Importance of risk assessment,endoscopic hemostasis,and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)is a common medical emergency in clinical practice.While the incidence has significantly reduced,the mortality rates have not undergone a similar reduction in the last few decades,thus presenting a significant challenge.This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis.Since ANUVGIB predominantly affects the elderly population,the impact of comorbidities may be responsible for the poor outcomes.A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly.Early risk stratification plays a crucial role in deciding the line of management and predicting mortality.Emerging scoring systems such as the ABC(age,blood tests,co-morbidities)score show promise in predicting mortality and guiding clinical decisions.While conventional endoscopic therapies remain cornerstone approaches,novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives,particularly in cases refractory to traditional modalities.By integrating validated scoring systems and leveraging novel therapeutic modalities,clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal(GI)bleeding is a significant cause of morbidity and mortality.Traditionally,through-the-scope(TTS)clips,thermal therapy,and injection therapies are used to treat GI bleeding.In this review,we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis.Specifically,we discuss the efficacy and applicability of over-thescope clips,hemostatic agents,TTS doppler ultrasound,and endoscopic ultrasound,each of which offer an effective method of reducing rates of GI rebleeding.

Challenges in Diagnosing and Managing Dieulafoy’s Lesions: A Case Report Highlighting the Importance of Clinical Suspicion and Multidisciplinary Approach in Obscure Gastrointestinal Bleeding

Upper gastrointestinal bleeding remains a significant cause of hospital admissions. Even though the incidence of peptic ulcer disease and gastritis is decreasing, the incidence rates in neoplasm, Dieulafoy’s lesions, angiodysplasia, and esophagitis are trending up, which necessities physicians to be aware of those pathologies and their specifics. Here, we represent a case of a 62-year-old male on dual antiplatelet therapy who was transferred to our hospital due to severe melena with suspicion of upper gastrointestinal bleeding. Due to hemodynamic instability, the patient was intubated and started on vasopressors. However, several repeated EGDs and CTs of the abdomen with GI bleeding protocol did not reveal the location of active bleeding to stop it. At the same time, clinically, the patient was hemodynamically unstable with continued melena. On the last EGD, a small area of concern resembling gastric varix was clipped for identification purposes, and the patient underwent a selective angiogram with further diagnosis of Dieulafoy’s lesion, which was successfully embolized. Our case demonstrates that Dieulafoy’s lesions can present as severe life-threatening hemorrhage, hard to diagnose with traditional methods such as EGD or CTs, in which case it is recommended to proceed with an angiogram sooner rather than later for further diagnosis and treatment if needed.

Uremic Bleeding in 2 Patients with Dieulafoy’s Lesion: Case Report and Literature Review

Dieulafoy’s lesions are rare vascular malformations of the gastrointestinal tract. A Dieulafoy’s lesion is an aberrant vessel that does not reduce in caliber when it extends from the submucosa to the mucosa. Damage to this artery can cause severe and intermittent arterial bleeding from small vascular stumps that are difficult to visualize. Furthermore, these catastrophic bleeding episodes frequently result in hemodynamic instability and the need for transfusion of multiple blood products. Recently, uremic syndrome has been identified as a risk factor for gastric mucosal lesions. We present two clinical cases of acute digestive bleeding due to Dielafoy lesion with chronic kidney disease as the main cause, where two different therapies were performed endoscopically. We concluded with the results of our patients that the best therapy was the application of the hemostatic hemoclip on the injury vs the injection with adrenaline on the wound site. Uremia is identified as a risk factor for upper gastrointestinal bleeding in patients with pre-existing Dieulafoy’s lesion, as well as a higher incidence of new bleeding.

