Lesions Associated with Gastroduodenal Haemorrhage,in Relation to Aspirin Intake

The incidence of aspirin ingestion during the week preceding overt gastroduodenal bleeding was recorded in 582 patients. A positive aspirin history was found in 80% of patients with acute gastric lesions, in 63% of those in whom no lesion was found, in 52% of those with a chronic duodenal ulcer, and in 49% of patients with a chronic gastric ulcer. In a control series of 542 consecutive patients without overt bleeding admitted to the same wards during part of the time of this investigation the aspirin incidence was 32%.The difference in aspirin habits between these two series confirms that aspirin is a factor in precipitating overt haemorrhage in acute and chronic peptic ulcers, and that it is an important cause of bleeding from the stomach or duodenum, or both, in the absence of a chronic peptic ulcer.     

Parathion Poisoning—A New Antidote!

Two thousand five hundred forty-five cases of upper gastrointestinal tract hemorrhage were studied especially with a view to determining the indications for urgent surgical treatment.Decisions as to whether and when to operate were as follows:Immediate operation for patients over 50 years with a good history of ulcer and a severe initial bleed.Operation after the first repetition of bleeding in patients (1) over 50 with a good history and a mild initial bleed, (2) over 50 with inconclusive history but severe initial bleed, (3) under 50 with a good history and a severe initial bleed.In all other cases, operation was used only if conservative treatment failed.Absolute indications for operation were (a) association with perforation, (b) association with stenosis, (c) persistence of severe ulcer pain after hemorrhage, (d) continuous bleeding.Since operation is to be avoided if possible in cases of esophagitis, erosive gastritis and small acute or subacute ulcers, emergency gastroscopy has valuable uses.Where operation is deemed necessary and no obvious lesion found at laparotomy, blind gastrectomy^* appears to be the most satisfactory procedure.The mortality rate associated with upper gastrointestinal tract bleeding in patients less than 60 years of age was low (2.5 per cent). Even in cases in which operation was required, it was 6.2 per cent. Over 60 years the mortality rises steeply with increasing age, and in cases of operation the rise is even steeper.By using the methods of selection the overall mortality rate was appreciably reduced.     

Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial.

OBJECTIVE--To determine the efficacy of oral nimodipine in reducing cerebral infarction and poor outcomes (death and severe disability) after subarachnoid haemorrhage. DESIGN--Double blind, placebo controlled, randomised trial with three months of follow up and intention to treat analysis. To have an 80% chance with a significance level of 0.05 of detecting a 50% reduction in an incidence of cerebral infarction of 15% a minimum of 540 patients was required. SETTING--Four regional neurosurgical units in the United Kingdom. PATIENTS--In all 554 patients were recruited between June 1985 and September 1987 out of a population of 1115 patients admitted with subarachnoid haemorrhage proved by the results of lumbar puncture or computed tomography, or both. The main exclusion criterion was admission to the neurosurgical units more than 96 hours after subarachnoid haemorrhage. There were four breaks of code and no exclusions after entry. One patient was withdrawn and in 130 treatment was discontinued early. All patients were followed up for three months and were included in the analysis, except the patient who had been withdrawn. INTERVENTIONS--Placebo or nimodipine 60 mg was given orally every four hours for 21 days to 276 and 278 patients, respectively. Treatment was started within 96 hours after subarachnoid haemorrhage. END POINTS--Incidence of cerebral infarction and ischaemic neurological deficits and outcome three months after entry. MEASUREMENTS--Demographic and clinical data, including age, sex, history of hypertension and subarachnoid haemorrhage, severity of haemorrhage according to an adaptation of the Glasgow coma scale, number and site of aneurysms on angiography, and initial findings on computed tomography were measured at entry. Deterioration, defined as development of a focal sign or fall of more than one point on the Glasgow coma scale for more than six hours, was investigated by using clinical criteria and by computed tomography, by lumbar puncture, or at necropsy when appropriate. All episodes of deterioration and all patients with a three month outcome other than a good recovery were assessed by a review committee. MAIN RESULTS--Demographic and clinical data at entry were similar in the two groups. In patients given nimodipine the incidence of cerebral infarction was 22% (61/278) compared with 33% (92/276) in those given placebo, a significant reduction of 34% (95% confidence interval 13 to 50%). Poor outcomes were also significantly reduced by 40% (95% confidence interval 20 to 55%) with nimodipine (20% (55/278) in patients given nimodipine v 33% (91/278) in those given placebo). CONCLUSIONS--Oral nimodipine 60 mg four hourly is well tolerated and reduces cerebral infarction snd improves outcome after subarachnoid haemorrhage.     

