of Gastroenterology A 71-year-old woman with hypertension, hypercholesterolemia, and ischemic heart and Hepatology (I.M.G.) and Medical disease, who had a cardiac stent placed 4 months earlier, presents to the emergency Imaging Institute (Z.N.), Emek Medical Center, Afula, and Rappaport Faculty of department with multiple episodes of red or maroon-colored stool mixed with clots Medicine, Technion–Israel Institute of Tech­ during the preceding 24 hours. Current medications include atenolol, atorvastatin, nology, Haifa (I.M.G.) — both in Israel; aspirin (81 mg daily), and clopidogrel. On physical examination, the patient is dia- and the Department of Medicine, Divi­ sion of Gastroenterology, University of phoretic. While she is in a supine position, the heart rate is 91 beats per minute and Washington School of Medicine, Seattle the blood pressure is 106/61 mm Hg; while she is sitting, the heart rate is 107 beats (L.L.S.). Address reprint requests to Dr. per minute and the blood pressure is 92/52 mm Hg. The remainder of the examina- Gralnek at the Institute of Gastroenterol­ ogy and Hepatology, Emek Medical Cen­ tion is unremarkable, except for maroon-colored stool on digital rectal examination.
    [Show full text]
  • BILIARY ATRESIA, Treatment Results and Native Liver Function
    Pediatric Surgery and Pediatric Graduate School, Children’s Hospital Institute of Clinical Medicine, University of Helsinki and National Graduate School of Clinical Investigation Helsinki, Finland BILIARY ATRESIA Treatment Results and Native Liver Function HANNA LAMPELA ACADEMIC DISSERTATION To be publicly discussed, with the permission of the Faculty of Medicine, University of Helsinki, in the Niilo Hallman Auditorium, Children’s Hospital, on 1st of March 2013, at 12 noon. Helsinki 2013 Supervisor Docent Mikko Pakarinen Pediatric Surgery Pediatric Transplantation Surgery Children’s Hospital University of Helsinki Finland Reviewers Docent Tarja Ruuska Pediatrics Tampere University Hospital Tampere, Finland Docent Paulina Salminen Gastrointestinal Surgery Turku University Hospital Turku, Finland Opponent Professor Mark Davenport Paediatric Surgery King’s College Hospital London, UK ISBN 978-952-10-8592-5 (paperback) ISBN 978-952-10-8593-2 (PDF) http://ethesis.helsinki.fi Unigrafia Oy Helsinki 2013 “And if I have the gift of prophecy, and know all mysteries and all knowledge; and if I have all faith, so as to remove mountains, but have not love, I am nothing.” 1. Corinthians 13:2 CONTENTS ABSTRACT 6 LIST OF ORIGINAL PUBLICATIONS 8 ABBREVIATIONS 9 INTRODUCTION 10 REVIEW OF THE LITERATURE 11 History 11 Early descriptions 11 Development of operative techniques 11 Classifications 13 Epidemiology 14 Incidence 14 Seasonality 14 Etiology 14 Isolated BA 14 Congenital BA 15 Diagnosis 16 Symptoms and screening 16 Diagnostic tools and differential
    [Show full text]
  • Stent Placement for Benign Esophageal Leaks, Perforations, and Fistulae: a Clinical Prediction Rule for Successful Leakage Control
    Original article Stent placement for benign esophageal leaks, perforations, and fistulae: a clinical prediction rule for successful leakage control Authors Emo E. van Halsema1,WouterF.W.Kappelle2,BasL.A.M.Weusten3, Robert Lindeboom4, Mark I. van Berge Henegouwen5,PaulFockens1, Frank P. Vleggaar2, Manon C. W. Spaander6,JeaninE.vanHooft1 Institutions Scan this QR-Code for the authorʼs interview. 1 Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands 2 Department of Gastroenterology and Hepatology, University Medical Center Utrecht, the Netherlands 3 Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands 4 Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, Amsterdam, the Netherlands ABSTRACT 5 Department of Surgery, Academic Medical Center, Background and study aims Sealing esophageal leaks by Amsterdam, the Netherlands stent placement allows healing in 44%– 94% of patients. 6 Department of Gastroenterology and Hepatology, Weaimedtodevelopapredictionruletopredictthechance Erasmus University Medical Center, Rotterdam, the of successful stent therapy. Netherlands Patients and methods In this multicenter retrospective cohort study, patients with benign upper gastrointestinal submitted 26.4.2017 leakage treated with stent placement were included. We accepted after revision 26.7.2017 used logistic regression analysis including four known clini- cal predictors of stent therapy outcome. The model per- Bibliography formance to predict successful stent therapy was evaluated DOI https://doi.org/10.1055/s-0043-118591 in an independent validation sample. Published online: 21.9.2017 | Endoscopy 2018; 50: 98–108 Results We included etiology, location, C-reactive protein, © Georg Thieme Verlag KG Stuttgart · New York and size of the leak as clinical predictors. The model was es- ISSN 0013-726X timated from 145 patients (derivation sample), and 59 pa- tients were included in the validation sample.