Management dilemmas in patients with mechanical heart valves and warfarin-induced major bleeding

Management of warfarin-induced major bleeding in patients with mechanical heart valves is challenging.There is vast controversy and confusion in the type of treatment required to reverse anticoagulation and stop bleeding as well as the ideal time to restart warfarin therapy safely without recurrence of bleeding and/or thromboembolism.Presently,the treatments available to reverse warfarin-induced bleeding are vitamin K,fresh frozen plasma,prothrombin complex concentrates and recombinant activated factor Ⅶa.Currently,vitamin K and fresh frozen plasma are the recommended treatments in patients with mechanical heart valves and warfarin-induced major bleeding.The safe use of prothrombin complex concentrates and recombinant activated factor Ⅶa in patients with mechanical heart valves is controversial and needs well-designed clinical studies.With regard to restarting anticoagulation in patients with warfarin-induced major bleeding and mechanical heart valves,the safe period varies from 7-14 d after the onset of bleeding for patients with intracranial bleed and 48-72 h for patients with extra-cranial bleed.In this review article,we present relevant literature about these controversies and suggest recommendations for management of patients with warfarin-induced bleeding and a mechanical heart valve.Furthermore,there is an urgent need for separate specific guidelines from major associations/professional societies with regard to mechanical heart valves and warfarin-induced bleeding.

Comparative Analysis of Continuous versus Intermittent Proton Pump Inhibitor Therapy in Patients with Upper Gastrointestinal Bleeding Due to Ulcers

Upper gastrointestinal bleeding (UGIB) presents as a prevalent clinical challenge, with annual incidence rates ranging from 80 to 150 cases per 100,000 individuals. Guidelines for managing patients with UGIB due to bleeding ulcers recommend a continuous infusion of proton pump inhibitors (PPI). However, studies comparing intermittent dosing of PPI therapy show that this regimen achieves similar clinical benefits. If the clinical efficacy remains equivalent, intermittent dosing will be more cost-effective for patients and the health care system. Our research study aims to analyze the comparative effectiveness of intermittent versus continuous PPI therapy after endoscopic treatment in patients with UGIB, focusing on such endpoints as rebleeding risk at 3-and 7-day mortality rates. Methods: Resources searched included MEDLINE, EMBASE, PUBMED, and the Cochrane Central Register of Controlled Trials databases from January 2010 through December 2023 with the inclusion of meta-analysis, systematic review, review, or ACG guideline recommendations. Results of the analysis show how recommendations regarding high vs. low PPI regimen changed over time: from no difference in regimen in 2010 to recommending continuous regimen in 2012 to declaring insufficient evidence between choosing one regimen over another in 2013 to determine that both regimens were comparable to each other in 2014-2018 and finally to recommending both regimens in 2021. To conclude, our review shows that in patients with bleeding ulcers and high-risk endoscopic findings, intermittent PPI therapy is non-inferior to continuous PPI infusion for three days, seven days bleeding risk or mortality rates;however, it remains challenging to determine the most optimal intermittent regimen due to heterogeneity of RCTs included in meta-analyses, and further trials will need to be performed.

Comparison on serum biomarkers for anovulatory and ovulatory dysfunctional uterine bleeding in Lizu females

Objective:To screen,identify,and compare the serum biomarkers between anovulatory dysfunctional uterine bleeding(ADUB)and ovulatory dysfunctional uterine bleeding(ODUB)in Lizu females.Methods:The subjects included 128 ADLB patients,63 ODUB patients,and 93controls.The serum and supernate of the subjects'mense were collected and stored at-80°C until use.Differential proteins in the sera of three groups were screened using surface-enhaneed laser desorption ionization time-of-flight mass spectrometry.The screened proteins were then identified by tricine-SDS-PAGE gel and spectrometry.Protein expression levels in the menses of ADUB,ODUB,and control subjects were determined using ELISA,RT-PCR,and Western blotting.SPSS 14.1 was used for statistical analysis and chart drawing(a=0.05),Results:Three differentia)protein peaks with peak values of 11.80,13.59,and 14.68 km/z were,screened and identified as serum amyploid protein A(SAA),vascular endothelial growth factor,and vitamin K epoxide reductase,respectively.The SAA was highly expressed in the menses of ADUB and ODUB patients but poorly expressed in the controls.The vascular endothelial growth factor was highly expressed in the menses of ODUB and controls but poorly expressed in ADUB patients.Meanwhile,the vitamin K epoxide reductase was highly expressed in the menses of ADUB and control subjects but poorly expressed in ODUB patients.Conclusions:The SAA is the common serum biomarker of ADUB and ODUB.ADUB may be related to angiogenesis impairment,whereas ODUB may be associated with blood coagulation disruption.

