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Exploring Predictors of in-Hospital Mortality in Dieulafoy's Lesions of theStomach and IntestineSteve Serrao, Christian S. Jackson, David Juma, Diana Ibrahim, Manjit Randhawa, SamSoret, Lauren B. Gerson

Introduction: Dieulafoy's lesions (DL) are a rare and often unrecognized cause of obscure,and sometimes significant upper gastrointestinal (GI) hemorrhage. There are currently nopopulation-based studies evaluating mortality risk associated with the locality of DL. Weused a national database to assess the association between in-hospital mortality and demo-graphic, co-morbidities and intervention variables, among patients with DL of the stomachand intestine. Methods: Using National Inpatient Sample (NIS) data between January 2004and December 2009, simple and multiple logistic regression analyses were conducted toassess the effect of the various covariates on mortality. Demographic covariates explored in thisanalysis included gender, age, race/ethnicity, income, and type of insurance. Co-morbidities ofinterest include atrial fibrillation (AFIB), coronary heart disease (CAD), congestive heartfailure (CHF), acute renal failure (ARF), chronic kidney disease (CKD), end stage renaldisease (ESRD) and coagulopathies (COAG). Additionally, the Charlson-Deyo Index (CDI)was used to measure the burden of co-morbidities. Interventions include packed red celltransfusion (PCT), endoscopic control of gastric hemorrhage (EGD), small bowel endoscopy(SBE) and intensive level of care (ICU). Results: We identified 4,652 patients with a primarydiagnosis of DL, out of which 88% were located in the stomach and 12% were found inthe small and large intestine. The overall percentage mortality of DL is around 3%. Therewas no significant difference in mortality between DL of the stomach and intestine. Whencompared to 2004, there is a significant decrease in mortality from year to year. Multiplelogistic regression, modeling mortality as the outcome variable, was statistically significantfor patients with age greater than 85, odds ratio (OR) =5.30 and patients with ARF OR=4.21. About 1,335 patients or 29% of the total population had small bowel endoscopy andwas found to be associated with an OR=1.78. About 70% or 3290 patients had EGD and60% or 2786 patients had PCT. About 6% of the patients had ICU level of care, asdefined by the use of mechanical ventilation (6%), central venous catheterization (13%) andhemodialysis (3%). If patient had ICU level of care, it was associated with OR=16.8 of death.Coagulopathies were not found to be significantly associated with death. Conclusion: Thisis the first population-based study that explored factors associated with in-hospital mortalityfor DL. Among demographic variables, only age greater than 85 was associated with signifi-cantly higher mortality. Disparity in care was not a factor since gender, race/ethnicity, incomeand type of insurance had no bearing on mortality. Mortality however, was significantlyassociated with the development of ARF and if the patient was admitted to ICU level of care.

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Antithrombotic vs. Ulcer Effects in Non-Variceal Bleeding in Users ofAntithrombotic DrugsAli S. Taha, Caroline McCloskey, Theresa Craigen, Wilson J. Angerson

BACKGROUND The use of antithrombotic drugs (ATDs) remains a considerable challengein the etiology and management of non-variceal upper gastrointestinal bleeding (NVUGIB).In this controlled analysis, we AIMED to clarify the significance of the antithrombotic effectas compared with the ulcer effect in patients with NVUGIB using ATDs. METHODS Wepreviously found that ATD users tended to be older and to have higher comorbidity anddifferent endoscopy findings. To overcome these confounding factors, we compared 202patients with NVUGIB using ATDs (ATD Group) with 202 patients with NVUGIB but notusing ATDs (Controls), having matched both groups in a pairwise manner for age, Charlsoncomorbidity score and a composite endoscopic score covering the oesophagus, stomach,and duodenum. Antithrombotic drugs included low-dose aspirin, clopidogrel, dipyridamole,warfarin, and heparin. Patients using NSAIDs were excluded. Characteristics of the groupswere compared using the Wilcoxon signed rank test and McNemar's test. Continuousvariables are reported as median (IQR). RESULTS The Characteristics of the two matchedstudy groups are shown in Table-1 CONCLUSIONS After matching for age, comorbidity,and composite endoscopy score, patients with NVUGIB and using ATDs had significantlylower haemoglobin level, higher Blatchford risk score, and were 1.5 times more likely tobe transfused. These effects are most likely to be due to the antithrombotic activity of ATDsrather than ulcers alone, and they need to be considered in the management of NVUGIBTable-1. The characteristics of patients with NVUGIB using antithrombotic drugs as comparedwith matched controls not using these drugs

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Sa1884

Validation of a New Bedside Prognostic Score (AIMS65) in UpperGastrointestinal BleedRagesh B. Thandassery, Manik Sharma, Saad Al Kaabi

