Predictors of mortality in patients with acute upper gastrointestinal hemorrhage who underwent endoscopy and confirmed to have variceal hemorrhage

Background: Variceal hemorrhage (VH) is a major complication of chronic liver disease. Several factors have been validated for the prediction of the outcome of an acute VH. The clinical risk characteristics reported in developed countries may be different from developing countries.Aim: The aim of this study was to determine the predictors of mortality in patients admitted to our hospital with acute upper gastrointestinal (UGI) hemorrhage who underwent endoscopy and confirmed to have VH.Patients and methods: This was a cross sectional hospital based study performed over a seven-year period between January 2006 and January 2013.Results: A total of 224 patients were analyzed. Nineteen patients (8%) died within the first two weeks of their hospital admission. Eighteen variables were studied and included in a multivariate analysis using a logistic regression model. Five variables were predictors of death. Hemodynamic instability at admission (AOR= 5.5, 95% CI= 22.3 + 1.4, P = 0.017), Child class C (AOR =5.9, 95% CI =24 + 1.5, P =0.013), blood in upper gastrointestinal (UGI) tract at the index endoscopy (AOR =12.8, 95% CI= 126.5+ 1.3, P = 0.03), rebleeding within five days of endoscopy (AOR =25.4, 95% CI =109.2 + 5.9, P = 0.000), and in-hospital  complications (AOR= 23.4, 95% CI= 122.5+ 4.5, P = 0.000) were independent predictors of mortality after the acute VH episode.Conclusion: Patients with acute VH and hemodynamic instability at admission, Child class C, blood in UGI tract at the index endoscopy, rebleeding within five days of endoscopy and in-hospital complications are at an increased risk of mortality after the acute VH episode. Rebleeding within five days of endoscopy and in-hospital complications are the most significant independent predictors of mortality

Endoscopy audit over 10 years in a community hospital in Egypt

Background: Practice variation is likely to have an important impact on the effectiveness of endoscopy. Performing regular quality audits allows identification of potential underperformance and consequently can result in significant improvement in endoscopy quality. An annual audit was conducted in a community hospital in Egypt.Aim: The aim of the study was to determine if practice and performance of endoscopy is influenced by a consistent audit process by looking for improvement in completeness of procedures over a 10-year period.Patients and methods: A total of 3736 consecutive procedures were prospectively assessed between years 2004 and 2014.Results: The completion rates improved consistently. Esophagogastroduodenoscopy (EGD) completion rate was 99.9% in 2004–2008 and 99% in 2009–2013 (P = 0.5). Initial hemostasis of EGDgastrointestinal bleed increased from 82% in 2004–2008 to 86% in 2009–2013 (P = 0.04). Adequate bowel cleansing increased from 60% in 2004–2008 to 67% in 2009–2013 (P = 0.13). Crude completion rates increased from 66% in 2004–2008 to 79% in 2009–2013 (P = 0.007). Adjusted completion rates increased from 80% in 2004–2008 to 95% in 2009–2013 (P = 0.0001). Ileoscopy rates in patients with chronic diarrhea increased from 79% in 2004–2008 to 97% in 2009–2013 (P = 0.01). Endoscopic polypectomy rates increased from 65% in 2004–2008 to 94% in 2009–2013 (P = 0.0004). Complete polyp removal rates increased from 77% in 2004–2008 to 87% in 2009–2013 (P = 0.19). Complete polyp retrieval rates increased from 85% in 2004–2008 to 89% in 2009–2013 (P = 0.34).Conclusion: Continuous audit over 10 years can enhance endoscopy performance, improve the quality of endoscopic procedures and lead to better outcomes.Keywords: Endoscopy, Audit, Quality, Egyp