Using a novel hemostatic peptide solution to prevent bleeding after endoscopic submucosal dissection of a gastric tumor

BACKGROUND Endoscopic mucosal dissection has become the standard treatment for early gastric cancer.However,post-endoscopic submucosal dissection(ESD)ulcer occurs in 4.4%of patients.This study hypothesized whether applying PuraStat,a novel hemostatic peptide solution,prevents post-ESD bleeding.AIM To investigate the preventive potential of PuraStat,a hemostatic formulation,against bleeding in post-ESD gastric ulcers.METHODS Between May 2022 and March 2023,101 patients(Group P)underwent ESD for gastric diseases at our hospital and received PuraStat(2 mL)for post-ESD ulcers.We retrospectively compared this group with a control group(Group C)com-prising 297 patients who underwent ESD for gastric diseases at our hospital between April 2017 and March 2021.P values<0.05 on two-sided tests indicated significance.RESULTS Post-ESD bleeding occurred in 6(5.9%)(95%CI:2.8-12.4)and 20(6.7%)(95%CI:4.4-10.2)patients in Groups P and C,respectively,with no significant between-group difference.The relative risk was 1.01(95%CI:0.95-1.07).The lesser curvature or anterior wall was the bleeding site in all 6 patients who experienced postoperative bleeding in Group P.In multivariate analysis,the odds ratios for resection diameter≥50 mm and oral anticoagulant use were 6.63(95%CI:2.52-14.47;P=0.0001)and 4.04(1.26-0.69;P=0.0164),respectively.The adjusted odds ratio of post-ESD bleeding and PuraStat was 1.28(95%CI:0.28-2.15).CONCLUSION PuraStat application is not associated with post-ESD bleeding.However,the study suggests that gravitational forces may affect the effectiveness of applied PuraStat.

Portal hypertension and gastrointestinal bleeding:Diagnosis,prevention and management

Bleeding from esophageal varices is a life threatening complication of portal hypertension.Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal.Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol.Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method.Therapy of acute bleeding is based on three strategies:vasopressor drugs like terlipressin,antibiotics and endoscopic therapy.In refractory bleeding,self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt(TIPS).Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate.Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking.Therapy of refractory bleeding relies on shuntprocedures like TIPS.Bleeding from ectopic varices,portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common.Possible medical and endoscopic treatment options are discussed.

Appendiceal bleeding caused by vascular malformation: A case report

BACKGROUND Acute lower gastrointestinal bleeding(LGIB)is a common occurrence in clinical practice.However,appendiceal bleeding is an extremely rare condition that can easily be overlooked and misdiagnosed.The preoperative detection of appen-diceal bleeding often poses challenges due to the lack of related guidelines and consensus,resulting in controversial treatment approaches.CASE SUMMARY We presented a case of a 33-year-old female who complained of hematochezia that had lasted for 1 d.Colonoscopy revealed continuous bleeding in the appen-diceal orifice.A laparoscopic appendectomy was performed immediately,and a pulsating blood vessel was observed in the mesangium of the appendix,accor-dingly,active bleeding into the appendicular lumen was considered.Pathological examination revealed numerous hyperplastic vessels in the appendiceal mucosa and dilated capillary vessels.CONCLUSION The preoperative detection of appendiceal bleeding is often challenging,colo-noscopy is extremely important,bowel preparation is not routinely recommend-ed for patients with acute LGIB or only low-dose bowel preparation is recom-mended.Laparoscopic appendectomy is the most appropriate treatment for appendiceal bleeding.

