Scoring systems for peptic ulcer bleeding: which one to use?

AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012consecutive patients admitted with peptic ulcer bleeding(PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores(RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics(AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome(AUROC 0.82 vs 0.67 vs0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality(AUROC0.84 vs 0.57 vs 0.64), rebleeding(AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion(AUROC 0.83 vs0.63 vs 0.58) and surgical intervention(0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome(AUROC 0.82 vs 0.69, respectively).CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

AIM:To compare the recurrent bleeding after endoscopic injection of different epinephrine volumes with hemoclips in patients with bleeding peptic ulcer.METHODS:Between January 2005 and December 2009,150 patients with gastric or duodenal bleeding ulcer with major stigmata of hemorrhage and nonbleeding visible vessel in an ulcer bed(Forrest Ⅱa) were included in the study.Patients were randomized to receive a small-volume epinephrine group(15 to 25 mL injection group;Group 1,n = 50),a large-volume epinephrine group(30 to 40 mL injection group;Group 2,n = 50) and a hemoclip group(Group 3,n = 50).The rate of recurrent bleeding,as the primary outcome,was compared between the groups of patients included in the study.Secondary outcomes compared between the groups were primary hemostasis rate,permanent hemostasis,need for emergency surgery,30 d mortality,bleeding-related deaths,length of hospital stay and transfusion requirements.RESULTS:Initial hemostasis was obtained in all patients.The rate of early recurrent bleeding was 30%(15/50) in the small-volume epinephrine group(Group 1) and 16%(8/50) in the large-volume epinephrine group(Group 2)(P = 0.09).The rate of recurrent bleeding was 4%(2/50) in the hemoclip group(Group 3);the difference was statistically significant with regard to patients treated with either small-volume or large-volume epinephrine solution(P = 0.0005 and P = 0.045,respectively).Duration of hospital stay was significantly shorter among patients treated with hemoclips than among patients treated with epinephrine whereas there were no differences in transfusion requirement or even 30 d mortality between the groups.CONCLUSION:Endoclip is superior to both small and large volume injection of epinephrine in the prevention of recurrent bleeding in patients with peptic ulcer.

Gut peptide changes in patients with obstructive jaundice undergoing biliary drainage:A prospective case control study

BACKGROUND Biliary obstruction is a relatively common condition that affects approximately 5 in 1000 people annually.Malnutrition is very common in patients with biliary obstruction and since it is associated with significant morbidity and mortality,it is important to identify factors and mechanisms involved in its development.AIM To determine the influence of obstructive jaundice on the hormones controlling appetite and nutritive status.METHODS This was a prospective case control study performed in a tertiary center in Zagreb,Croatia.Patients with biliary obstruction undergoing internal biliary drainage from September 2012 until August 2013 were enrolled.After excluding patients who developed procedure related complications or were lost in the follow-up,out of initial 73 patients,55 patients were included in the analysis,including 34 with benign and 21 with malignant disease.Meanwhile,40 non-jaundiced controls were also included.Appetite,nutritional status,and serum ghrelin,cholecystokinin(CCK),interleukin 6(IL-6),and tumor necrosis factorα(TNF-α)were determined at admission,48 h and 28 d after internal biliary drainage.Chi square test was used for categorical variables.Continuous variables were analysed for normality by Kolmogorov-Smirnov test and relevant non-parametric(Mann-Whitney,Kruskal-Wallis,and Friedman)or parametric(t-test and analysis of variance)tests were used.RESULTS Patients with obstructive jaundice were significantly malnourished compared to controls,regardless of disease etiology.Plasma ghrelin and CCK levels were significantly higher in patients with obstructive jaundice.Serum bilirubin concentrations were negatively correlated with ghrelin levels and positively correlated with TNF-α,but had no correlation with CCK concentrations.After internal biliary drainage,a significant improvement of nutritional status was observed although serum concentrations of ghrelin,IL-6,and TNF-α remained significantly elevated even 28 d after the procedure.CCK levels in patients without malnutrition remained elevated 28 d after the procedure,but in patients with malnutrition,CCK levels decreased to levels comparable with those in the control group.We have not established any correlation between appetite and serum levels of ghrelin,CCK,IL-6,and TNF-α before and after biliary drainage.CONCLUSION Possible abnormalities in ghrelin and CCK regulation may be associated with the development ofmalnutrition during the inflammatory response in patients with biliary obstruction.