Ethical Issues in the Management of Helicobacter pylori Infection

Medical ethics are not absolute; they change according to social attitudes, technological advances and alterations in the doctor/patient relationship. The discovery of Helicobacter pylori highlighted entrenched attitudes in academia and the pharmaceutical industry that were not always appropriate. The explosion of research that followed was ethically controlled by local research ethics committees and the system of peer review and editorial responsibility. Now that effective treatments are available, the control arm in trials of new therapy should be either placebo (giving the option of effective treatment later) or a first-line treatment; mono and dual therapy should not be employed because of the risk of inducing bacterial resistance. Ethical issues that still remain include whether always to test patients for H pylori at endoscopy and what information should be given when they test positive. The most important issue is the approach of the medical profession to the high death rate carried by H pylori infection. Peptic ulcer and gastric cancer together account for a large number of deaths worldwide, and the medical profession and public health services have not yet grappled with this problem, neither advocating universal testing and treatment nor funding or research to determine whether this approach would be effective

Patient safety and error management in endoscopy ATR Axon MD FRCP

This paper addresses the risk of complications in patients who undergo digestive endoscopy, the reasons why they arise and the precautions that should be taken to prevent them. It also considers issues relating to potential litigation and how to minimize this risk. The advice focuses on the importance of maintaining high-quality endoscopic practice including the day-to-day running of the service. It emphasizes the importance of teamwork, the preparation of in-house protocols, patient management before, during, and after the examination, and what measures should be taken in the event that problems do arise. It is an updated and expanded version of an invited lecture given at the Asian Pacific meeting in Bali in 2014 on behalf of the World Endoscopy Organization

Role of Bacterial Overgrowth in the Stomach as an Additional Risk Factor for Gastritis

Gastric bacteria can either be ingested or ascend from the distal bowel; however, their survival is usually limited by gastric acidity and motility. A reduction in gastric acid can result in bacterial overgrowth in the stomach and proximal small bowel, and the number of organisms rises as the intragastric pH rises

Accidental IV administration of epinephrine instead of midazolam at colonoscopy

Drug administration errors appear to be a major source of iatrogenic harm to hospitalized patients. They often, particularly in the case of epinephrine, have catastrophic consequences both for the patient and the well-meaning provider. The following incident is a medication error case report which illustrates one way that incorrect medication may be administered. IV epinephrine was accidentally administered instead of midazolam at colonoscopy

Prevalence and outcome of peptic ulcer bleeding in patients with liver cirrhosis

Background: Upper gastrointestinal bleeding is usually classified as either variceal or non-variceal. In cirrhotic patients, variceal bleeding has been extensively studied but, 30–40% of cirrhotic patients who bleed have non-variceal upper gastrointestinal bleeding (NVUGIB) that is frequently caused by gastro duodenal ulcers. Peptic ulcer bleeding (PUB) leads to substantial morbidity and mortality in patients with liver cirrhosis. Aim: The aim of this study was to assess the prevalence and outcome of PUB in patients with liver cirrhosis. Materials and methods: This was a cross-sectional study. Data on cirrhotic patients with PUB over a seven-year period between January 2006 and January 2013 were collected. Results: Among 103 patients with NVUGIB, 62 patients (60%) having PUB were assessed. Fifty percent were male. Ages ranged from 37 to 72 years, mean 59 ± 7 years. The most common symptom on presentation was hematemesis (53%). Hemodynamic instability on admission was found in 30 patients (48%). Eighteen patients (29%) had initial hemoglobin less than 7 g/dl. Twenty-seven patients (44%) required blood transfusion and the average number of transfused blood units was two. Forty patients (65%) bled from gastric ulcers. Eleven patients (18%) had ulcers with adherent clot. Twenty-four percent of patients had a Rockall score more than five. Five patients (8%) rebled. Complications were reported in seven patients (11%), mainly liver failure. Overall mortality was 8%. Male gender, adherent clot, bleeding recurrence, development of complications during admission and a Rockall score >5 were significant factors for increasing mortality (P = 0.02, 0.016, 0.00001, 0.034 and 0.00003 respectively). Conclusion: The commonest cause of NVUGIB in patients with liver cirrhosis was PUB. Mortality in patients with PUB was particularly high among males, patients who had adherent clot, bleeding recurrence, development of complications and a high Rockall score