Advancements in hemostatic strategies for managing upper gastrointestinal bleeding: A comprehensive review

Upper gastrointestinal(GI)hemorrhage presents a substantial clinical challenge.Initial management typically involves resuscitation and endoscopy within 24 h,although the benefit of very early endoscopy(<12 h)for high-risk patients is debated.Treatment goals include stopping acute bleeding,preventing rebleeding,and using a multimodal approach encompassing endoscopic,pharmacological,angiographic,and surgical methods.Pharmacological agents such as vasopressin,prostaglandins,and proton pump inhibitors are effective,but the increase in antithrombotic use has increased GI bleeding morbidity.Endoscopic hemostasis,particularly for nonvariceal bleeding,employs techniques such as electrocoagu-lation and heater probes,with concerns over tissue injury from monopolar electrocoagulation.Novel methods such as Hemospray and Endoclot show promise in creating mechanical tamponades but have limitations.Currently,the first-line therapy includes thermal probes and hemoclips,with over-the-scope clips emerging for larger ulcer bleeding.The gold probe,combining bipolar electrocoagulation and injection,offers targeted coagulation but has faced device-related issues.Future advancements involve combining techniques and improving endoscopic imaging,with studies exploring combined approaches showing promise.Ongoing research is crucial for developing standardized and effective hemorrhage management strategies.

Abnormal uterine bleeding successfully treated via ultrasoundguided microwave ablation of uterine myoma lesions: Three case reports

BACKGROUND Microwave endometrial ablation(MEA)is a minimally invasive treatment method for heavy menstrual bleeding.However,additional treatment is often required after recurrence of uterine myomas treated with MEA.Additionally,because this treatment ablates the endometrium,it is not indicated for patients planning to become pregnant.To overcome these issues,we devised a method for ultrasound-guided microwave ablation of uterine myoma feeder vessels.We report three patients successfully treated for heavy menstrual bleeding,secondary to uterine myoma,using our novel method.CASE SUMMARY All patients had a favorable postoperative course,were discharged within 4 h,and experienced no complications.Further,no postoperative recurrence of heavy menstrual bleeding was noted.Our method also reduced the myoma’s maximum diameter.CONCLUSION This method does not ablate the endometrium,suggesting its potential appli-cation in patients planning to become pregnant.

Automatic detection of small bowel lesions with different bleeding risks based on deep learning models

BACKGROUND Deep learning provides an efficient automatic image recognition method for small bowel(SB)capsule endoscopy(CE)that can assist physicians in diagnosis.However,the existing deep learning models present some unresolved challenges.AIM To propose a novel and effective classification and detection model to automatically identify various SB lesions and their bleeding risks,and label the lesions accurately so as to enhance the diagnostic efficiency of physicians and the ability to identify high-risk bleeding groups.METHODS The proposed model represents a two-stage method that combined image classification with object detection.First,we utilized the improved ResNet-50 classification model to classify endoscopic images into SB lesion images,normal SB mucosa images,and invalid images.Then,the improved YOLO-V5 detection model was utilized to detect the type of lesion and its risk of bleeding,and the location of the lesion was marked.We constructed training and testing sets and compared model-assisted reading with physician reading.RESULTS The accuracy of the model constructed in this study reached 98.96%,which was higher than the accuracy of other systems using only a single module.The sensitivity,specificity,and accuracy of the model-assisted reading detection of all images were 99.17%,99.92%,and 99.86%,which were significantly higher than those of the endoscopists’diagnoses.The image processing time of the model was 48 ms/image,and the image processing time of the physicians was 0.40±0.24 s/image(P<0.001).CONCLUSION The deep learning model of image classification combined with object detection exhibits a satisfactory diagnostic effect on a variety of SB lesions and their bleeding risks in CE images,which enhances the diagnostic efficiency of physicians and improves the ability of physicians to identify high-risk bleeding groups.

