Upper gastrointestinal bleeding risk scores: who, when and why?

Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.info:eu-repo/semantics/publishedVersio

Strangulated Spiegel's hernia mimicking ischaemic colitis: endoscopic diagnosis of a rare surgical emergency

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Updating predictors of endoscopic recurrence after ileocolic resection for Crohn disease

Background/Aims: Identifying predictors of endoscopic recurrence (ER) has become very important to guide the decision of postoperative strategy. This study aimed to determine the rate of endoscopic recurrence until 12 months after ileocolic resection for Crohn disease (CD) in a cohort and identify its possible predictors. Materials and Methods: We conducted a retrospective single-center study that included patients with CD who underwent ileocolic resection between 2003 and 2014. ER was defined according to the Rutgeerts' score, defined as i2, i3, or i4 at ileocolonoscopy that was performed 6-12 months after surgery. The patients were classified into two groups according to the Rutgeerts' score: non-ER (Rutgeerts i0/i1) and ER (Rutgeerts >= i2). Multivariate logistic regression analysis was performed, including significant variables on univariable analysis, to identify ER predictors. Results: Forty-two patients were included. The mean period of the first postoperative colonoscopy was 9 months, and ER was observed in 25 patients (59.5%). The perianal disease and shorter duration of CD were the only ER predictors (p=0.024; OR, 8.36; 95% CI, 1.329-52.642 and p=0.039; OR, 0.965; 95% CI, 0.933-0.998, respectively). Conclusion: Endoscopic recurrence affects almost two-thirds of patients with CD after ileocolic resection, with perianal involvement and a shorter duration of disease being significant risk factors. These factors may indicate a more aggressive disease associated with rapid progression and support the need of intensive early treatment to improve patients' outcomes.info:eu-repo/semantics/publishedVersio

Small bowel capsule endoscopy in obscure gastrointestinal bleeding : normalcy is not reassuring

BACKGROUND/AIM: Small bowel capsule endoscopy (SBCE) is currently a fundamental tool in the etiological study of obscure gastrointestinal bleeding (OGIB). However, the impact of a negative exam and the risk of rebleeding are not entirely known. The aim of this study was to evaluate the outcomes of patients with OGIB and a negative SBCE examination in terms of follow-up duration, additional diagnostic studies, and achievement of a diagnosis as well as to assess the incidence of rebleeding and possible associated factors. MATERIALS AND METHODS: We retrospectively analyzed 256 patients who consecutively underwent an SBCE examination for the study of OGIB between April 2006 and December 2011, and then selected the 79 whose results excluded potentially bleeding lesions. Eleven patients were lost to follow-up and the remaining 68 were eligible for a nested case-control analysis. Pre-SBCE and post-SBCE information was collected, including follow-up interval and incidence of rebleeding, defined as admission to the hospital for symptomatic anemia, need for blood transfusion, decrease in hemoglobin value of greater than 2?g/dl, or evidence of melena or hematochezia. Univariate analysis included age, sex, OGIB presentation (occult or visible), hemoglobin levels at presentation, and comorbidities. RESULTS: In the 68 patients analyzed, the mean age was 52±18 years and 61.8% were women. The OGIB was occult in 54 patients (79.4%) and overt in 14 patients (20.6%). Patients were followed up for an average of 32 months. Thirty-nine patients (57.4%) underwent further diagnostic investigations during the period of follow-up and a cause for the gastrointestinal bleeding was found in five of them. Rebleeding was documented in 16 (23.5%) patients, occurring on average 15±13.8 months after the SBCE. Male sex was associated significantly with higher incidence of rebleeding (P=0.004). CONCLUSION: Approximately one quarter of patients with OGIB and negative SBCE examination will experience rebleeding, with higher incidence among men; thus, a negative SBCE in this setting is not reassuring. As the vast majority of rebleeding episodes seem to occur within the following 2 years after SBCE, the maintenance of regular medical surveillance during the above-mentioned period of time after a negative SBCE seems advisable

