Melena

A retrospective chart review of 288 adult patients (>18 years of age) who were admitted to Chang Gung Memorial Hospital, Tao-Yuan, Taiwan, for caustic ingestion between June 1999 and July 2006 was conducted. Parameters analysed were age, gender, intent of ingestion, substance ingested and amount, time to expiration, ICU admittance, length of hospital stay, complications, and the severity of mucosal injury as assessed by EGD.
EGD with a standard upper GI endoscope was performed by experienced physicians within 24 hours of ingestion. Endoscopes used were Olympus GIF XQ-230, GIF Q-240X, and GIF Q-260, with diameters of 9.2 mm, 9.4 mm, and 9.2 mm, respectively (Olympus, Tokyo, Japan). Oral cavity xylocaine spray was used for anaesthesia except in 15 cases, which received ventilation support under general anaesthesia because of respiratory difficulty (n = 11) or unclear consciousness (n = 4). Gentle insufflations and retrovisual methods were performed carefully or avoided in the presence of severe stomach injury. Mucosal damage was graded using a modified endoscopic classification described by Zagar et al [11 (link)] (Table 1).
Patients were treated with a proton pump inhibitor or H2 antagonist and were maintained without oral intake until their condition was considered stable. Patients received parenteral nutrition during this period. If infection was suspected, antibiotics (a 1^st generation cepholasporin and gentamicin) were administered after blood cultures were obtained. If a patient's condition destablized or respiratory difficulty was encountered, they were transferred to the intensive care unit for further evaluation. After discharge, patients were followed in the outpatient clinic for at least 6 months. Any complications observed during follow-up were recorded. Upper GI complications included bleeding, perforation, and stricture formation. Bleeding was defined as melena, hematemasis, and/or coffee-ground vomitus. Perforation was diagnosed by the presence of free air on a plain chest radiograph. Stricture was defined as dysphagia, symptoms of regurgitation, or difficulty in swallowing with confirmation by endoscopy, esophagogram, and/or upper GI radiography. Systemic complications included renal insufficiency, liver damage, diffuse intravascular coagulation, and hemolysis. Liver damage was defined as an elevation in the serum level of alanine aminotransferase or asparatate aminotransferase greater than 3 times the upper normal limit. Renal insufficiency was defined as a plasma creatinine level of >1.4 mg/dL in the absence of other renal diseases. Criteria for disseminated intravascular coagulation and/or hemolysis were prolonged plasma coagulation time, decreased fibrinogen or antithrombin levels, and decreased platelet count.
Demographic data were described by mean and standard deviations for normally distributed continuous variables, median and interquartile range for non-normally distributed continuous variables, and frequencies and percentages for categorical variables. Wald's Chi-Square tests adjusted for age obtained by generalized estimation equations were used to evaluate for overall survival and complications over grade of mucosal injury. Data subset was subsequently analyzed using logistic regression. Data were analyzed using SAS 9.0 (SAS Institute Inc, Cary, NC, US), and P < 0.05 was considered significant.

Demographic data, comorbidities and chronic medical conditions, vital signs, and laboratory values (as based value) were registered on the ICU admission day. APACHE II and SOFA scoring were performed and recorded in the first 24 hours and day to day for SOFA score. The primary outcome was mortality in the ICU, hospital, or discharge. All patients were followed up to determine this outcome, and the relevant information was recorded, and the secondary outcome was organ dysfunction. Other data such as ICU and hospital length of stay and the need for different ventilation support types were considered factors that may affect patients' outcomes. Laboratory routine tests for COVID-19 management were run, and results were collected. The worse values and vital signs associated with the worse medical conditions in the first 24 hours were used to calculate the APACHE II score and approximate ICU mortality rates. For SOFA score, the first day and mean of daily SOFA scores during ICU admission were calculated. We recorded adverse effects on the kidney (acute kidney injury, oliguria, anuria, and need for dialysis), cardiac (new abnormalities in electrocardiography, rise of serum levels of troponin I, decrease of ejection fraction under 40%, need to vasopressor/inotrope), liver (an increase of liver enzymes and bilirubin, abnormal INR), hematologic (leukocytosis, lymphopenia, neutrophilia, anemia, platelet count <100000 μ/ml), gastrointestinal (bleeding, diarrhea, melena), neurologic (loss of consciousness, seizure, lethargy, delirium, paresthesia/plegia), and respiratory (acute respiratory distress syndrome, hemoptysis, pneumothorax, emphysema, effusion) as the adverse organic outcomes due to COVID-19 disease. Acute kidney injury (AKI) was identified based on Acute Kidney Injury Network (AKIN) criteria [15 (link)]. ARDS was defined according to the Berlin definition [16 (link)].

Patients over 18 years old admitted to the hospital complex with signs and symptoms of UGIB and diagnosed by upper digestive endoscopy (UDE) or surgical intervention (laparoscopy) were determined as our study group.
UGIB was defined as: i) presence of endoscopically proven ulcers, perforation, or hemorrhagic erosions and ii) presence of dark or “coffee grounds” vomiting, melena, hematemesis, hematochezia, epidegastric pain, sudden loss, heavy sweating, and/or pallor.
Patient exclusion criteria were (i) bleeding from gastric or esophageal varices or neoplasm; (ii) presence of cirrhosis, Mallory-Weiss tears, and/or Dieulafoy lesions; (iii) serious health condition; (iv) UDE performed after 48 h of hospital admission; (v) hospitalization within 15 days prior to the current hospital admission; and (vi) in-hospital UGIB.
For each recruited case participant, controls were matched by sex, age (±5 years), and recruitment data (3 months). Control participants were admitted to preoperative units of the same hospital complex for mild surgery unrelated to gastrointestinal disorders (i.e., inguinal/umbilical hernia correction; plastic surgery; phacectomy (eye cataract); and prostatectomy).
Participants were recruited regardless of the use of NSAIDs and LDA in order to verify whether the proposed genetic variants are associated with the risk of UGIB or whether there is synergism between the variants and the use of these drugs in the risk of UGIB. Hence, it is essential that both case and control groups include NSAIDs or LDA-exposed and NSAIDs or LDA-unexposed individuals to assess the likely direct effect of functional variants on risk of suffering UGIB (7 (link)).
In order to reduce possible bias, only biologically unrelated participants were included. Participants with history of neoplasia, immunodeficiency syndrome, coagulopathies, nasogastric or percutaneous tube holders; patients who use narcotics; and non-residents of the study region for at least 3 months were excluded.
The inclusion and exclusion criteria for the participants are described in detail in our three previous studies (4 (link), 10 (link), 11 (link)).