BACKGROUND: Low-molecular-weight heparin (LMWH) is the standard treatment for venous thromboembolism (VTE) in patients with active cancer. However, use of factor Xa inhibitors, such as rivaroxaban, is increasing on the basis of limited clinical evidence. The present single-center study compared the incidence of bleeding and other treatment outcomes in gastrointestinal and pancreatobiliary cancer (GI tract cancer) patients administered rivaroxaban or LMWH for the treatment of VTE. METHODS: Retrospective data from 281 GI tract cancer patients who were treated for VTE with rivaroxaban (n = 78) or LMWH (n = 203) between 1 January 2012 and 31 December 2016, were analyzed. Primary end-point was the incidence of major and clinically relevant bleeding. Secondary outcomes included the incidence of recurrent VTE and mortality. RESULTS: Clinically relevant bleeding occurred in 19 patients (24.4%) in the rivaroxaban group and 31 (15.3%) in the LMWH group (P = 0.074). No inter-group difference was observed for rate of VTE recurrence (3.8% with rivaroxaban vs. 3.9% with LMWH; P > 0.999) or incidence of major bleeding (5.1% with rivaroxaban vs. 8.9% with LMWH; P = 0.296). Multivariate Cox proportional hazards analysis for age, cancer type, metastasis, history of chemotherapy or recent surgery, and Eastern Cooperative Oncology Group performance status revealed a 1.904-fold higher risk of bleeding with rivaroxaban than LMWH (1.031–3.516; P = 0.040). No significant inter-group difference was found in terms of hazard ratio for all-cause mortality. CONCLUSION: Compared to LMWH, rivaroxaban was associated with a higher incidence of clinically relevant bleeding in GI tract cancer patients presenting with VTE.
Colorectal Neoplasms ; Drug Therapy ; Factor Xa Inhibitors ; Gastrointestinal Tract ; Hemorrhage ; Heparin, Low-Molecular-Weight ; Humans ; Incidence ; Mortality ; Neoplasm Metastasis ; Recurrence ; Retrospective Studies ; Rivaroxaban ; Stomach Neoplasms ; Venous Thromboembolism

Mesenteric venous thrombosis has a low prevalence and nonspecific clinical symptoms, and it may cause bowel infarction and death. Early diagnosis and prompt surgical intervention with anticoagulants are important to patients. We examined a 27-year-old woman complaining of diffuse abdominal pain and hematochezia, and diagnosed extensive mesenteric venous thrombosis with intestinal infarction and pulmonary thromboembolism. In light of the patient's symptoms, an operation seemed necessary. However, because of the high risk of mortality, we decided to look for another option. The patient was successfully treated with intensive medical care and a radiological procedure in spite of intestinal infarction.
Abdominal Pain ; Adult ; Anticoagulants ; Early Diagnosis ; Female ; Gastrointestinal Hemorrhage ; Humans ; Infarction ; Mesenteric Ischemia ; Mesenteric Vascular Occlusion ; Mortality ; Prevalence ; Pulmonary Embolism ; Thrombectomy ; Thrombolytic Therapy ; Thrombosis ; Urokinase-Type Plasminogen Activator

OBJECTIVETo investigate the clinical epidemiology change trend of upper gastrointestinal bleeding (UGIB) over the past 15 years.

METHODSConsecutive patients who was diagnosed as continuous UGIB in the endoscopy center of The First Affiliated Hospital of Sun-Yat University during the period from 1 January 1997 to 31 December 1998 and the period from 1 January 2012 to 31 December 2013 were enrolled in this study. Their gender, age, etiology, ulcer classification, endoscopic treatment and hospitalization mortality were compared between two periods.

