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The clinical outcome of acute nonvariceal gastrointestinal bleeding at after-hours: The role of urgent endoscopy
Abstracts
by ciprofloxacin displays a short latency, suggesting an idiosyncratic hypersensitivity reaction. If pancreatitis was detected early, the prognosis was very good. During ciprofloxacin use, practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy. And regular screening of chemical profiles is warranted. Keywords: Pancreatitis, Ciprofloxacin, Adverse effect, Infectious colitis doi:10.1016/j.ejim.2013.08.199
RO
OF
ID: 277 The clinical outcome of acute nonvariceal gastrointestinal bleeding at after-hours: The role of urgent endoscopy D.W. Ahna,b, S.H. Leea,c, Y.S. Parka,c, K.W. Jeonga, C.M. Shina,c, J.H. Hwanga,c, J.W. Kima,c, S.H. Jeonga,c, N. Lima,c, D.H. Leea,c a Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea b Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea c Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
Objective: While early esophagogastroduodenoscopy (EGD) within 24 hours has become a standard therapeutic approach for acute nonvariceal upper gastrointestinal bleeding (NVUGIB), the clinical role and benefit of urgent EGD (within 8 hours) by experienced endoscopists at after-hours in high risk patients has not been established yet. This study was performed to record the clinical outcome of acute NVUGIB at after-hours and to investigate the clinical role and benefit of the urgent EGD (within 8 h). Methods: Between January 2009 and December 2010, medical records of patients who visited to emergent unit for acute NVUGIB were reviewed. Results: A total of 158 patients visited the emergent unit for acute NVUGIB at after-hours. All of the patients underwent EGD within 24 h by two experienced endoscopists. Among these 158 patients, 60 underwent urgent EGD (within 8 h) and 98 underwent early EGD (8 to 24 h). The frequencies of hemodynamic instability, fresh blood aspirate on nasogastric tube, high risk endoscopic findings were significantly higher in the urgent EGD group (P b .05). Primary hemostasis was achieved in all except for two patients (each one in the urgent and early EGD groups, respectively). There were 9 cases of recurrent bleeding: 4 (6.7%) and 5 (5.1%) in the urgent and early EGD groups, respectively. Among them, 5 achieved successful hemostasis with repeated EGD while other 4 required angiographic embolization or surgery for hemostasis. 30-day mortality occurred in three patients (one and two in urgent and early EGD groups, respectively). There were no significant differences between the two groups in the primary hemostasis, recurrent bleeding, and 30-day mortality. In patients with high clinical Rockall score (more than 3), the urgent EGD tended to decrease the hospital stay, although it is not statistically significant (7.7 vs. 12.0 days, P N .05). In a multiple linear regression analysis, the urgent EGD significantly reduced the hospital stay compared with the early EGD (7.8 vs. 10.6 days, P = .04). Conclusions: Urgent EGD group, despite higher rate of high risk patients, had an excellent endoscopic success rate and clinical outcome not inferior to early EGD group. The urgent EGD reduced the length of hospital stay in high risk groups. The results of this study show a possible role of urgent EGD (if it is performed by experienced endoscopists) in high-risk patients. The urgent EGD at after-hours should be considered in high risk groups such as high clinical Rockall score because of excellent endoscopic success rate and shorter length of hospital stay. A prospective study to investigate the role of the urgent EGD by experienced endoscopists would be required.
DP
University because of the ongoing complaints. The colonoscopic examination performed at our center at 01/19/2012 revealed a normal terminal ileum and cecum, aphthous ulcers from the distal part of the ascending colon up to the distal end of the transverse colon, and deep, linear and exudating ulcers from the proximal part of the descending colon up to the distal end of the sigmoid colon. Pathologic examination of the biopsies showed periglandular granuloma in the ileum, focal crypt abscess formation in the ascending colon, crypt abscesses, ulcerative ground and focal granuloma formation in the descending colon, ulcerative ground and glandular distortion in the sigmoid colon, and cryptitis and granuloma formation in the rectum. The tests for C. difficile toxins and amoeba antigens were negative. Then, methylprednisolone at a dose of 32 mg/day was commenced at 05/12/2011. The number of defecations reduced from 6 to 4 and serum level of CRP reduced to normal range 2 weeks after beginning the glucocorticoid therapy. Thereon, the dose of methylprednisolone was reduced to 24 mg/day and reduced 4 mg further every week. While patient on therapy was in clinical remission, abdominal pain emerged. Azathioprine was added gradually in dosage of 50 mg bid. Abdominal pain was alleviated but on 04/13/2012 she reported vaginal discharge. Physical examination showed purulent discharge, pain, and erythema on the lateral side of the left labia majora on admission to the hospital. The pelvic MRI examination, was done immediately, revealed abscess formations one on the perianal region and two on the labia majora. Doxycycline therapy was started according to gynecologic consultation. The abscess localized to labia majora drained spontaneously during the antibacterial treatment. The patient was discharged on doxycycline, ciprofloxacin and metronidazole therapy. The control MRI examination taken two weeks after showed no abscess formation. Because of the fistulizing disease, she was commenced on infliximab therapy which led to clinically end endoscopic remission eventually.
