Background. Nonvariceal upper gastrointestinal bleeding (NVUGIB) can occur following cardiac surgery, with sparse contemporary data on patient characteristics and predictors of outcome in this setting. Aim. To describe the clinical and endoscopic characteristics of patients with NVUGIB following cardiac surgery and characterize predictors of outcome. Methods. 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. Results. 69.5% were male, mean age: 68.8 ± 10.2？yrs, mean Parsonnet score: 24.6 ± 14.2. Commonest symptoms included melena (59.4%) or coffee ground emesis (25.8%). In-hospital medications included ASA (88.5%), heparin (95.4%, low molecular weight 6.9%), coumadin (48.1%), clopidogrel (22.9%), and NSAIDS (42%). Initial hemodynamic instability was noted in 47.1%. Associated laboratory results included hematocrit 26 ± 6, platelets 243 ± 133 109/L, INR 1.7 ± 1.6, and PTT 53.3 ± 35.6？s. Endoscopic evaluation (122 patients) yielded ulcers (85.5%) with high-risk lesions in 45.5%. Ulcers were located principally in the stomach (22.5%) or duodenum (45.9%). Many patients had more than one lesion, including esophagitis (28.7%) or erosions (26.8%). 48.8% received endoscopic therapy. Mean lengths of intensive care unit and overall stays were 10.4 ± 18.4 and 39.4 ± 46.9 days, respectively. Overall mortality was 19.1%. Only mechanical ventilation under 48 hours predicted mortality (O.R = 0.11; 95% CI = 0.04？0.34). Conclusions. 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. 1. Introduction Upper gastrointestinal bleeding (UGIB) remains an important complication following cardiac surgery since, although infrequent, these complications are clinically relevant because of their associated mortality [1]. Many GI complications are reported, with only few studies addressing specifically upper GI bleeding in this context [1–3]. Moreover, the generalizability of past study findings is limited by differences between the supportive cares administered over a decade ago versus today. Indeed, data are limited on endoscopic findings, the role of modern endoscopic treatment, and the effectiveness of currently approved pharmacological approaches such modern endoscopic
References
[1]
R. A. Perugini, R. K. Orr, D. Porter, E. M. Dumas, and B. S. Maini, “Gastrointestinal complications following cardiac surgery: an analysis of 1477 cardiac surgery patients,” Archives of Surgery, vol. 132, no. 4, pp. 352–357, 1997.
[2]
M. Hata, M. Shiono, H. Sekino et al., “Prospective randomized trial for optimal prophylactic treatment of the upper gastrointestinal complications after open heart surgery,” Circulation Journal, vol. 69, no. 3, pp. 331–334, 2005.
[3]
F. Filsoufi, P. B. Rahmanian, J. G. Castillo, C. Scurlock, P. E. Legnani, and D. H. Adams, “Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery,” Annals of Surgery, vol. 246, no. 2, pp. 323–329, 2007.
[4]
A. N. Barkun, M. Bardou, E. J. Kuipers et al., “International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding,” Annals of Internal Medicine, vol. 152, no. 2, pp. 101–113, 2010.
[5]
A. Barkun, S. Sabbah, R. Enns et al., “The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting,” American Journal of Gastroenterology, vol. 99, no. 7, pp. 1238–1246, 2004.
[6]
V. Parsonnet, D. Dean, and A. D. Bernstein, “A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease,” Circulation, vol. 79, no. 6, part 2, pp. I3–I12, 1989.
[7]
A. A. Mangi, E. R. Christison-Lagay, D. F. Torchiana et al., “Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients,” Annals of Surgery, vol. 241, no. 6, pp. 895–904, 2005.
[8]
B. Andersson, R. Andersson, J. Brandt, P. H？glund, L. Algotsson, and J. Nilsson, “Gastrointestinal complications after cardiac surgery—improved risk stratification using a new scoring model,” Interactive Cardiovascular and Thoracic Surgery, vol. 10, no. 3, pp. 366–370, 2010.
[9]
G. L. Moneta, G. A. Misbach, and T. D. Ivey, “Hypoperfusion as a possible factor in the development of gastrointestinal complications after cardiac surgery,” American Journal of Surgery, vol. 149, no. 5, pp. 648–650, 1985.