RESULTSIn periods from 1997 to 1998 and 2012 to 2013, the detection rate of UGIB was 9.99%(928/9 287) and 4.49%(1 092/24 318)(χ=360.089, P=0.000); the percentage of male patients was 73.28%(680/928) and 72.44% (791/1 092) (χ=0.179, P=0.672), and the onset age was (47.3±16.4) years and (51.4±18.2) years (t=9.214, P=0.002) respectively. From 1997 to 1998, the first etiology of UGIB was peptic ulcer bleeding, accounting for 65.2%(605/928)[duodenal ulcer 47.8%(444/928), gastric ulcer 8.3%(77/928), stomal ulcer 2.3%(21/928), compound ulcer 6.8%(63/928)],the second was cancer bleeding(7.0%,65/928), and the third was esophageal and gastric varices bleeding (6.4%,59/928). From 2012 to 2013, peptic ulcer still was the first cause of UGIB, but the ratio obviously decreased to 52.7%(575/1092)(χ=32.467, P=0.000)[duodenal ulcer 31.9%(348/1092), gastric ulcer 9.4%(103/1092), stomal ulcer 2.8%(30/1092), compound ulcer 8.6%(94/1092)]. The decreased ratio of duodenal ulcer bleeding was the main reason (χ=53.724, P=0.000). Esophageal and gastric varices bleeding became the second cause (15.1%,165/1 092, χ=38.976, P=0.000), and cancer was the third cause (9.2%,101/1 092, χ=3.352, P=0.067). The largest increasing amplitude of the onset age was peptic ulcer bleeding [(46.2±16.7) years vs. (51.9±18.9) years, t=-5.548, P=0.000), and the greatest contribution to the amplitude was duodenal ulcer bleeding [(43.4±15.9) years vs. (48.4±19.4) years, t=-3.935, P=0.000], while the onset age of esophageal and gastric varices bleeding [(49.8±14.1) years vs. (48.8±13.9) years, t=0.458, P=0.648] and cancer [(58.4±13.4) years vs. (58.9±16.7) years, t=-0.196, P=0.845] did not change significantly. Compared with the period from 1997 to 1998, the detection rate of high risk peptic ulcer rebleeding (Forrest stage I(a, I(b, II(a and II(b) increased (χ=39.958, P=0.000) in the period from 2012 to 2013. From 1997 to 1998, 54 patients underwent endoscopic treatment, and the achievement ratio of hemostasis was 79.6% (43/54). From 2012 to 2013, 261 patients underwent endoscopic treatment and the achievement ratio of hemostasis was 96.9%(253/261), which was significantly higher (χ=23.287, P=0.000). Compared to the period from 1997 to 1998, more patients with variceal bleeding or non-variceal bleeding received endoscopic treatment in time (39.0% vs. 70.3%, χ=51.930, P=0.000; 3.6% vs. 15.6%, χ=62.292, P=0.000, respectively), and higher ratio of patients staging Forrest stage I(a to II(b also received endoscopic treatment in the period from 2012 to 2013 [27.4%(26/95) vs. 68.5%(111/162), χ=40.739, P=0.000]. More qualified endoscopic hemostatic techniques were used, containing thermocoagulation (0 vs. 15.2%, χ=79.518, P=0.000), hemostatic clip (0 vs. 55.9%, χ=20.879, P=0.000), hemostatic clip combined with thermocoagulation (4.3% vs. 16.4%, χ=5.154, P=0.023), while less single injection was used (87.1% vs. 6.2%, χ=10.420, P=0.001), and single spraying for hemostasis was completely abandoned in the period from 2012 to 2013. The ratio of inpatients undergoing reoperation decreased obviously in the period from 2012 to 2013 [9.3%(86/928) vs. 6.0%(65/1092), χ=7.970, P=0.005], while no significant difference was found in mortality during hospitalization between two periods.

CONCLUSIONCompared with the period from 1997 to1998, the mean onset age of UGIB increased, and the ratio of peptic ulcer bleeding decreased due to the reduction of duodenal ulcer bleeding, the detection rate of high risk peptic ulcer rebleeding increased, the cure rate of endoscopic treatment for UGIB increased, more reasonable and immediate hemostatic methods were used, but overall mortality did not change obviously in the period from 2012 to 2013.