MH-STRALP:A scoring system for prognostication in patients with upper gastrointestinal bleeding

BACKGROUND Upper gastrointestinal bleeding(UGIB)is a common medical emergency and early assessment of its outcomes is vital for treatment decisions.AIM To develop a new scoring system to predict its prognosis.METHODS In this retrospective study,692 patients with UGIB were enrolled from two cen-ters and divided into a training(n=591)and a validation cohort(n=101).The clinical data were collected to develop new prognostic prediction models.The en-dpoint was compound outcome defined as(1)demand for emergency surgery or vascular intervention,(2)being transferred to the intensive care unit,or(3)death during hos-pitalization.The models’predictive ability was compared with previously esta-blished scores by receiver operating characteristic(ROC)curves.RESULTS Totally 22.2%(131/591)patients in the training cohort and 22.8%(23/101)in the validation cohort presented poor outcomes.Based on the stepwise-forward Lo-gistic regression analysis,eight predictors were integrated to determine a new post-endoscopic prognostic scoring system(MH-STRALP);a nomogram was de-termined to present the model.Compared with the previous scores(GBS,Rock-all,ABC,AIMS65,and PNED score),MH-STRALP showed the best prognostic prediction ability with area under the ROC curves(AUROCs)of 0.899 and 0.826 in the training and validation cohorts,respectively.According to the calibration cur-ve,decision curve analysis,and internal cross-validation,the nomogram showed good calibration ability and net clinical benefit in both cohorts.After removing the endoscopic indicators,the pre-endoscopic model(pre-MH-STRALP score)was conducted.Similarly,the pre-MHSTRALP score showed better predictive value(AUROCs of 0.868 and 0.767 in the training and validation cohorts,respectively)than the other pre-endoscopic scores.CONCLUSION The MH-STRALP score and pre-MH-STRALP score are simple,convenient,and accurate tools for prognosis prediction of UGIB,and may be applied for early decision on its management strategies.

Endoscopic treatment of bleeding gastric ulcer causing gastric wall necrosis:A case report

BACKGROUND Gastric wall necrosis is a rare complication of endoscopic treatment for bleeding gastric ulcer,which may exacerbate the patient’s condition once it occurs and may even require surgical intervention for treatment.CASE SUMMARY A 59-year-old man was admitted to our department with melena.Endoscopy revealed a giant ulcer in the gastric antrum with a visible vessel in its center,which was treated with sclerosants and tissue glue injection and resulted in necrosis of the gastric wall.CONCLUSION Injection of sclerosants and tissue glue may lead to gastric wall necrosis,which is a serious complication.Therefore,before administering this treatment to patients,we should consider other more effective methods of hemostasis to avoid gastric wall necrosis.

Ileal collision tumor associated with gastrointestinal bleeding: A case report and review of literature

BACKGROUND Collision tumors involving the small intestine,specifically the combination of a hamartomatous tumor and a lipoma,are extremely rare.To our knowledge,no previous case report has described a collision tumor composed of two benign tumors of different origins in the small intestine.CASE SUMMARY Here,we present the case of an 82-year-old woman who presented with hemorrhagic shock and was found to have a mass measuring approximately 50 mm×32 mm×30 mm in the terminal ileum.Based on computed tomography scan findings,the mass was initially suspected to be a lipoma.A subsequent colonoscopy revealed a pedunculated submucosal elevation consisting of two distinct parts with a visible demarcation line.A biopsy of the upper portion suggested a juvenile polyp(JP).Owing to the patient’s advanced age,multiple comorbidities,and poor surgical tolerance,a modified endoscopic submucosal dissection was performed.Histopathological examination of the excised mucosal mass revealed a lipoma at the base and a JP at the top,demonstrating evidence of rupture and associated bleeding.The patient’s overall health remained satisfactory,with no recurrence of hematochezia during the six-month follow-up period.CONCLUSION This case report provides new evidence for the understanding of gastrointestinal collision tumors,emphasizing their diverse clinical presentations and histopathological characteristics.It also offers diagnostic and therapeutic insights as well as an approach for managing benign collision tumors.

