BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a common cause of hospitalizations in adult Filipinos. Upper endoscopy is the cornerstone of diagnosis and therapy with guidelines recommending endoscopy within 24 hours of hospital admission. However, data on the clinical outcomes in relation to the optimal timing of endoscopy remains limited in Davao City.

METHODS

A retrospective cohort study of adult patients (age ≥19) with a primary or secondary diagnosis of UGIB who underwent an upper endoscopy was conducted in a tertiary hospital in Davao City, Philippines from January 2019 to December 2022. Patient demographics and clinical data were analyzed by chart review. Patients were categorized based on the timing of endoscopy from admission or from the presentation of UGIB symptoms in patients previously admitted for other complaints: urgent (t ≤6 hours), early (t >6-24 hours), late (t >24-48 hours), and very late (t >48 hours). The 30-day all-cause in-hospital mortality, and the rates for further bleeding, endoscopic treatment, average units of blood transfused, intensive care unit admission, and duration of hospitalization within 30 days were compared. Statistical analyses were performed using the JASP software, and a P value < 0.05 was considered as statistically significant.

RESULTS

A total of 142 patients were included in the study. Mean age was 62 years, with more males (66.2%) than females (33.8%). Non-variceal causes, particularly erosive diseases (53.7%), were the most common endoscopy findings in our center. Endoscopic treatments were only performed in 26 patients (18.3%). The 30-day all-cause in-hospital mortality rate did not differ between the urgent, early, late and very late elective endoscopy groups (25% vs 2.6% vs 9.3% vs 13%; p=0.26). Although it did not reach statistical significance, urgent timing (n=4) was associated with a higher further bleeding rate (25%), and the need for endoscopic intervention (50%). A significant association between early and late endoscopy groups in the duration of hospitalization of only one week was demonstrated (p=0.032). There was no difference regarding the rate of ICU admissions and mean number of blood transfused among the four groups.

CONCLUSION

There were no significant differences in mortality and other clinical outcomes between all four endoscopy groups except for the duration of hospitalization. Among admitted UGIB patients, optimal medical management is still emphasized and elective endoscopy within 24 hours or until the patient is stabilized can be safely performed in most acute UGIB patients.

Human ; Endoscopy

BACKGROUND: Dermatitis herpetiformis (DH) is a rare autoimmune blistering disease characterized by pruritic papulovesicular eruptions. It can be differentiated from other vesiculobullous skin diseases by skin biopsy with direct immunofluorescence. DH is most often associated with gluten enteropathy (celiac disease) also an uncommon disease.

CASE PRESENTATION: We report a case of a 20-year-old male with a five-week history of multiple vesicles and bullae associated with fever and body malaise. Lesions were symmetrically found on the entire face, axillae, trunk, buttocks and lower extremities. Hematology revealed leukocytosis with neutrophilic predominance. Skin punch biopsy revealed subepidermal blister with neutrophilic predominance. A direct immunofluorescence (DIP) of the perilesional skin showed granular IgA staining at the tips of the dermal papillae, consistent of DH.

TREATMENT AND OUTCOME: The patient was started with cloxacillin and mupirocin ointment for the infected skin lesions. Dapsone 100 mg daily was started with significant improvement of lesions after seven days. Endoscopy was suggested to investigate for gluten enteropathy, however patient did not consent. The patient was advised on gluten-free diet (GED). Complete resolution of lesions with postinflamamtory hypo- and hyperpigmented scarring were noted after nine weeks of dapsone therapy.

CONCLUSION: Bullous skin lesions present as a great challenge to non-dermatologists, hence a thorough investigation was clearly of utmost importance in arriving at a diagnosis of DH in this case. Internists must be aware that skin lesions could provide clues of other internal diseases, such as in DH and gluten enteropathy. Treatment of DH can be as simple as diet modification and avoidance of gluten¬containing food.

Human ; Male ; Adult ; Diet, Gluten-free ; Dermatitis Herpetiformis ; Glutens ; Celiac Disease ; Blister ; Mupirocin ; Dapsone ; Cicatrix ; Fluorescent Antibody Technique, Direct ; Leukocytosis ; Buttocks ; Cloxacillin