Adult ; Age of Onset ; Aged ; Electrocoagulation ; methods ; trends ; Endoscopy, Digestive System ; trends ; Esophageal and Gastric Varices ; pathology ; therapy ; Esophagus ; pathology ; Female ; Gastrointestinal Hemorrhage ; classification ; epidemiology ; etiology ; mortality ; Gastrointestinal Neoplasms ; pathology ; Hemostasis, Endoscopic ; methods ; trends ; Hemostatic Techniques ; trends ; Hemostatics ; therapeutic use ; Humans ; Male ; Middle Aged ; Peptic Ulcer ; pathology ; therapy ; Peptic Ulcer Hemorrhage ; pathology ; therapy ; Reoperation ; trends ; Stomach Ulcer ; pathology ; therapy ; Surgical Instruments ; trends ; Ulcer ; epidemiology ; therapy

The anastomotic complications following radical gastrectomy mainly include anastomotic leakage, anastomotic hemorrhage, and anastomotic stricture. Theanastomotic complications are not rare and remain the most common complications resulting in the perioperativedeath of patients with gastric cancer. Standardized training could let surgeons fully realize that strict selection of operative indications, thorough preoperative assessment and preparation, and refined operation in surgery are the essential measures to prevent the anastomotic complications following radical gastrectomy. In addition, identifying these complications timely and taking effective measures promptly according to the clinical context are the keys to treating these complications, reducing the treatment cycle, and decreasing the mortality.
Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; prevention & control ; therapy ; Constriction, Pathologic ; prevention & control ; therapy ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; prevention & control ; therapy ; Humans ; Postoperative Complications ; diagnosis ; therapy ; Preoperative Care ; methods ; standards ; Risk Assessment ; methods ; standards ; Risk Factors ; Stomach Neoplasms ; complications ; mortality ; surgery

BACKGROUND/AIMS: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency that can be life threatening. This study evaluated predictive factors of 30-day mortality in patients with this condition. METHODS: A prospective observational study was conducted at a single hospital between April 2010 and November 2012, and 336 patients with symptoms and signs of gastrointestinal bleeding were consecutively enrolled. Clinical characteristics and endoscopic findings were reviewed to identify potential factors associated with 30-day mortality. RESULTS: Overall, 184 patients were included in the study (men, 79.3%; mean age, 59.81 years), and 16 patients died within 30 days (8.7%). Multivariate analyses revealed that comorbidity of diabetes mellitus (DM) or metastatic malignancy, age > or = 65 years, and hypotension (systolic pressure < 90 mmHg) during hospitalization were significant predictive factors of 30-day mortality. CONCLUSIONS: Comorbidity of DM or metastatic malignancy, age > or = 65 years, and hemodynamic instability during hospitalization were predictors of 30-day mortality in patients with NVUGIB. These results will help guide the management of patients with this condition.
Adult ; Age Factors ; Aged ; Chi-Square Distribution ; Comorbidity ; Diabetes Mellitus/mortality ; Endoscopy, Gastrointestinal ; Female ; Gastrointestinal Hemorrhage/diagnosis/*mortality/physiopathology/therapy ; Hemodynamics ; Hospital Mortality ; Hospitalization ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Neoplasm Metastasis ; Odds Ratio ; Predictive Value of Tests ; Prospective Studies ; Republic of Korea ; Risk Assessment ; Risk Factors ; Time Factors ; Treatment Outcome