Future directions of noninvasive prediction of esophageal variceal bleeding:No worry about the present computed tomography inefficiency

In this editorial,we comment on the minireview by Martino A,published in the recent issue of World Journal of Gastrointestinal Endoscopy 2023;15(12):681-689.We focused mainly on the possibility of replacing the hepatic venous pressure gradient(HVPG)and endoscopy with noninvasive methods for predicting esophageal variceal bleeding.The risk factors for bleeding were the size of the varices,the red sign and the Child-Pugh score.The intrinsic core factor that drove these changes was the HVPG.Therefore,the present studies investigating noninvasive methods,including computed tomography,magnetic resonance imaging,elastography,and laboratory tests,are working on correlating imaging or serum marker data with intravenous pressure and clinical outcomes,such as bleeding.A single parameter is usually not enough to construct an efficient model.Therefore,multiple factors were used in most of the studies to construct predictive models.Encouraging results have been obtained,in which bleeding prediction was partly reached.However,these methods are not satisfactory enough to replace invasive methods,due to the many drawbacks of different studies.There is still plenty of room for future improvement.Prediction of the precise timing of bleeding using various models,and extracting the texture of variceal walls using high-definition imaging modalities to predict the red sign are interesting directions to lay investment on.

Blood loss,predictors of bleeding,transfusion practice and strategies of blood cell salvaging during liver transplantation

Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system,portal hypertension with multiple collateral vessels,portal vein thrombosis,previous abdominal surgery,splenomegaly,and poor "functional" recovery of the new liver.The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge,and,despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss,the requirements for blood or blood products remains high.The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome.Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated.Isovolemic hemodilution,the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion.The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications.In this article we report on the common preoperative and intraoperative factors contributing to blood loss,intraoperative transfusion practices,anesthesiologic and surgical strategies to prevent blood loss,and on intraoperative blood salvaging techniques and autologous blood transfusion.Even though the advances in surgical technique and anesthetic management,as well as a better understanding of the risk factors,have resulted in a steady decrease in intraoperative bleeding,most patients still bleed extensively.Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center.Unfortunately,despite the large number of OLTx performed each year,there is still paucity of large randomized,multicentre,and controlled studies which indicate how to prevent bleeding,the transfusion needs and thresholds,and the "evidence based" perioperative strategies to reduce the amount of transfusion.

大穗型丰产优质小麦新品种绵阳33号和绵阳35号的选育

绵阳33号和绵阳35号是绵阳市农业科学研究所1992和1993年以自育中间材料为主要亲本杂交育成,具有绵阳系列品种特色的大穗型小麦新品种。主要持点是丰产性好,抗病力强,品质优良,适应性广泛。综合农艺性状优良,株高适中,穗层整产,穗大粒多,籽粒白皮大粒,饱满均匀,商品性突出,适应市场需求,具有良好的利用前景。两品种于2003年10月通过四川省品种审定,定名推广。

大尺寸回转体型面点坐标及形心轴线测量系统的研制

针对大型回转体型面测量问题,根据柱坐标机的测量原理,研制了大尺寸回转体型面点坐标及形心轴线测量系统。对影响系统测量精度的不确定度因素进行了量化分析。应用双频激光干涉仪和激光跟踪仪与该系统进行了测量数据比对。该系统不仅能测量回转体工件的任意截面点坐标和形心轴线,还可测量圆柱度、径向跳动、同轴度等,具有高精度、高效率、操作简单等特点。