<i>Background</i>. The mortality from nonvariceal upper gastrointestinal bleeding is still around 5&#x25;, despite the increased use of proton-pump inhibitors and the advancement of endoscopic therapeutic modalities. <i>Aim</i>. To review the state-of-the-art management of acute non variceal upper gastrointestinal bleeding from the presentation to the emergency department, risk stratification, endoscopic hemostasis, and postendoscopic consolidation management to reduce the risk of recurrent bleeding from peptic ulcers. <i>Methods</i>. A PubMed search was performed using the following key words acute management, non variceal upper gastrointestinal bleeding, and bleeding peptic ulcers. <i>Results</i>. Risk stratifying patients with acute non variceal upper gastrointestinal bleeding allows the categorization into low risk versus high risk of rebleeding, subsequently safely discharging low risk patients early from the emergency department, while achieving adequate hemostasis in high-risk lesions followed by continuous proton-pump inhibitors for 72 hours. Dual endoscopic therapy still remains the recommended choice in controlling bleeding from peptic ulcers despite the emergence of new endoscopic modalities such as the hemostatic powder. <i>Conclusion</i>. The management of nonvariceal upper gastrointestinal bleeding involves adequate resuscitation, preendoscopic risk assessment, endoscopic hemostasis, and post endoscopic pharmacological and nonpharmacological treatment.

Hisham AL Dhahab

Alan Barkun

The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding

Ulcerative lesions in Behcet&#x2019;s disease (BD) are regarded as important manifestation for diagnosis. Various kinds of ulcerative lesions appear in patients with BD. They present as orogenital ulcers, necrotizing vasculitis and pyoderma gengrenosum. Gastrointestinal system involvement (Gis) in Beh&#xe7;et&#x2019;s disease affects all areas from the esophagus to the anus. Most authors believe that the Gis manifestations of Beh&#xe7;et&#x2019;s disease should be confined to aphthous ulcers, which can occur throughout the Gis tract. All patients with oro-genital and Gis ulcerations should be fully investigated to establish a definitive diagnosis and eliminate the possibility of an underlying BD.

&#xdc;mit T&#xfc;rsen

Belma T&#xfc;rsen

Ulcerative Lesions in Behcet's Disease

<i>Background</i>. Peptic ulcer disease (PUD) in children is reported worldwide, although it is relatively rare as compared with adults. <i>Helicobacter pylori</i> (HP) infection is a common cause of PUD in the pediatric age. Other risk factors include the use of nonsteroidal anti-inflammatory agents (NSAIDs), steroids, immunosuppressive drugs, and stressful events. <i>Aim</i>. To critically review the evidence on epidemiology, diagnostic management, and available treatments for PUD in the pediatric age. <i>Methods.</i> A MEDLINE search was performed indicating keywords as &#x201c;Peptic Ulcer Disease,&#x201d; &#x201c;Epidemiology,&#x201d; &#x201c;Pediatric,&#x201d; &#x201c;<i>Helicobacter pylori</i>,&#x201d; &#x201c;Gastric ulcer,&#x201d; &#x201c;Bulbar Ulcer,&#x201d; and &#x201c;Upper Gastrointestinal Bleeding.&#x201d; A selection of clinical trials, systematic reviews, and meta-analyses within the time period 2002&#x2013;2012 was performed. <i>Results.</i> PUD in children is reported worldwide with an estimated frequency of 8.1&#x25; in Europe and of 17.4&#x25; in the US. When the underlying cause of PUD is addressed, the prognosis is excellent. Standard triple therapy, bismuth-based quadruple therapy, and the sequential therapy represent the current recommended treatments for HP related ulcers. NSAIDs related ulcers are treated by stopping the causative medications and by administration of proton-pump inhibitors or antisecretory drugs. <i>Conclusions</i>. PUD still represents a major concern in the paediatric age. A careful differential diagnosis and an adequate treatment constitute an excellent prognosis.