Impact of the age of diagnosis on the natural history of ulcerative colitis

Background: Ulcerative colitis (UC) has a recognized phenotypic heterogeneity. Some studies suggest that age at diagnosis may influence features and natural history of the disease. Aim: This study aimed to compare patients', disease's and treatment's features between Portuguese patients diagnosed before and after the age of 40-years-old. Methods: Retrospective single-center study that included 310 patients with UC, divided in two groups: Those diagnosed before the age of 40-years-old (early onset UC) and those diagnosed later than that (late onset UC). In each group features of the patients (gender, family history, smoking), of the disease (duration, extension, severity, clinical course, hospitalization, extraintestinal manifestations), and of treatment (oral aminosalicylates, systemic steroids or immunomodulators) were analyzed. Statistical analysis was performed using SPSSv22.0. Univariate and multivariate analyses were performed to assess factors associated with early and late onset UC. Results: From the analyzed patients, 207 had UC diagnosed before the age of 40 years old (43.5% men; mean age at diagnosis 29.4 +/- 6.9 years) and 103 were diagnosed after that age (61.2% men; mean age at diagnosis 51.8 +/- 8.1 years). In the group diagnosed before 40 years old, female gender (p = 0.003), severe disease (p = 0.002), chronic intermittent clinical course (p = 0.026), and hospitalizations (p = 0.001) were significantly more frequent. The use of oral aminosalicylates (p = 0.032), systemic steroids (p = 0.003) and immunomodulators (p = 0.012) were also more common in the early onset UC group. No differences between groups were found in family history, smoking, disease's extension, extraintestinal manifestations, and use of biological agents. Multivariate analysis pointed early onset UC to be significantly associated with female gender (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.08-2.91; p = 0.024), chronic intermittent symptoms (OR, 2.34; 95% CI, 1.17-4.70; p = 0.016), and need of hospitalization (OR, 2.89; 95% CI, 1.46-5.72; p = 0.002). Conclusions: When diagnosed before the age of 40-years-old, UC preferably affects women and manifests as a more severe disease, with more frequent hospitalizations and chronic intermittent symptoms. These facts might have implications in planning timely and individualized future therapeutic strategies.info:eu-repo/semantics/publishedVersio

Otimização da abordagem do risco na hemorragia digestiva alta: comparação de cinco scores na predição de sete outcomes

Although different scores have been suggested to predict outcomes in the setting of upper gastrointestinal bleeding (UGIB), few comparative studies between simplified versions of older scores and recent scores have been published. We aimed to evaluate the accuracy of pre- (PreRS) and postendoscopic Rockall scores (PostRS), the Glasgow-Blatchford score (GBS) and its simplified version (sGBS), as well as the AIMS65 score in predicting different clinical outcomes.(undefined)info:eu-repo/semantics/publishedVersio

Update on the role of Rifaximin in digestive diseases

© Journal of Gastrointestinal and Liver Diseases. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Various environmental factors affecting the human microbiota may lead to gut microbial imbalance and to the development of pathologies. Alterations of gut microbiota have been firmly implicated in digestive diseases such as hepatic encephalopathy, irritable bowel syndrome and diverticular disease. However, while these three conditions may all be related to dysfunction of the gut-liver-brain axis, the precise pathophysiology appears to differ somewhat for each. Herein, current knowledge on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease are reviewed, with a special focus on the gut microbiota modulation associated with these disorders during therapy with rifaximin. In general, the evidence for the efficacy of rifaximin in hepatic encephalopathy appears to be well consolidated, although it is less supported for irritable bowel syndrome and diverticular disease. We reviewed current clinical practice for the management of these clinical conditions and underlined the desirability of more real-world studies to fully understand the potential of rifaximin in these clinical situations and obtain even more precise indications for the use of the drug.info:eu-repo/semantics/publishedVersio

Update on the Role of Rifaximin in Digestive Diseases

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Various environmental factors affecting the human microbiota may lead to gut microbial imbalance and to the development of pathologies. Alterations of gut microbiota have been firmly implicated in digestive diseases such as hepatic encephalopathy, irritable bowel syndrome and diverticular disease. However, while these three conditions may all be related to dysfunction of the gut-liver-brain axis, the precise pathophysiology appears to differ somewhat for each. Herein, current knowledge on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease are reviewed, with a special focus on the gut microbiota modulation associated with these disorders during therapy with rifaximin. In general, the evidence for the efficacy of rifaximin in hepatic encephalopathy appears to be well consolidated, although it is less supported for irritable bowel syndrome and diverticular disease. We reviewed current clinical practice for the management of these clinical conditions and underlined the desirability of more real-world studies to fully understand the potential of rifaximin in these clinical situations and obtain even more precise indications for the use of the drug.Peer reviewe

New insights on an old medical emergency: non-portal hypertension related upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation, but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and post-procedure care. The aim of this paper is to review the extended approach to the patient with non-portal hypertension related UGIB