Epidemiology and Course of Gastrointestinal Haemorrhage in North-east Scotland

A prospective study was made of 817 consecutive episodes of major gastrointestinal haemorrhage in patients admitted to hospital during 1967-8 from the defined population of North-East Scotland. The yearly admission rate was 116 per 100,000 population. Comparison of the data for city and country residents showed no appreciable differences. In the duodenal ulcer group there was an undue incidence of bleeding among foremen and skilled workers and among those who were unmarried or widowed.Both the clinical history and the results of any previous barium meal examinations were unreliable guides to the source of the current haemorrhage. Prognosis was worse for patients who did not have a dyspeptic history and was better for those who had bled on a previous occasion. The simultaneous ingestion of alcohol and aspirin had an adverse effect on the occurrence of bleeding. Forty-seven per cent. of the patients had another major coincidental disease.Mortality was 13·7% in the whole series and 8·6% in those with peptic ulcer (duodenal ulcer 7·1%, gastric ulcer 16·9%). In 28% of the patients further haemorrhage occurred after admission to hospital and caused a 28·8% mortality. Seventy-four patients were already in hospital when they first bled and 44% of them died.     

Upper gastrointestinal haemorrhage in patients over 80 years-old

Objectives

To evaluate the patient characteristics, outcome, and prognosis of upper gastrointestinal haemorrhage in the elderly.

Material and methods

A prospective study was conducted on 103 patients aged 80 years and over, admitted to a Gastrointestinal Bleeding Unit after an episode of upper gastrointestinal bleeding. We analysed the personal history, the characteristics of the bleeding event, and whether an urgent diagnostic or therapeutic endoscopy was performed, in order to identify clinical data and endoscopic findings that may have an influence on the outcome of the haemorrhage.

Results

The major cause of the haemorrhage was peptic ulcer in 65.1%, and 60.2% of patients were on chronic treatment with non-steroidal anti-inflammatory drugs. An urgent diagnostic endoscopy was performed in all of them, identifying the source of bleeding in 94.2%, and treatment was carried out on 28.2%. The likelihood of rebleeding was 8%, and 4.9% of patients underwent emergency surgery, with an overall mortality rate of 5.8%.

Conclusions

The performance of urgent endoscopy and the application of endoscopic haemostasis are safe and effective in stopping upper gastrointestinal bleeding in the elderly. This has significantly reduced the need for emergency surgery, improving the survival of the bleeding elderly patient and preventing recurrent bleeding.     

Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study.

OBJECTIVES: To determine the incidence and case fatality of acute upper gastrointestinal haemorrhage in the west of Scotland and to identify associated factors. DESIGN: Case ascertainment study. SETTING: All hospitals treating adults with acute upper gastrointestinal haemorrhage in the west of Scotland. SUBJECTS: 1882 patients aged 15 years and over treated in hospitals for acute upper gastrointestinal haemorrhage during a six month period. MAIN OUTCOME MEASURES: Incidence of acute upper gastrointestinal haemorrhage per 100,000 population per year, and case fatality. RESULTS: The annual incidence was 172 per 100,000 people aged 15 and over. The annual population mortality was 14.0 per 100,000. Both were higher among elderly people, men, and patients resident in areas of greater social deprivation. Overall case fatality was 8.2%. This was higher among those who bled as inpatients after admission for other reasons (42%) and those admitted as tertiary referrals (16%). Factors associated with increased case fatality were age, uraemia, pre-existing malignancy, hepatic failure, hypotension, cardiac failure, and frank haematemesis or a history of syncope at presentation. Social deprivation, sex, and anaemia were not associated with increased case fatality after adjustment for other factors. CONCLUSIONS: The incidence of acute upper gastrointestinal haemorrhage was 67% greater than the highest previously reported incidence in the United Kingdom, which may be partially attributable to the greater social deprivation in the west of Scotland and may be related to the increased prevalence of Helicobacter pylori. Fatality after acute upper gastrointestinal haemorrhage was associated with age, comorbidity, hypotension, and raised blood urea concentrations on admission. Although deprivation was associated with increased incidence, it was not related to the risk of fatality.     