Graziella Guariso

Marco Gasparetto

Update on Peptic Ulcers in the Pediatric Age

Chronic nonsurgical skin wounds such as venous stasis and diabetic ulcers have been associated with a number of comorbid conditions; however, the strength of these associations has not been compared. We utilized the Stanford Translational Research Integrated Database Environment (STRIDE) system to identify a cohort of 637 patients with chronic skin ulcers. Preliminary analysis (<svg style="vertical-align:-0.1638pt;width:52.5625px;" id="M1" height="11.125" version="1.1" viewBox="0 0 52.5625 11.125" width="52.5625"      xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,0,0,-.017,.062,10.863)"><path id="x1D45B" d="M495 86q-46 -47 -87 -72.5t-63 -25.5q-43 0 -16 107l49 210q7 34 8 50.5t-3 21t-13 4.5q-35 0 -109.5 -72.5t-115.5 -140.5q-21 -75 -38 -159q-50 -10 -76 -21l-6 8l84 340q8 35 -4 35q-17 0 -67 -46l-15 26q44 44 85.5 70.5t64.5 26.5q35 0 10 -103l-24 -98h2&#xD;&#xA;q42 56 97 103.5t96 71.5q46 26 74 26q9 0 16 -2.5t14 -11.5t9.5 -24.5t-1 -44t-13.5 -68.5q-30 -117 -47 -200q-4 -19 -3.5 -25t6.5 -6q21 0 70 48z"/></g><g transform="matrix(.017,0,0,-.017,13.305,10.863)"><path id="x3D" d="M535 323h-483v50h483v-50zM535 138h-483v50h483v-50z"/></g><g transform="matrix(.017,0,0,-.017,28.008,10.863)"><path id="x33" d="M285 378v-2q65 -13 102 -54.5t37 -97.5q0 -57 -30.5 -104.5t-74 -75t-85.5 -42t-72 -14.5q-31 0 -59.5 11t-40.5 23q-19 18 -16 36q1 16 23 33q13 10 24 0q58 -51 124 -51q55 0 88 40t33 112q0 64 -39 96.5t-88 32.5q-29 0 -64 -11l-6 29q77 25 118 57.5t41 84.5&#xD;&#xA;q0 45 -26.5 69.5t-68.5 24.5q-67 0 -120 -79l-20 20l43 63q51 56 127 56h1q66 0 107 -37t41 -95q0 -42 -31 -71q-22 -23 -68 -54z"/></g><g transform="matrix(.017,0,0,-.017,36.168,10.863)"><path id="x30" d="M241 635q53 0 94 -28.5t63.5 -76t33.5 -102.5t11 -116q0 -58 -11 -112.5t-34 -103.5t-63.5 -78.5t-94.5 -29.5t-95 28t-64.5 75t-34.5 102.5t-11 118.5q0 58 11.5 112.5t34.5 103t64.5 78t95.5 29.5zM238 602q-32 0 -55.5 -25t-35.5 -68t-17.5 -91t-5.5 -105&#xD;&#xA;q0 -76 10 -138.5t37 -107.5t69 -45q32 0 55.5 25t35.5 68.5t17.5 91.5t5.5 105t-5.5 105.5t-18 92t-36 68t-56.5 24.5z"/></g><g transform="matrix(.017,0,0,-.017,44.327,10.863)"><use xlink:href="#x30"/></g>

		
	
