Summary
Background
The increased risk of upper gastrointestinal bleeding (UGIB) related to direct oral anticoagulants (DOACs) as compared to vitamin K antagonists (VKA) remains debated.
Aims
To describe the epidemiology and outcomes of UGIB in patients treated with oral anticoagulants.
Methods
A prospective, multicentre study in French general hospitals enrolled all consecutive patients with UGIB during one year. Patients treated with oral anticoagulants were retrieved from the cohort. Main outcomes were mortality and rebleeding during the first 6 weeks and need for non‐endoscopic treatment (surgery or interventional radiology).
Results
Among the 2498 patients included, 475 (19%) had an oral anticoagulant, mostly with VKA (267 patients [56.2%]). Baseline characteristics were similar between the groups except for renal failure and cirrhosis that were more prevalent in the VKA group. Gastroscopy was normal in 73 patients (15.3%); peptic lesions were the main cause of UGIB (n = 233, 49%). Endoscopic treatment was performed in 128 patients (26.9%), leading to bleeding resolution in 74% (n = 95). Mortality rate at 6 weeks was 12.4% (59 patients), and was higher in the VKA group compared to DOACs (16.1% vs 7.8%, P < 0.01). By multivariate analysis, only the Charlson index ≥ 5 and UGIB occurrring in in‐patients were independently associated with mortality. Rebleeding (56 patients [11.8%]) and need for non‐endoscopic treatment (18 patients [3.8%]) were not associated with the type of anticoagulant.
Conclusion
DOACs do not alter outcomes of UGIB as compared to VKA. Comorbidities and associated treatment are the most important factors worsening the prognosis of UGIB.
The general quality of the studies focusing on the treatment of SRUS was poor due to the heterogeneity of the population, the sample size of the cohorts, and the heterogeneity of efficacy assessments. The therapeutic approach appears to be multimodal and multidisciplinary and validated in centres of expertise. Further studies evaluating multimodal strategies are needed.
Aim
Data on the pathogenesis and symptoms of enterocele are limited. The objectives of this study were to determine the clinical phenotype of patients with enterocele, to highlight the main functional and/or anatomical associations and to improve the accuracy of the preoperative assessment of pelvic floor disorders.
Method
A total of 588 patients who were referred to a tertiary unit for an anorectal complaint completed a self‐administered questionnaire and underwent physical examination, anorectal manometry and defaecography. Using defaecography, enterocele was defined as a radiological hernia of the small bowel into an enlarged rectovaginal space. One hundred and thirty‐five patients with enterocele were age‐ and gender‐matched with 270 patients without enterocele. Factors associated with enterocele were assessed using univariate and multivariate analysis models.
Results
Patients with enterocele were less frequently obese than patients without enterocele (8/135 vs 36/270; P = 0.02) and more frequently had a past history of pelvic surgery (51/135 vs 75/270; P = 0.04). They complained more frequently of pelvic pain on bearing down (29/135 vs 24/270; P = 0.003), anal procidentia (37/135 vs 46/270; P = 0.01) and more frequently had irritable bowel syndrome (83/135 vs 131/270; P = 0.01) and severe constipation according to the Kess score (104/135 vs 182/270; P = 0.04). Anorectal function was comparable between the two groups. Patients with enterocele had more frequent rectoceles and overt rectal prolapses than patients without enterocele.
Conclusions
Enterocele should be investigated in patients with chronic pelvic pain, overt rectal prolapse and/or a past history of pelvic surgery.
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