Effects of fibrinolytic inhibitors on mortality from upper gastrointestinal haemorrhage.

OBJECTIVE--To see whether fibrinolytic inhibitors are of value when given to patients with upper gastrointestinal haemorrhage. DESIGN--Meta-analysis of six randomised double blind placebo controlled trials. Two methods used for obtaining an overall estimate of effect, including a random effects model incorporating any heterogeneity of outcome in the estimate of the overall treatment effect. SETTING--Inpatient care in hospitals in the United Kingdom, Sweden, and Australia. PATIENTS--1267 Patients admitted to hospital with primary diagnosis of acute upper gastrointestinal haemorrhage. Five of the six trials included a high proportion of elderly patients. Most patients were bleeding from peptic ulcers in the stomach and duodenum (43-88%) or gastric erosions (4-23%). A variable proportion had a degree of clinical shock at entry. INTERVENTIONS--Tranexamic acid 3-6 g/day given intravenously for two or three days followed by 3-6 g/day by mouth for a further three to five days (four trials) or 4.5-12 g/day by mouth for two to seven days (two trials). END POINTS--Frequency of recurrent haemorrhage, need for surgery, and death. MAIN RESULTS--Treatment with tranexamic acid was associated with a 20-30% reduction in the rate of rebleeding, a 30-40% reduction (95% confidence interval 10% to 60%) in mortality. CONCLUSIONS--Treatment with tranexamic acid may be of value to patients considered to be at risk of dying after an upper gastrointestinal haemorrhage.     

Controlled trial of propranolol to prevent recurrent variceal bleeding in patients with non-cirrhotic portal fibrosis.

Fifty patients with non-cirrhotic portal fibrosis who were admitted to hospital because of upper gastrointestinal bleeding were randomly assigned to treatment with either oral propranolol given in doses that reduced the resting pulse rate by 25% (25 patients) or with a placebo (25 patients). One year after the start of the study 20 patients in the propranolol group and five patients in the placebo group were free from recurrent gastrointestinal bleeding (p less than 0.0001). Giving continuous oral propranolol treatment is therefore effective in preventing recurrent upper gastrointestinal bleeding in patients with non-cirrhotic portal fibrosis.     

Clinical findings,early endoscopy,and multivariate analysis in patients bleeding from the upper gastrointestinal tract.

A simple system has been developed to identify patients with upper gastrointestinal tract haemorrhage who run a high risk of continued bleeding or rebleeding. The system is based on six items of patient data available at or soon after arrival in hospital. It was evaluated in a prospective study of 66 patients with upper gastrointestinal tract haemorrhage. Over half of the patients classified by the system into a high-risk category either continued bleeding or rebled after apparent cessation (as against one out of 33 patients in the low-risk category). The high-rish group also had a higher mortality (21%) than those in the low-risk group (nil). The addition or subtraction of early endoscopic findings made little difference to the accuracy of prognosis.     

Management of variceal haemorrhage.

Fig 2 gives an algorithm for the treatment of bleeding oesophageal varices. Initial resuscitation of the patient is of paramount importance, ideally followed by early interventional endoscopy. Recent advances in available endoscopic techniques enable the endoscopist to suit the therapeutic approach to the clinical situation. Injection sclerotherapy remains the initial treatment of choice in bleeding patients. Endoscopic banding ligation is an alternative, best used in patients who have spontaneously stopped bleeding or as a complementary treatment a few days after the initial session of injection sclerotherapy. The tissue adhesives and thrombin can be used to treat bleeding gastric varices. [table: see text] Should the endoscopic expertise not be available, drug treatment (with somatostatin or octreotide) or balloon tamponade are the treatments of choice. Transjugular intrahepatic portal-systemic stent shunt is a new effective technique, not yet widely available, which has a documented complication rate that has yet to be fully defined. It is a good alternative to surgery as a "rescue" procedure for patients who continue to bleed despite two sessions of endoscopic intervention.     