Non-variceal upper gastrointestinal bleeding, the most common etiology of which is peptic ulcer disease, remains a persistent challenge despite a reduction in both its incidence and mortality. Both pharmacologic and endoscopic techniques have been developed to achieve hemostasis, with varying degrees of success. Among the pharmacologic therapies, proton pump inhibitors remain the mainstay of treatment, as they reduce the risk of rebleeding and requirement for recurrent endoscopic evaluation. Tranexamic acid, a derivative of the amino acid lysine, is an antifibrinolytic agent whose role requires further investigation before application. Endoscopically delivered pharmacotherapy, including Hemospray (Cook Medical), EndoClot (EndoClot Plus Inc.), and Ankaferd Blood Stopper (Ankaferd Health Products), in addition to standard epinephrine, show promise in this regard, although their mechanisms of action require further investigation. Non-pharmacologic endoscopic techniques use one of the following two methods to achieve hemostasis: ablation or mechanical tamponade, which may involve using endoscopic clips, cautery, argon plasma coagulation, over-the-scope clipping devices, radiofrequency ablation, and cryotherapy. This review aimed to highlight these novel and fundamental hemostatic strategies and the research supporting their efficacy.
Argon Plasma Coagulation ; Catheter Ablation ; Cautery ; Cryotherapy ; Drug Therapy ; Embolization, Therapeutic ; Endoscopy ; Epinephrine ; Gastrointestinal Hemorrhage ; Hemorrhage* ; Hemostasis ; Incidence ; Lysine ; Mortality ; Peptic Ulcer ; Proton Therapy ; Tranexamic Acid

BACKGROUND/AIMS: Practice guidelines recommend endoscopic band ligation (EBL) and endoscopic variceal obturation (EVO) for bleeding from esophageal varices and fundal varices, respectively. However, the optimal treatment for bleeding from cardiac varices along the lesser curvature of the stomach (GOV1) remains undefined. This retrospective study compared the efficacy between EBL and EVO for bleeding from GOV1. METHODS: Patients treated by EBL or EVO via cyanoacrylate injection for bleeding from GOV1 were enrolled. Patients diagnosed with hepatocellular carcinoma or treated with endoscopic injection sclerotherapy were excluded. RESULTS: The study included 91 patients treated for bleeding from GOV1. The mean age was 56.3±10.9 years (mean±SD), and 78 of them (85.7%) were men. Overall, 51 and 40 patients were treated with EBL and EVO, respectively. A trend for a higher hemostasis rate was noted in the EVO group (100%) than in the EBL group (82.6%, P=0.078). Varices rebled in 15 patients during follow-up. The rebleeding rate was significantly higher in the EBL group than in the EVO group (P=0.004). During follow-up, 13 patients died (11 in the EBL group and 2 in the EVO group); the survival rate was marginally significant between two groups (P=0.050). The rebleeding-free survival rate was significantly higher in the EVO group than in the EBL group (P=0.001). CONCLUSIONS: Compared to EBL, EVO offered significantly lower rebleeding rates, significantly higher rebleeding-free survival rates, and a trend for higher hemostasis and survival rates. EVO appears to be the better therapeutic option for bleeding from GOV1.
Adult ; Aged ; Carcinoma, Hepatocellular/complications ; Cyanoacrylates/*therapeutic use ; Disease-Free Survival ; Endoscopy, Gastrointestinal ; Female ; Gastrointestinal Hemorrhage/etiology/mortality/*therapy ; Humans ; Ligation ; Liver Cirrhosis/complications/diagnosis ; Liver Neoplasms/complications ; Male ; Middle Aged ; Proportional Hazards Models ; Recurrence ; Retrospective Studies ; Sclerotherapy ; Survival Rate ; Treatment Outcome

