Clinical and endoscopic features of severe acute gastrointestinal bleeding in elderly patients treated with direct oral anticoagulants: a multicentre study

Abstract

Background: The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs). Methods: Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission. Results: A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1–31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%. Conclusions: In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high.

A Validated Prognostic Model and Nomogram to Predict Early-Onset Complications Leading to Surgery in Patients With Crohn’s Disease

“…The main outcome of this study was the occurrence of complications that could lead to surgery, including severe GI bleeding, stenosis, and perforations. Severe GI bleeding was defined as hemorrhage in any part of the digestive tract with a Glasgow-Blatchford score ≥6 8 , 9 confirmed by endoscopy, CT scan, and/or interventional radiology. We considered the cause for bleeding to be exclusively associated with CD.…”

Impact of clinical characteristics of colonic diverticular bleeding in extremely elderly patients treated with direct oral anti-coagulant drugs: a retrospective multi-center study

“…They have reported that half of the cause of mortality was GI bleeding. ( 32 ) In contrast, Brodie et al ( 33 ) have also reported that no death occurred at day 30 in an American retrospective cohort. We have first to report clinical outcomes including mortality and required units of blood transfusions in DOAC-treated or warfarin-treated extremely elderly patients with diverticular bleeding.…”

“…In addition, in our data there was not significant differences in mortality between DOAC-treated and warfarin-treated extremely elderly patients in spite of high ratios of discontinuation of oral anticoagulant therapy in both groups. Deutsch et al ( 32 ) have reported mortality rate at the day 30 was relatively high (11.8%) in elderly patients treated with DOACs. They have reported that half of the cause of mortality was GI bleeding.…”

Anticoagulant‐associated gastrointestinal bleeding: Framework for decisions about whether, when and how to resume anticoagulants

“…In OAC reversal studies and observational cohorts, 30-day all-cause mortality after OAC-associated major GI bleeding is 11%-13%. 6,7,17,41,52 For example, in the RE-VERSE AD and ANNEXA-4 studies, all-cause mortality among patients presenting with acute major GI bleeding was 11% and 13%, respectively, despite the treatment with agents that reversed anticoagulant effect and reduced levels of active drug. 6 Subgroup analyses of the ROCKET AF and ENGAGE TIMI trials reported case-fatality rates (adjudicated as death due to bleeding) of 1.7% and 2.1% among patients receiving rivaroxaban or edoxaban, respectively.…”