Bleeding varices: 1. Emergency management.

The aim of the emergency management of bleeding varices is to stop the hemorrhage nonoperatively if possible, avoiding emergency shunt surgery, an operation that has a higher mortality than elective shunt surgery. Patients with an upper gastrointestinal hemorrhage should undergo endoscopy immediately to verify the diagnosis of bleeding varices. They can then be categorized according to whether they stop bleeding spontaneously (group 1), continue to bleed slowly (group 2) or continue to bleed rapidly (group 3). Group 1 patients are discussed in the second part of this two-part series. Group 2 patients are initially treated with vasopressin given intravenously; those who fail to respond should undergo emergency angiography and receive vasopressin intra-arterially. If this fails, patients at low surgical risk should undergo urgent shunt surgery; those at high risk do better with endoscopic sclerotherapy. Group 3 patients are also given an intravenous infusion of vasopressin. Patients at low surgical risk who continue to bleed then receive tamponade with a Sengstaken--Blakemore tube. If this fails, they undergo emergency creation of an H-shaped mesocaval shunt. Patients at high surgical risk who fail to respond to vasopressin given intravenously are next treated intra-arterially. If this fails they are given either endoscopic or transhepatic sclerotherapy.     

Alcohol consumption as a risk factor for poor outcome after aneurysmal subarachnoid haemorrhage.

OBJECTIVE--To evaluate the effect of factors existing before aneurysmal subarachnoid haemorrhage on outcome of haemorrhage. DESIGN--Prospective follow up study. SETTING--Helsinki University Hospital. PATIENTS--291 consecutive patients (149 men) aged 15 to 65 years admitted within 96 hours after the bleeding. MAIN OUTCOME MEASURES--Potential risk factors (baseline characteristics, health habits, and clinical variables) for poor outcome after haemorrhage (dependent state in the activities of daily living, or death) were studied using multiple logistic regression. RESULTS--One year after haemorrhage, 179 (62%) patients were independent in the activities of daily living and 28 (10%) dependent; 84 (29%) had died. Risk of poor outcome was predicted, after adjustment for sex and age, by clinical condition at admission according to the Glasgow coma scale (p less than 0.0001); occurrence of rebleeding (relative risk 7.1, 95% confidence interval 2.8 to 18.0, p less than 0.0001) or delayed cerebral ischaemia (10.3, 4.2 to 25.4, p less than 0.0001); surgery on an aneurysm (0.13, 0.05 to 0.35, p less than 0.0001); and heavy consumption of alcohol (4.5, 1.8 to 11.0, p = 0.0014). Heavy drinking remained a significant risk factor after additional adjustment for hypertension, body mass index, and presence of intracerebral haematoma. Heavy drinkers had a more unfavourable outcome after rebleeding and delayed ischaemia than did others with rebleeding or ischaemia. Those who had salicylates in urine on admission had delayed ischaemia with fixed neurological deficits less commonly than others. CONCLUSIONS--Heavy drinking impairs outcome mainly through severe rebleeding and delayed ischaemia and to a lesser extent through a poor initial condition and presence of intracerebral haematoma.     

不同剂量氯吡格雷治疗急性ST段抬高心肌梗死的临床研究

目的:观察标准治疗基础上联合不同剂量氯吡格雷治疗急性ST段抬高心肌梗死的疗效及安全性。方法:2004年9月至2008年3月就诊我院的124例12小时以内发病的ST段抬高型心肌梗死患者,随机分为3组,3组均在入院后前3天给予阿司匹林300mg/d,此后给予阿司匹林100mg/d,A组常规不给予氯吡格雷治疗,B组给予氯吡格雷75mg/d,C组入院即刻给予氯吡格雷300mg,继之75 mg/d治疗,随访30天。观察溶栓血管再通率、梗死后心绞痛发作、心力衰竭事件及死亡、再发心肌梗死、或脑卒中的联合终点。结果:与A组相比,B组、C组患者溶栓成功率提高、梗死后心绞痛发作减少。P<0.05:进一步分析发现C组与B组差异无统计学意义,P>0.05。三组均无主要和次要出血事件发生,轻微出血发生率无统计学差异,P<0.05。结论:ST段抬高的急性心肌梗死患者在标准治疗的基础上早期加用氯吡格雷75 mg/d或先予300 mg负荷量,继之75 mg/d口服,均可提高溶栓成功率,降低梗死后心绞痛发生,而氯吡格雷负荷剂量组并不优于普通剂量组,且两组安全耐受性好。     