BACKGROUND/AIMS: The risk of gastrointestinal (GI) bleeding with dabigatran when compared to warfarin has been controversial in the literature. The aim of our study was to assess this risk with the use of dabigatran. METHODS: We examined the medical records of patients who were started on dabigatran or warfarin from October 2010 to October 2012. The study was conducted in two hospitals. RESULTS: A total of 417 patients were included (208 dabigatran vs. 209 warfarin). GI bleeding occurred in 10 patients (4.8%) in the dabigatran group compared to 21 patients (10.1%) in the warfarin group (p=0.0375). Multivariate analysis showed that patients who were on dabigatran for < or =100 days had a higher incidence of GI bleeding than those who were on it for >100 days (p=0.0007). The odds of GI bleeding in patients who were on dabigatran for < or =100 days was 8.2 times higher compared to those who were on the drug for >100 days. The incidence of GI bleeding in patients >65 years old was higher than in those <65 years old (p=0.0453, OR=3). History of previous GI bleeding was another risk factor for GI bleeding in the dabigatran group (p=0.036, OR=6.3). The lower GI tract was the most common site for GI bleeding in the dabigatran group (80.0% vs. 38.1%, p=0.014). CONCLUSIONS: The risk of GI bleeding was lower with dabigatran. The risk factors for GI bleeding with dabigtran were the first 100 days, age >65 years, and a history of previous GI bleeding.
Age Factors ; Aged ; Aged, 80 and over ; Anticoagulants/*adverse effects/therapeutic use ; Atrial Fibrillation/drug therapy ; Dabigatran/*adverse effects/therapeutic use ; Female ; Gastrointestinal Hemorrhage/*chemically induced/epidemiology/mortality ; Humans ; Incidence ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Retrospective Studies ; Risk Factors ; Warfarin/*adverse effects/therapeutic use

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.
Adult ; Aged ; Aged, 80 and over ; Chi-Square Distribution ; Enbucrilate/*administration & dosage/adverse effects ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/diagnosis/mortality/*therapy ; Female ; Gastrointestinal Hemorrhage/diagnosis/etiology/mortality/*therapy ; Hemostasis, Endoscopic/adverse effects/*methods/mortality ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Proton Pump Inhibitors/adverse effects/*therapeutic use ; Recurrence ; Retrospective Studies ; Risk Factors ; Sclerosing Solutions/*administration & dosage/adverse effects ; Sclerotherapy/adverse effects/*methods/mortality ; Time Factors ; Treatment Outcome ; Young Adult

BACKGROUND/AIMS: To evaluate the long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (NBC; Histoacryl) for treatment of bleeding gastric varices. METHODS: We retrospectively analyzed the records of 455 patients with gastric variceal hemorrhage (GVH) who were consecutively treated with NBC from January 2004 to July 2013, with a mean follow-up period of 582 days. The patients' endoscopic findings, initial hemostasis, complications, rebleeding rates, and bleeding-related death rates were reviewed. RESULTS: Hemostasis was achieved initially in 96.9% (441/455) of patients; rebleeding occurred in 35.2% (160/455), and the bleeding-related death rate was 6.8% (31/455) during follow-up. Complications included fever (6.8%), abdominal pain (3.7%), diarrhea (1.3%), spontaneous bacterial peritonitis (0.7%), bacteremia (0.4%), and embolism (0.2%). A red-color sign on concomitant esophageal varices (EVs) (p = 0.002) and previous history of variceal bleeding (p < 0.001) were significant risk factors for rebleeding within 1 year. The Child-Pugh score (p < 0.001), presence of hepatocellular carcinoma (p = 0.001), and failure of initial hemostasis (p < 0.001) were the risk factors most closely associated with bleeding-related death. CONCLUSIONS: This study provides a comprehensive overview of the outcomes and prognostic factors of patients with GVH. The results may help in the selection of effective treatment strategies for patients with GVH.
Adult ; Aged ; Aged, 80 and over ; Enbucrilate/adverse effects/*therapeutic use ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/diagnosis/mortality/*therapy ; Female ; Gastrointestinal Hemorrhage/diagnosis/etiology/mortality/*therapy ; *Hemostatic Techniques/adverse effects/mortality ; Humans ; Male ; Middle Aged ; Recurrence ; Retrospective Studies ; Time Factors ; Treatment Outcome ; Young Adult