Paradigm Shift in Etiology of Upper Gastrointestinal Bleed in Emergency Department
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Keywords
alcoholic liver disease, peptic ulcer disease, upper gastrointestinal bleed
Abstract
Acute upper gastrointestinal (UGI) bleed is an emergency requiring immediate intervention. Recent data have shown peptic ulcer disease (PUD) to be the commonest cause of UGI bleed. We aimed to evaluate all patients with UGI bleed reporting in the emergency department.
A cross-sectional, observational study from a tertiary care center; evaluated all patients with UGI bleed presenting to the outpatient and emergency departments between December 2017 and December 2018.
A total of 356 patients with UGI bleed were enlisted for diagnostic and therapeutic endoscopy. Variceal bleed was present in 231 (65%) [cir-rhosis 217 (61%) vs noncirrhotic 14 (4%)] patients, nonvariceal bleed was present in 93 (26%) [cirrhosis 22(6%) vs noncirrhotic 71(20%)] patients, and no cause was determined in 32 (9%) patients. Among cirrhotic patients, alcoholic liver disease (n = 172) was the most common, followed by cryptogenic cirrhosis (n = 32), and cirrhosis related to Hepatitis B (n =7) and hepatitis C virus (n =22), and AIH (n = 6). Among variceal noncirrhotic causes, noncirrhotic portal hypertension was present in 14 patients. In the noncirrhotic, nonvariceal group, causes of UGI bleed included esophagitis (n = 26), erosive gastritis (n = 9), and Mallory Weiss Tear (n = 7), followed by PUD (n = 23), carcinoma stomach (n = 3), carcinoma esophagus (n = 2), and duodenal polyp (n= 1). Nonvariceal cirrhotic patients had portal hypertensive gastropathy (n = 8), PUD (n = 5), duodenal erosions (n = 1), esophagitis (n= 7), and antral varix (n = 1). Interestingly, even in the nonvariceal group, alcohol was the underlying cause of UGI bleed in majority of the patients with esophagitis and erosive gastritis.
Alcohol was the commonest cause of UGI bleed in majority of the cases with or without chronic liver disease, followed by PUD in small numbers in the emergency department.
References
2. Silverstain FE, Gilbert DA, Tedesco FJ, Buenger NK, Persing J. The national ASGE survey on upper gastrointestinal bleeding. II Clinical prognostic factors. Gastrointestinal Endosc.1981;27:80–93. http://dx.doi.org/10.1016/S0016-5107(81)73156-0
3. Rathi P, Abraham P, Jakareddy R, Pai N. Spectrum of upper gastrointestinal bleeding in Western India. Indian J Gastroenterol. 2001;20(Suppl 2):A37.
4. Gajendra O, Ponsek T, Varghese J, Sadasivan S, Nair P, Narayanan VA. Single center study of upper GI endoscopic findings in patients with overt and occult upper GI bleed. Indian J Gastroenterol. 2009;28:A111.
5. Anand CS, Tandon BN, Nundy S. The causes, management and outcome of upper gastrointestinal haemorrhage in an Indian hospital. Br J Surg. 1983;70:209–11. http://dx.doi.org/10.1002/ bjs.1800700407
6. Krishnakumar R, Padmanabhan P, Premkumar, Selvi C, Ramkumar, Joe A. Upper GI bleed – A study of 408 cases. Indian J Gastroenterol. 2007;26(Suppl 2):A133.
7. Sharma V, Jeyaraman P, Rana SS, Gupta R, Malhotra S, Bhalla A, et al. Utility of clinical and complete Rockall score in Indian patients with upper gastrointestinal bleeding. Trop Gastroenterol. 2016;37:276–82. http://dx.doi.org/10.7869/tg.373
8. Sarin SK, Kumar A, Chawla YK, Baijal SS, Dhiman RK, Jafri W, et al. Noncirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and treatment. Hepatol Int. 2007;1(3):398–413. http://dx.doi.org/10.1007/ s12072-007-9010-9
9. Merican I, Guan R, Amarapuka D, Alexander MJ, Chutaputti A, Chien RN, et al. Chronic hepatitis B virus infection in Asian countries. J Gastroenterol Hepatol. 2000;15:1356– 61. http://dx.doi.org/10.1046/j.1440-1746.2000.0150121356.x
10. Liangpunsakul S, Haber P, McCaughan GW. Alcoholic liver disease in Asia, Europe, and North America. Gastroenterology. 2016;150:1786–97. http://dx.doi.org/10.1053/j.gastro.2016.02.043
11. Singh SP, Panigrahi S, Mishra D, Khatua CR. Alcohol-associated liver disease, not hepatitis B, is the major cause of cirrhosis in Asia. J Hepatol. 2019;70:1031–2. http://dx.doi. org/10.1016/j.jhep.2019.01.003
12. Agrawal S, Duseja A, Gupta T, Dhiman RK, Chawla Y. Simple organ failure count versus CANONIC grading system for predicting mortality in acute-on-chronic liver failure. J Gastroenterol Hepatol. 2015;30:575–81. http://dx.doi. org/10.1111/jgh.12778
13. Dhiman RK, Agrawal S, Gupta T, Duseja A, Chawla Y. Chronic liver failure-sequential organ failure assessment is better than the Asia-Pacific Association for the Study of liver criteria for defining acute-on-chronic liver failure and predicting outcome. World J Gastroenterol. 2014;20:14934–41. http://dx.doi. org/10.3748/wjg.v20.i40.14934
14. Gupta T, Dhiman RK, Rathi S, Agrawal S, Duseja A, Taneja S, et al. Impact of hepatic and extrahepatic insults on the outcome of acute-on-chronic liver failure. J Clin Exp Hepatol. 2017;7:9– 15. http://dx.doi.org/10.1016/j.jceh.2016.10.006
15. Wong RJ, Aguilar M, Cheung R, Perumpail RB, Harrison SA, Younossi ZM, et al. Nonalcoholic steatohepatitis is the second leading etiology of liver disease among adults awaiting liver transplantation in the United States. Gastroenterology. 2015;148:547–55. http://dx.doi.org/10.1053/j.gastro.2014.11.039
16. Bhattarai S, Dewan KR, Shrestha G, Patowary BS. Spectrum of upper gastrointestinal bleed in patients with cirrhosis of liver. JCMS Nepal. 2017;13:318–22. http://dx.doi.org/10.3126/jcmsn. v13i3.17938
17. Romcea AA, Tant¸a?u M, Seicean A, Pascu O. The etiology of upper gastrointestinal bleeding in cirrhotic patients. Clujul Med. 2013;86:21–3.
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Tarana Gupta, Pt B D Sharma University of Health Sciences, Rohtak, India.
Department of Medicine, Pt B D Sharma University of Health Sciences, Rohtak, India.
Sandeep Goyal, Pt B D Sharma University of Health Sciences, Rohtak, India.
Department of Medicine, Pt B D Sharma University of Health Sciences, Rohtak, India.