Background There are various risk stratification scores available for predicting outcome inupper gastrointestinal (GI) bleed. However they are cumbersome and sometimes requireendoscopic evaluation and therefore are rarely applied for early risk stratification. Aim Toprospectively evaluate the newly proposed early bedside score, AIMS65 (A-albumin, I-INR,M-Mental status, S -Systolic Blood pressure), in patients with acute upper GI bleed admittedto our tertiary care hospital Methods 251 consecutive patients presenting with acute upperGI bleed, from January 2012 to December 2012, were included in the study. The AIMS65scores were calculated by allotting 1 points each for albumin (A) <30g/l, INR (I) >1.5,alteration in mental status (M), systolic blood pressure (S) ≤90mmHg and age ≥ 65 years.The risk stratification was completed within 24 hours of hospital admission. Patients weremanaged as per standard protocol and outcomes were evaluated. Results The mean age ofstudy group was 52.4 years with 193 males. The etiology for upper GI bleed was duodenalulcer in 74 (29.6%), gastric ulcer in 38 (15.2%) and esophageal varices in 32 (12.8%)patients. 51 patients (20.3%) required intensive care unit (ICU) admission. The mean hospitaland ICU stay were 10.6±16.9 and 4.6±5.4 days respectively. The overall mortality was10.3% (n=26). The mortality in those with AIMS65 scores of 0,1,2,3 and 4 were 3%, 7.8%,20%, 36% and 40% respectively. The mortality was significantly higher in those with score≥3 (37.1%) as compared to those with score <3 (6%), p<0.001. The predictive accuracyfor mortality with a score ≥3 was high (area under the receiver operator characteristicscurve = 0.70, 95% CI= 0.57-0.82). The mean hospital stay (21.5±31.1 versus 9.0±12.8days, p=0.040) and ICU stay (5.1± 6.1 versus 3.5±3.6 days, p=0.042) were significantlyhigher in patients with scores ≥3 as compared to those with <3. Conclusion AIMS65 is asimple, accurate, non endoscopic risk score that can be applied early (within 24 hours ofhospital admission) in patients with acute upper GI bleeding. AIMS65 score ≥3 predictshigh in-hospital mortality and increased duration of hospital and ICU stay.

Sa1885

The Initial Management of Upper Gastrointestinal Bleeding: A NationalSurveyPeter S. Liang, John R. Saltzman

Background & Aims: Upper gastrointestinal bleeding (UGIB) causes significant morbidityand mortality. Several national and international guidelines have addressed the initial manage-ment of UGIB, but it is unknown to what extent these guidelines are followed in clinicalpractice. We performed a cross-sectional survey to assess practice patterns in the initialmanagement of UGIB in the United States. Methods: We conducted a national survey ofemergency physicians, internists, and gastroenterologists practicing in hospitals affiliatedwith one of the 165 gastroenterology fellowships accredited by the Accreditation Councilfor Graduate Medical Education. Both attending physicians and trainees were invited toparticipate. Participants rated their agreement and adherence with nine recognized pre-endoscopic quality indicators for the initial management of UGIB. We assessed awarenessand use of prognostic risk scores as well as barriers to their utilization. Results: A total of1402 surveys were completed, with responses from 345 gastroenterologists, 495 internists,and 562 emergency physicians. Gastroenterologists agreed with all nine UGIB quality indica-tors more strongly than non-gastroenterologists. The median agreement score (range 9-45)was 42 for gastroenterologists and 40 for non-gastroenterologists (p<0.001). Trainees (n=544) agreed with the UGIB quality indicators more than attending physicians (n=858).However, there was no difference in overall adherence with the UGIB quality indicators byspecialty or between attending vs. trainee physicians. The median adherence score (range9-45) was 37 for gastroenterologists, non-gastroenterologists, attending physicians, andtrainees. The use of UGIB prognostic risk scores generated the most disagreement amongall UGIB quality indicators. Among all physicians, 53% had ever heard of and 30% hadever used an UGIB prognostic risk score. More gastroenterologists than non-gastroenterolo-gists have heard of (82% vs. 44%, p<0.001) and used (51% vs. 23%, p<0.001) an UGIBprognostic risk score; however, there was no difference between attending and traineephysicians overall. Gastroenterologists and attending physicians overall more often cited thebelief that UGIB prognostic risk scores are not clinically useful as a reason for not havingused them, whereas non-gastroenterologists and trainees overall more often cited lack ofknowledge as a reason. Conclusions: Among attending physicians and trainees in emergencymedicine, internal medicine, and gastroenterology in the United States, agreement withguidelines on the initial management of UGIB was high, but adherence—especially pertainingto the use of prognostic risk scores—was low.

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Transcatheter Arterial Embolization Is the Best First-Line Treatment in PepticUlcer Bleeding Not Responding to Endoscopic TherapyMark Jakobsen, Michael M. Nielsen, Claus Hovendal, Ove B. Schaffalitzky de Muckadell,Stig B. Laursen

INTRODUCTION: In 5-10% of cases with peptic ulcer bleeding (PUB) it is not possible toachieve endoscopic hemostasis. In these patients transcatheter arterial embolization (TAE)is frequently used as an alternative to surgical hemostasis. Studies comparing the outcomesof these methods are needed in order to identify the treatment of choice. AIMS & METHODS:The aim of this study was to examine the efficacy and safety of TAE compared with surgicalhemostasis in patients with PUB not responding to endoscopic treatment. The study wasconducted as a retrospective study. Consecutive patients treated with TAE or surgery forendoscopy-refractory bleeding in the period June 1997 to June 2012 were included. Patientcharacteristics, endoscopic findings, received treatment, and outcome were registered. Anadjusted 30-day mortality was calculated using multivariate logistic regression analysis.RESULTS: A total of 41 and 75 patients were treated with TAE and surgery, respectively.Patients treated with TAE had a higher level of comorbidity (median Charlson comorbidity