e81
TE
doi:10.1016/j.ejim.2013.08.198
EC
ID: 271 Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis M.Y. Jeong, J.I. Kim, S.J. Lee, H.Y. Sung, D.Y. Cheung, S.H. Park, J.K. Kim
RR
Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
UN
CO
Background/aim: Ciprofloxacin is considered to be a safe and effective treatment of acute infectious colitis. However, this drug, albeit rarely, may cause drug-induced pancreatitis. This study was conducted to analyze the clinical features of pancreatitis caused by ciprofloxacin. Method: From January 2007 to March 2011, we registered 227 patients who were hospitalized infectious colitis at St. Mary's hospital, Seoul, Korea. All the patients received ciprofloxacin therapy for a treatment of infectious colitis. We observed a few cases of rare adverse events; ciprofloxacin-induced acute pancreatitis diagnosed by the Naranjo algorithm. Results: During ciprofloxacin therapy, 7 of 227 patients (3.1%) were met with rare adverse events (4 males and 3 females with a mean age of 46.9 ± 17.4 years; range: 24–71). They were diagnosed with probable pancreatitis secondary to ciprofloxacin by the Naranjo algorithm; pancreatic enzyme was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average time interval until development of pancreatitis was 5.5 days (range: 4–7). In abdominal computed tomography, pancreatic swelling and homogenous enhancement were noted in 3 of 7 patients. Complicating acute pancreatitis was completely resolved gradually after the cessation of ciprofloxacin administration. Mean recovery time was 11.3 days (range: 8–15). Conclusion: We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Drug-induced pancreatitis
doi:10.1016/j.ejim.2013.08.200
by ciprofloxacin displays a short latency, suggesting an idiosyncratic hypersensitivity reaction. If pancreatitis was detected early, the prognosis was very good. During ciprofloxacin use, practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy. And regular screening of chemical profiles is warranted. Keywords: Pancreatitis, Ciprofloxacin, Adverse effect, Infectious colitis doi:10.1016/j.ejim.2013.08.199
RO
OF
ID: 277 The clinical outcome of acute nonvariceal gastrointestinal bleeding at after-hours: The role of urgent endoscopy D.W. Ahna,b, S.H. Leea,c, Y.S. Parka,c, K.W. Jeonga, C.M. Shina,c, J.H. Hwanga,c, J.W. Kima,c, S.H. Jeonga,c, N. Lima,c, D.H. Leea,c a Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea b Internal Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea c Internal Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
Objective: While early esophagogastroduodenoscopy (EGD) within 24 hours has become a standard therapeutic approach for acute nonvariceal upper gastrointestinal bleeding (NVUGIB), the clinical role and benefit of urgent EGD (within 8 hours) by experienced endoscopists at after-hours in high risk patients has not been established yet. This study was performed to record the clinical outcome of acute NVUGIB at after-hours and to investigate the clinical role and benefit of the urgent EGD (within 8 h). Methods: Between January 2009 and December 2010, medical records of patients who visited to emergent unit for acute NVUGIB were reviewed. Results: A total of 158 patients visited the emergent unit for acute NVUGIB at after-hours. All of the patients underwent EGD within 24 h by two experienced endoscopists. Among these 158 patients, 60 underwent urgent EGD (within 8 h) and 98 underwent early EGD (8 to 24 h). The frequencies of hemodynamic instability, fresh blood aspirate on nasogastric tube, high risk endoscopic findings were significantly higher in the urgent EGD group (P b .05). Primary hemostasis was achieved in all except for two patients (each one in the urgent and early EGD groups, respectively). There were 9 cases of recurrent bleeding: 4 (6.7%) and 5 (5.1%) in the urgent and early EGD groups, respectively. Among them, 5 achieved successful hemostasis with repeated EGD while other 4 required angiographic embolization or surgery for hemostasis. 30-day mortality occurred in three patients (one and two in urgent and early EGD groups, respectively). There were no significant differences between the two groups in the primary hemostasis, recurrent bleeding, and 30-day mortality. In patients with high clinical Rockall score (more than 3), the urgent EGD tended to decrease the hospital stay, although it is not statistically significant (7.7 vs. 12.0 days, P N .05). In a multiple linear regression analysis, the urgent EGD significantly reduced the hospital stay compared with the early EGD (7.8 vs. 10.6 days, P = .04). Conclusions: Urgent EGD group, despite higher rate of high risk patients, had an excellent endoscopic success rate and clinical outcome not inferior to early EGD group. The urgent EGD reduced the length of hospital stay in high risk groups. The results of this study show a possible role of urgent EGD (if it is performed by experienced endoscopists) in high-risk patients. The urgent EGD at after-hours should be considered in high risk groups such as high clinical Rockall score because of excellent endoscopic success rate and shorter length of hospital stay. A prospective study to investigate the role of the urgent EGD by experienced endoscopists would be required.