    [Show full text]
  • Biliary Atresia
    6 Biliary atresia MARK DAVENPORT 6.1 Historical aspects Property of Taylor & Francis71 Group6.6 -Su Notrgery: for Kasai redistribution portoenterostomy 78 6.2 Incidence and epidemiology 71 6.7 Complications 82 6.3 Phenotypic classification 72 Further reading 83 6.4 Pathogenesis 75 References 83 6.5 Clinical features 76 Biliary atresia (BA) is the most common ‘surgical’ cause of jaundice in infancy. • Definition: Obliterative disorder affecting both loop to the denuded porta hepatis – a Kasai intra- and extrahepatic parts of the biliary tree – a portoenterostomy (KPE) panductular cholangiopathy • Outcome: Long-term survival without the need for • Surgery: Radical resection of all affected extrahepatic transplantation in ~50% of infants and children ducts and a reconstruction anastomosing a Roux 6.1 HISTORICAL ASPECTS 6.2 INCIDENCE AND EPIDEMIOLOGY In 1891, John Thomson from Edinburgh described an infant BA remains a rare disease with a frequency in the United dying from liver failure secondary to congenital biliary Kingdom, North America and Europe varying from 1 in obstruction and reviewed other possible cases described 15,000 to 1 in 20,000 live births [4–7]. Within the United previously [1] (Figure 6.1). Further cases were described Kingdom, we have shown significant regional variation, during the early twentieth century that had restoration of probably due to differences within various racial groups [4] bile flow following conventional biliary anastomosis, but (Figure 6.1). The highest reported incidence is from this remained exceptional and the outlook for the vast Taiwan [8], with about 1 in 5000 live births. One of the majority was dismal.
    [Show full text]
  • Lower Gastrointestinal Bleeding—Computed Tomographic Angiography, Colonoscopy Or Both?
    Clerc et al. World Journal of Emergency Surgery (2017) 12:1 DOI 10.1186/s13017-016-0112-3 RESEARCHARTICLE Open Access Lower gastrointestinal bleeding—Computed Tomographic Angiography, Colonoscopy or both? Daniel Clerc1, Fabian Grass1, Markus Schäfer1, Alban Denys2, Nicolas Demartines1* and Martin Hübner1 Abstract Background: Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control. Methods: Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control. Results: Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P <0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery. Conclusions: Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy.
    [Show full text]
  • Scientific Session II - Raymond H
    Scientific Session II - Raymond H. Alexander, MD Paper Competition Paper #6 January 10, 2018 10:00 am MOBILE FORWARD LOOKING INFRARED TECHNOLOGY ALLOWS RAPID ASSESSMENT OF RESUSCITATIVE ENDOVASCULAR BALLOON OCCLUSION OF THE AORTA IN HEMORRHAGE AND BLACKOUT CONDITIONS Morgan R. Barron, MD, John P. Kuckelman, DO, John McClellan, Michael Derickson, Cody Phillips, Shannon Marko, Joshua Smith, Matthew J. Eckert, MD*, Matthew J. Martin, MD* Madigan Army Medical Center Presenter: Morgan R. Barron, MD Discussant: Joseph J. DuBose, MD, R Adams Cowley Shock Trauma Center Objectives: Objective assessment of final REBOA position and adequate distal occlusion is clinically limited. We propose that mobile forward looking infrared (FLIR) thermal imaging is a fast, reliable, and non-invasive method to assess REBOA position and efficacy in scenarios applicable to battlefield care. Methods: Ten swine were randomized to a 40% hemorrhage group (H, n=5) or non-hemorrhage group (NH, n=5). Three experiments were completed after zone one placement of a REBOA catheter. REBOA was deployed for 30 minutes in all animals followed by randomized continued deployment vs sham in both light and blackout conditions. FLIR images and hemodynamic data were obtained. Images were presented to 62 blinded observers for assessment of REBOA inflation status. Results: There was no difference in hemodynamic or laboratory values at baseline. The H group was significantly more hypotensive (MAP 44 vs 60, p<0.01), vasodilated (SVR 634 vs 938, p=0.02), and anemic (HCT 12 vs 23.2, p<0.01). H animals remained more hypotensive, anemic, and acidotic throughout all 3 experiments. There was a significant difference in the temperature change (ΔTemp) measured by FLIR between animals with REBOA inflated vs not inflated (5.7°C vs 0.7°C, p<0.01).