Computerized tomography in the diagnosis of hemorrhage caused by ruptured intracranial aneurysm]

The authors presented current views on usefulness of computed tomography (CT) for diagnosing the bleeding from a ruptured intracranial aneurysm. CT should be done in every such case, whereas the lumbar puncture remains the diagnostic method of choice, when CT is not available or in those patients in whom CT shows no haemorrhage. Sensitivity of CT decreases with time that elapsed from the stroke; false negative results are the least likely to occur within the first 48 hours after bleeding episode to subarachnoid space.     

Neodymium yttrium aluminium garnet laser photocoagulation for major haemorrhage from peptic ulcers and single vessels: a single blind controlled study.

A prospective single blind controlled trial was performed to assess the efficacy of the neodymium yttrium aluminium garnet laser in the management of patients bleeding from peptic ulcers and single vessels. Over 20 months 184 patients were found at endoscopy to be bleeding from peptic ulcers and single vessels; 130 of these failed to meet the criteria for entry into the study, but their bleeding stopped with conservative management. Forty-five patients entered the study: in all 25 who were bleeding from ulcers with spots the bleeding stopped irrespective of the treatment allocated. Twenty patients were bleeding from arteries. Eight were allocated to placebo treatment, and all later underwent emergency surgery for further haemorrhage. Twelve were allocated to receive laser treatment, and only one of eight who actually received it required surgery (p less than 0.002). It is concluded that laser treatment reduces the incidence of further haemorrhage and the need for emergency surgery, but the technique is difficult and not always applicable.     

Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial

A prospective randomised trial was performed to assess the efficacy of endoscopic injection of adrenaline for actively bleeding ulcers. Emergency endoscopy in 961 patients admitted for upper gastrointestinal haemorrhage identified 68 patients with actively bleeding ulcers. These 68 patients were randomised to receive either endoscopic injection of adrenaline or no endoscopic treatment. After endoscopy both groups were managed in an identical manner, and strict criteria for emergency operation were adhered to in both groups. Bleeding was initially controlled in all 34 patients assigned to the treatment group. Significantly fewer patients in the treatment group than in the control group needed emergency operations (five v 14, respectively). In addition, in the treatment group the median transfusion requirement was significantly less (three v five units of blood) and the median hospital stay shorter (six v eight days). No complications were observed with the injection of adrenaline, and the rate of healing of ulcers in those attending for endoscopy six weeks after discharge was similar in both groups (81% (17 out of 21 patients) in the treatment group v 79% (11 out of 14) in the control group).Injection of adrenaline is effective in stopping bleeding from actively bleeding ulcers.     

Epileptic seizures after a first stroke: the Oxfordshire Community Stroke Project.

OBJECTIVE: To describe the immediate and long term risk of epileptic seizures after a first ever stroke. DESIGN: Cohort study following up stroke survivors for 2 to 6.5 years; comparison with age specific incidence rates of epileptic seizures in the general population. SETTING: Community based stroke register. SUBJECTS: 675 patients with a first stroke, followed up for a minimum of 2 years. MAIN OUTCOME MEASURES: Occurrence of single and recurrent seizures. RESULTS: 52 patients had one or more post stroke seizures; in 25 the seizures were recurrent. The 5 year actuarial risk of a post stroke seizure in survivors (excluding 19 patients with a history of epilepsy and 3 patients in whom the seizure occurred shortly before death from another cause) was 11.5% (95% confidence interval 4.8% to 18.2%). The relative risk of seizures, in comparison with the general population, was estimated at 35.2 in the first year after stroke and 19.0 in year 2. The risk of seizures was increased in survivors of subarachnoid and intracerebral haemorrhage (hazard ratio for intracranial haemorrhage v cerebral infarction 10.2 (3.7 to 27.9)). The risk of seizures after ischaemic stroke was substantial only in patients presenting with severe strokes due to total anterior circulation infarction. Only 9 of 295 patients (3%) independent one month after stroke suffered a seizure between 1 month and 5 years (actuarial risk 4.2% (0.1% to 8.3%)). CONCLUSION: Stroke patients have about an 11.5% risk of single or recurrent seizures in the first 5 years after a stroke. Patients with more severe strokes or haemorrhagic strokes are at higher risk.     