DP
University because of the ongoing complaints. The colonoscopic examination performed at our center at 01/19/2012 revealed a normal terminal ileum and cecum, aphthous ulcers from the distal part of the ascending colon up to the distal end of the transverse colon, and deep, linear and exudating ulcers from the proximal part of the descending colon up to the distal end of the sigmoid colon. Pathologic examination of the biopsies showed periglandular granuloma in the ileum, focal crypt abscess formation in the ascending colon, crypt abscesses, ulcerative ground and focal granuloma formation in the descending colon, ulcerative ground and glandular distortion in the sigmoid colon, and cryptitis and granuloma formation in the rectum. The tests for C. difficile toxins and amoeba antigens were negative. Then, methylprednisolone at a dose of 32 mg/day was commenced at 05/12/2011. The number of defecations reduced from 6 to 4 and serum level of CRP reduced to normal range 2 weeks after beginning the glucocorticoid therapy. Thereon, the dose of methylprednisolone was reduced to 24 mg/day and reduced 4 mg further every week. While patient on therapy was in clinical remission, abdominal pain emerged. Azathioprine was added gradually in dosage of 50 mg bid. Abdominal pain was alleviated but on 04/13/2012 she reported vaginal discharge. Physical examination showed purulent discharge, pain, and erythema on the lateral side of the left labia majora on admission to the hospital. The pelvic MRI examination, was done immediately, revealed abscess formations one on the perianal region and two on the labia majora. Doxycycline therapy was started according to gynecologic consultation. The abscess localized to labia majora drained spontaneously during the antibacterial treatment. The patient was discharged on doxycycline, ciprofloxacin and metronidazole therapy. The control MRI examination taken two weeks after showed no abscess formation. Because of the fistulizing disease, she was commenced on infliximab therapy which led to clinically end endoscopic remission eventually.
e81
TE
doi:10.1016/j.ejim.2013.08.198
EC
ID: 271 Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis M.Y. Jeong, J.I. Kim, S.J. Lee, H.Y. Sung, D.Y. Cheung, S.H. Park, J.K. Kim
RR
Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, South Korea
UN
CO
Background/aim: Ciprofloxacin is considered to be a safe and effective treatment of acute infectious colitis. However, this drug, albeit rarely, may cause drug-induced pancreatitis. This study was conducted to analyze the clinical features of pancreatitis caused by ciprofloxacin. Method: From January 2007 to March 2011, we registered 227 patients who were hospitalized infectious colitis at St. Mary's hospital, Seoul, Korea. All the patients received ciprofloxacin therapy for a treatment of infectious colitis. We observed a few cases of rare adverse events; ciprofloxacin-induced acute pancreatitis diagnosed by the Naranjo algorithm. Results: During ciprofloxacin therapy, 7 of 227 patients (3.1%) were met with rare adverse events (4 males and 3 females with a mean age of 46.9 ± 17.4 years; range: 24–71). They were diagnosed with probable pancreatitis secondary to ciprofloxacin by the Naranjo algorithm; pancreatic enzyme was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average time interval until development of pancreatitis was 5.5 days (range: 4–7). In abdominal computed tomography, pancreatic swelling and homogenous enhancement were noted in 3 of 7 patients. Complicating acute pancreatitis was completely resolved gradually after the cessation of ciprofloxacin administration. Mean recovery time was 11.3 days (range: 8–15). Conclusion: We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Drug-induced pancreatitis
doi:10.1016/j.ejim.2013.08.200