</svg>) showed that 49.7&#x25; of the patients had a poor prognosis such as amputation or a nonhealing ulcer for at least a year. Factors significantly associated (<svg style="vertical-align:-0.1638pt;width:58.712502px;" id="M2" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"      xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,0,0,-.017,.062,11.113)"><path id="x1D443" d="M619 482q0 -69 -40.5 -119t-96 -72.5t-118.5 -26.5h-44l-70 20l-31 -151q-14 -67 0.5 -83t89.5 -22l-5 -28h-287l8 28q65 7 81.5 22t29.5 83l79 398q12 56 0.5 70.5t-78.5 20.5l7 28h255q108 0 164 -43t56 -125zM524 478q0 141 -146 141q-25 0 -47 -8q-16 -6 -20.5 -13.5&#xD;&#xA;t-10.5 -39.5l-43 -241q37 -13 83 -13q67 0 125.5 45t58.5 129z"/></g><g transform="matrix(.017,0,0,-.017,15.582,11.113)"><path id="x3C" d="M512 -3l-437 233v51l437 233v-58l-378 -200v-2l378 -199v-58z"/></g><g transform="matrix(.017,0,0,-.017,30.286,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,38.446,11.113)"><path id="x2E" d="M113 -12q-24 0 -39.5 16t-15.5 42q0 24 16 40.5t40 16.5t40 -16.5t16 -40.5q0 -26 -16 -42t-41 -16z"/></g><g transform="matrix(.017,0,0,-.017,42.321,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,50.481,11.113)"><path id="x35" d="M153 550l-26 -186q79 31 111 31q90 0 141.5 -51t51.5 -119q0 -93 -89 -166q-85 -69 -173 -71q-32 0 -61.5 11.5t-41.5 23.5q-18 17 -17 34q2 16 22 33q14 9 26 -1q61 -50 124 -50q60 0 93 43.5t33 104.5q0 69 -41.5 110t-121.5 41q-53 0 -102 -20l38 305h286l6 -8&#xD;&#xA;l-26 -65h-233z"/></g>

		
	
</svg>) with these outcomes included diabetes mellitus, chronic kidney disease, peripheral neuropathy, peripheral arterial disease, and need for systemic antibiotics. Patients with poor outcomes also tended to have lower hemoglobin levels (<svg style="vertical-align:-0.1638pt;width:58.712502px;" id="M3" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"      xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,0,0,-.017,.062,11.113)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,0,0,-.017,15.582,11.113)"><use xlink:href="#x3D"/></g><g transform="matrix(.017,0,0,-.017,30.286,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,38.446,11.113)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,0,0,-.017,42.321,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,50.481,11.113)"><path id="x31" d="M384 0h-275v27q67 5 81.5 18.5t14.5 68.5v385q0 38 -7.5 47.5t-40.5 10.5l-48 2v24q85 15 178 52v-521q0 -55 14.5 -68.5t82.5 -18.5v-27z"/></g>

		
	
</svg>), higher WBC levels (<svg style="vertical-align:-0.1638pt;width:58.712502px;" id="M4" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"      xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,0,0,-.017,.062,11.113)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,0,0,-.017,15.582,11.113)"><use xlink:href="#x3C"/></g><g transform="matrix(.017,0,0,-.017,30.286,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,38.446,11.113)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,0,0,-.017,42.321,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,50.481,11.113)"><use xlink:href="#x31"/></g>

		
	
</svg>), and lower albumin levels (<svg style="vertical-align:-0.1638pt;width:58.712502px;" id="M5" height="11.375" version="1.1" viewBox="0 0 58.712502 11.375" width="58.712502"      xmlns:xlink="http://www.w3.org/1999/xlink" xmlns="http://www.w3.org/2000/svg">
	
		
			<g transform="matrix(.017,0,0,-.017,.062,11.113)"><use xlink:href="#x1D443"/></g><g transform="matrix(.017,0,0,-.017,15.582,11.113)"><use xlink:href="#x3C"/></g><g transform="matrix(.017,0,0,-.017,30.286,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,38.446,11.113)"><use xlink:href="#x2E"/></g><g transform="matrix(.017,0,0,-.017,42.321,11.113)"><use xlink:href="#x30"/></g><g transform="matrix(.017,0,0,-.017,50.481,11.113)"><use xlink:href="#x31"/></g>

		
	
</svg>). On multivariate analysis, however, only diabetes mellitus (OR 5.87, 1.36&#x2013;25.3), need for systemic antibiotics (OR 3.88, 1.06&#x2013;14.2), and albumin levels (0.20 per unit, 0.07&#x2013;0.60) remained significant independent predictors of poor wound-healing outcomes. These data identify patients at the highest risk for poor wound-healing and who may benefit the most from more aggressive wound care and treatment.