    [Show full text]
  • Preventing Health Care-Associated Infection: Development of a Clinical Prediction Rule for Clostridium Difficile Infection. By
    Preventing Health Care-Associated Infection: Development of a Clinical Prediction Rule for Clostridium difficile Infection. by Greta L. Krapohl A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Nursing) in the University of Michigan 2011 Doctoral Committee: Professor Richard W. Redman, Co-Chair Emeritus Professor Bonnie L. Metzger, Co-Chair Professor Marita G. Titler Associate Professor Allison E. Aiello Assistant Professor Akke Neeltje Talsma © Greta L. Krapohl 2011 Dedication To the patients that have suffered from Clostridium difficile infection. ii Acknowledgements "Man's mind, once stretched by a new idea, never regains its original dimensions." -Oliver Wendell Holmes, US author & physician (1809 - 1894). The University of Michigan has given me the most well-rounded, challenging and thorough education I could have ever imagined. Not only did it give me the opportunity to ―stretch my mind beyond its original dimensions,‖ but I have had the great pleasure to meet some of the smartest, talented, and interesting faculty and staff from across the entire campus. I would like to start out by acknowledging my Co-Chairs, Dr. Bonnie Metzger and Dr. Richard Redman, both of whom have been there for me through every phase of my doctoral education and who are deserving of my deepest, heartfelt gratitude. Dr. Metzger has given me unfailing support, generous amounts of her time and has both challenged and inspired me when I needed it the most. It is fitting that the quote above was a part of her official electronic signature block as Dr. Metzger has changed the way I will think about nursing-- forever.
    [Show full text]
  • Noninvasive Methods of Predicting Large Esophageal Varices in Children with Intrahepatic Portal Hypertension
    ORIGINAL ARTICLE:HEPATOLOGY Noninvasive Methods of Predicting Large Esophageal Varices in Children With Intrahepatic Portal Hypertension ÃMarina Rossato Adami, ÃCarlos Oscar Kieling, yFernando Pereira Schwengber, zVania N. Hirakata, and §Sandra Maria Gonc¸alves Vieira ABSTRACT Objective: Esophageal variceal bleeding is a severe complication of portal What Is Known hypertension. The standard diagnostic screening test and therapeutic proce- dure for esophageal varices (EV) is endoscopy, which is invasive in pediatric patients. This study aimed to evaluate the role of noninvasive parameters as Platelet count, the Clinical Prediction Rule described predictors of large varices in children with intrahepatic portal hypertension. by Gana et al, and the risk score could be used in Methods: Participants included in this cross-sectional study underwent a children with portal hypertension to reduce the num- screening endoscopy. Variceal size, red marks, and portal gastropathy were ber of unnecessary endoscopies. assessed and rated. Patients were classified into two groups: Group 1 (G1) with small or no varices and Group 2 (G2) with large varices. The population consisted What Is New of 98 children with no history of gastrointestinal (GI) bleeding, with a mean age of 8.9Æ 4.7 years. The main outcome evaluated was the presence of large varices. A combined analysis of the Clinical Prediction Rule, Results: The first endoscopy session revealed the presence of large varices risk score, and platelet count/spleen size z score could in 32 children. The best noninvasive predictors for large varices were be helpful as a pre-endoscopy risk assessment to platelets (Area under the ROC Curve [AUROC] 0.67; 95% CI 0.57– select children with intrahepatic portal hypertension 0.78), the Clinical Prediction Rule (CPR; AUROC 0.65; 95% CI 0.54– who may benefit from a surveillance endoscopy.
    [Show full text]