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Acute on chronic gastrointestinal bleeding: a unique clinical entity
Don C Rockey1, Adam C Hafemeister2, Joan S Reisch3
1Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA (present Department of Internal Medicine, Medical Univeristy of South Carolina, Charleston, South Carolina, USA).
Insights
A new type of gastrointestinal bleeding, "acute on chronic," is identified. This condition, often linked to portal hypertension, shows lower mortality than acute bleeding, suggesting a potential adaptive response.
Area of Science:
- Gastroenterology
- Internal Medicine
- Clinical Research
Background:
- Gastrointestinal bleeding is typically classified as acute or chronic based on temporal and spatial characteristics.
- A novel classification, 'acute on chronic' gastrointestinal bleeding, is proposed to describe new bleeding in patients with pre-existing chronic bleeding (iron deficiency anemia).
Purpose of the Study:
- To define and characterize 'acute on chronic' gastrointestinal bleeding.
- To investigate the common locations and causes of bleeding lesions in this patient group.
- To compare the mortality rates of acute on chronic gastrointestinal bleeding with acute and chronic bleeding.
Main Methods:
- Prospective identification of patients undergoing endoscopic evaluation for gastrointestinal bleeding at a University Hospital.
- Classification of bleeding as acute, chronic, or acute on chronic based on clinical presentation and documented iron deficiency anemia.
- Categorization of bleeding lesions and analysis of patient demographics, lesion locations, and 30-day mortality.
Main Results:
- A total of 430 patients were identified with acute on chronic gastrointestinal bleeding.
- Common bleeding sites for acute on chronic bleeding were the esophagus (28%), colon/rectum (27%), and stomach (21%).
- In upper gastrointestinal bleeding, portal hypertensive lesions were the most frequent cause (47%) in the acute on chronic group, compared to acute (29%) and chronic (25%) bleeders.
- The 30-day mortality for acute on chronic bleeding (2%) was significantly lower than for acute bleeding (7%).
Conclusions:
- Acute on chronic gastrointestinal bleeding is a prevalent condition.
- Portal hypertensive pathology is a common cause of acute on chronic upper gastrointestinal bleeding.
- The lower mortality observed in acute on chronic bleeding suggests a possible adaptive physiological response.
Abstract:
Gastrointestinal bleeding is defined in temporal-spatial terms-as acute or chronic, and/or by its location in the gastrointestinal tract. Here, we define a distinct type of bleeding, which we have coined 'acute on chronic' gastrointestinal bleeding. We prospectively identified all patients who underwent endoscopic evaluation for any form of gastrointestinal bleeding at a University Hospital. Acute on chronic bleeding was defined as the presence of new symptoms or signs of acute bleeding in the setting of chronic bleeding, documented as iron deficiency anemia. Bleeding lesions were categorized using previously established criteria. We identified a total of 776, 254, and 430 patients with acute, chronic, or acute on chronic bleeding, respectively. In patients with acute on chronic gastrointestinal bleeding, lesions were most commonly identified in esophagus (28%), colon and rectum (27%), and stomach (21%) (p<0.0001 vs locations for acute or chronic bleeding). In those specifically with acute on chronic upper gastrointestinal bleeding (n=260), bleeding was most commonly due to portal hypertensive lesions, identified in 47% of subjects compared with 29% of acute and 25% of chronic bleeders, (p<0.001). In all patients with acute on chronic bleeding, 30-day mortality was less than that after acute bleeding alone (2% (10/430) vs 7% (54/776), respectively, p<0.001). Acute on chronic gastrointestinal bleeding is common, and in patients with upper gastrointestinal bleeding was most often a result of portal hypertensive upper gastrointestinal tract pathology. Reduced mortality in patients with acute on chronic gastrointestinal bleeding compared with those with acute bleeding raises the possibility of an adaptive response.
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