Omar Amir

Andy Liu

Anne Lynn S. Chang

Stratification of Highest-Risk Patients with Chronic Skin Ulcers in a Stanford Retrospective Cohort Includes Diabetes, Need for Systemic Antibiotics, and Albumin Levels

<i>Background</i>. Nonvariceal upper gastrointestinal bleeding (NVUGIB) can occur following cardiac surgery, with sparse contemporary data on patient characteristics and predictors of outcome in this setting. <i>Aim</i>. To describe the clinical and endoscopic characteristics of patients with NVUGIB following cardiac surgery and characterize predictors of outcome. <i>Methods</i>. Retrospective review of 131 consecutive patients with NVUGIB following cardiac surgery from 2002 to 2005. Demographic characteristics, therapeutic management, and predictors of outcomes were determined. <i>Results</i>. 69.5&#x25; were male, mean age: 68.8 &#xb1; 10.2&#x2009;yrs, mean Parsonnet score: 24.6 &#xb1; 14.2. Commonest symptoms included melena (59.4&#x25;) or coffee ground emesis (25.8&#x25;). In-hospital medications included ASA (88.5&#x25;), heparin (95.4&#x25;, low molecular weight 6.9&#x25;), coumadin (48.1&#x25;), clopidogrel (22.9&#x25;), and NSAIDS (42&#x25;). Initial hemodynamic instability was noted in 47.1&#x25;. Associated laboratory results included hematocrit 26 &#xb1; 6, platelets 243 &#xb1; 133 109/L, INR 1.7 &#xb1; 1.6, and PTT 53.3 &#xb1; 35.6&#x2009;s. Endoscopic evaluation (122 patients) yielded ulcers (85.5&#x25;) with high-risk lesions in 45.5&#x25;. Ulcers were located principally in the stomach (22.5&#x25;) or duodenum (45.9&#x25;). Many patients had more than one lesion, including esophagitis (28.7&#x25;) or erosions (26.8&#x25;). 48.8&#x25; received endoscopic therapy. Mean lengths of intensive care unit and overall stays were 10.4 &#xb1; 18.4 and 39.4 &#xb1; 46.9 days, respectively. Overall mortality was 19.1&#x25;. Only mechanical ventilation under 48 hours predicted mortality (O.R = 0.11; 95&#x25; CI = 0.04&#x2212;0.34). <i>Conclusions</i>. This contemporary cohort of consecutive patients with NVUGIB following cardiac surgery bled most often from ulcers or esophagitis; many had multiple lesions. ICU and total hospital stays as well as mortality were significant. Mechanical ventilation for under 48 hours was associated with improved survival.

Marcos Amorim

Alan N. Barkun

Martin Larocque

Karl Herba

Benoit DeVarennes

Myriam Martel

In-Hospital Nonvariceal Upper Gastrointestinal Bleeding following Cardiac Surgery: Patient Characteristics, Endoscopic Lesions and Prognosis

Though recently the mitochondrial bioenergetic coenzyme (Co)Q10 has been shown to protect  against indomethacin-induced gastric ulceration, yet the full mechanistic cassettes have not been investigated. Therefore, the current investigation assessed further gastroprotective mechanisms of CoQ10 using the indomethacin-induced gastropathy model. While CoQ10 was administered at 3 dose levels to male Wistar rats, the proton pump inhibitor, pantoprazole, was given at 4 dose levels ahead of pyloric ligation and indomethacin administration. Indomethacin evoked gastric ulcerations that were associated by decreased gastric mucosal nitric oxide and glutathione levels. The NSAID reduced gastric volume and mucin content,  but increased titratable acidity, acid output, and peptic activity. CoQ10, especially at the higher dose levels, as well as pantoprazole pretreatments reverted almost all diversions induced by the NSAID to different extends. Moreover, preadministration with the nonselective nitric oxide synthase inhibitor, L-NAME, boosted ulcer formation that was associated by suppression of gastric mucosal nitric oxide in CoQ10 and pantoprazole-treated groups. The current investigation shows that CoQ10 guards against gastric ulceration via its partial inhibition of titratable acidity and peptic activity, as well as enhancement of mucin secretion due to both gastric mucosal nitric oxide and glutathione replenishment, especially at the higher dose levels.

Asmaa M. Malash

Dalaal M. Abdallah

Azza M. Agha

Sanna A. Kenawy

Gastroprotective Efficacy of Coenzyme Q10 in Indomethacin-Induced Gastropathy: Other Potential Mechanisms

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