Effects of treatment for hypertension on cerebral haemorrhage and infarction.

One hundred and sixty nine patients admitted to hospital for stroke over 30 months were examined to see whether treating hypertension had influenced the incidence of cerebral haemorrhage and infarction. Seventy eight (46%) of them had normal blood pressure, 47 (28%) previously diagnosed hypertension for which they were receiving treatment, and 44 (26%) previously undiagnosed and untreated hypertension. Haemorrhagic stroke was commoner among patients with untreated hypertension, whereas infarction was commoner in patients with treated hypertension. Infarction and haemorrhage were equally prevalent in patients with normal blood pressure. Effective treatment in this population seemed to have had a substantially different impact on vascular disease, giving rise to cerebral haemorrhage as opposed to infarction. This is consistent with evidence from other studies that treatment for hypertension has little or no effect on the progression of atheroma.     

Placental Lactogen Levels as Guide to Outcome of Threatened Abortion

The clinical value has been assessed of circulating placental lactogen levels as a pointer to the outcome in a patient with vaginal bleeding in early pregnancy. By using a semiautomated radioimmunoassay the normal range of values for the first and second trimesters has been established. In patients admitted with vaginal bleeding after the eighth week of gestation estimation of plasma human placental lactogen showed that patients with low levels were those in whom the abortion was completed during the first admission. Women whose pregnancies continued normally or who aborted after their first discharge from hospital had normal levels. In a small group sampled before the onset of bleeding but who later aborted the mean levels were lower than normal. This simple and inexpensive test can indicate those women in whom abortion is inevitable and could be used to reduce substantially the length of hospital stay in this common complication of early pregnancy.     

Risk Factors for Intracranial Haemorrhage in Accidents Associated with the Shower or Bathtub

Background

There has been little research on bathroom accidents. It is unknown whether the shower or bathtub are connected with special dangers in different age groups or whether there are specific risk factors for adverse outcomes.

Methods

This cross-sectional analysis included all direct admissions to the Emergency Department at the Inselspital Bern, Switzerland from 1 January 2000 to 28 February 2014 after accidents associated with the bathtub or shower. Time, age, location, mechanism and diagnosis were assessed and special risk factors were examined. Patient groups with and without intracranial bleeding were compared with the Mann-Whitney U test.The association of risk factors with intracranial bleeding was investigated using univariate analysis with Fisher''s exact test or logistic regression. The effects of different variables on cerebral bleeding were analysed by multivariate logistic regression.

Results

Two hundred and eighty (280) patients with accidents associated with the bathtub or shower were included in our study. Two hundred and thirty-five (235) patients suffered direct trauma by hitting an object (83.9%) and traumatic brain injury (TBI) was detected in 28 patients (10%). Eight (8) of the 27 patients with mild traumatic brain injuries (GCS 13–15), (29.6%) exhibited intracranial haemorrhage. All patients with intracranial haemorrhage were older than 48 years and needed in-hospital treatment. Patients with intracranial haemorrhage were significantly older and had higher haemoglobin levels than the control group with TBI but without intracranial bleeding (p<0.05 for both).In univariate analysis, we found that intracranial haemorrhage in patients with TBI was associated with direct trauma in general and with age (both p<0.05), but not with the mechanism of the fall, its location (shower or bathtub) or the gender of the patient. Multivariate logistic regression analysis identified only age as a risk factor for cerebral bleeding (p<0.05; OR 1.09 (CI 1.01;1.171))

Conclusion

In patients with ED admissions associated with the bathtub or shower direct trauma and age are risk factors for intracranial haemorrhage. Additional effort in prevention should be considered, especially in the elderly.