[10]
T. Müller, A. N. Barkun, M. Martel et al., “Non-variceal upper GI bleeding in patients already hospitalized for another condition,” American Journal of Gastroenterology, vol. 104, no. 2, pp. 330–339, 2009.
[11]
A. T. Yilmaz, M. Arslan, U. Demirkilc, E. Ozal, E. Kuralay, H. Bingol, et al., “Gastrointestinal complications after cardiac surgery,” European Association for Cardio-Thoracic Surgery, vol. 10, no. 9, pp. 763–767, 1996.
[12]
I. D. Norton, C. S. Pokorny, D. K. Baird, and W. S. Selby, “Upper gastrointestinal haemorrhage following coronary artery bypass grafting,” Australian and New Zealand Journal of Medicine, vol. 25, no. 4, pp. 297–301, 1995.
[13]
E. Lebovics, S. S. Lee, B. M. Dworkin et al., “Upper gastrointestinal bleeding following open heart surgery. Predominant finding of aggressive duodenal ulcer disease,” Digestive Diseases and Sciences, vol. 36, no. 6, pp. 757–760, 1991.
[14]
U. Halm, F. Halm, D. Thein, F. W. Mohr, and J. M？ssner, “Helicobacter pylori infection: a risk factor for upper gastrointestinal bleeding after cardiac surgery?” Critical Care Medicine, vol. 28, no. 1, pp. 110–113, 2000.
[15]
G. S. Musleh, N. C. Patel, A. D. Grayson et al., “Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications,” European Journal of Cardio-thoracic Surgery, vol. 23, no. 2, pp. 170–174, 2003.
[16]
K. P. Croome, B. Kiaii, S. Fox, M. Quantz, N. McKenzie, and R. J. Novick, “Comparison of gastrointestinal complications in on-pump versus off-pump coronary artery bypass grafting,” Canadian Journal of Surgery, vol. 52, no. 2, pp. 125–128, 2009.
[17]
I. Sanisoglu, M. Guden, Z. Bayramoglu et al., “Does off-pump CABG reduce gastrointestinal complications?” Annals of Thoracic Surgery, vol. 77, no. 2, pp. 619–625, 2004.
[18]
D. J. Cook, H. D. Fuller, G. H. Guyatt et al., “Risk factors for gastrointestinal bleeding in critically ill patients,” The New England Journal of Medicine, vol. 330, no. 6, pp. 377–381, 1994.
[19]
A. Jayaprakash, C. McGrath, E. McCullagh, F. Smith, G. Angelini, and C. Probert, “Upper gastrointestinal haemorrhage following cardiac surgery: a comparative study with vascular surgery patients from a single centre,” European Journal of Gastroenterology and Hepatology, vol. 16, no. 2, pp. 191–194, 2004.
[20]
C. V. Egleston, T. F. Gorey, A. E. Wood, and E. M. McGovern, “Gastrointestinal complications after cardiac surgery,” Annals of the Royal College of Surgeons of England, vol. 75, no. 1, pp. 52–56, 1993.
[21]
G. D'Ancona, R. Baillot, B. Poirier et al., “Determinants of gastrointestinal complications in cardiac surgery,” Texas Heart Institute Journal, vol. 30, no. 4, pp. 280–285, 2003.
[22]
M. Ait houssa, C. Selkane, Y. Moutaki Allah et al., “Upper digestive bleedings after cardiac surgery,” Annales de Cardiologie et d'Angeiologie, vol. 56, no. 3, pp. 126–129, 2007.
[23]
M. Bhat, M. Larocque, M. Amorim et al., “Prediction and prevention of upper gastrointestinal bleeding after cardiac surgery: A case control study,” Canadian Journal of Gastroenterology, vol. 26, no. 6, pp. 340–344, 2012.
[24]
J. Leonard, J. K. Marshall, and P. Moayyedi, “Systematic review of the risk of enteric infection in patients taking acid suppression,” American Journal of Gastroenterology, vol. 102, no. 9, pp. 2047–2056, 2007.
