Effects of aspirin and anticoagulants on morbidity and mortality in patients with non-variceal upper gastrointestinal bleeding

Abstract

Non-variceal upper gastrointestinal bleeding (UGIB) is a critical clinical condition that requires an urgent management. Although there was a significant reduction in the incidence of bleeding peptic ulcers with the introduction of proton pump inhibitor (PPI) and eradication of Helicobacter pylori, UGIB still remains a clinically important issue due to the increase in the proportion of elderly population, use of non-steroidal antiinflammatory drugs (NSAIDs) and in-hospital UGIB. Anticoagulant therapy has historically consisted of heparins for the treatment of acute thrombosis and Vitamin K Antagonists (VKA) for long-term or chronic treatment. Though effective if appropriately dosed and monitored, these traditional agents have shortcomings that stem mainly from their nonspecific mechanisms of action and variable pharmacodynamics. This has left a persisting need for novel anticoagulants that have more specific and targeted action and are easier to administer and manage. Recent efforts have focused on the development of more specific agents that may offer benefits over traditional anticoagulants. As a result, today there are four major classes of anticoagulants available for the prevention and treatment of thrombosis: vitamin K antagonists, indirect thrombin inhibitors (Heparin, LMWH and heparinoids), direct thrombin inhibitors (intravenous agents, oral agents) and selective factor X inhibitors. 105 Nowadays, many patients receive chronic antithrombotic therapy for various cardiac diseases. Antiplatelet drugs are widely used in patients with coronary artery disease. Dual antiplatelet therapy, with a combination of aspirin plus a P2Y12 receptor inhibitor (such as clopidogrel, prasugrel or ticagrelor), is often necessary for a period of 12 months after an acute coronary event or after the implantation of a coronary stent. Vitamin-K antagonists (VKA) are indicated in patients with atrial fibrillation, thromboembolic venous disease or a mechanical heart valve, while recently the novel oral anticoagulants (NOAC), such as dabigatran, rivaroxaban and apixaban, have been used increasingly in nonvalvular atrial fibrillation and venous thromboembolism. We determined the impact of antiplatelets and anticoagulants on the clinical outcomes of patients who were admitted to hospital and hospitalized due to gastrointestinal bleeding, and to investigate the etiology of death in patients who had a fatal outcome. The study included 75 patients who were admitted to Ain Shams University Hospitals and Almenshawy Hospital with complaint of melena and or haematemsis and diagnosed by esophagogastroduodenoscopy. The patients are divided into 5 groups based on their drug: 106 1- Group A: Those who had not taken anticoagulants and antiplatelets. 2- Group B: Those taking heparin, warfarin and LMWH only. 3- Group C: Those taking aspirin only. 4- Group D: Those taking clopidogrel, ticlopidine with or without aspirin. 5- Group E: Those taking combined anticoagulants and antiplatelets.. All patients were subjected to full history taking, full examination, full laboratory investigations (including complete blood count, liver function tests, renal function tests, prothrombin time and partial thromboplastin time) and upper endoscopy. Our results showed that · There were non-significant differences between the studied patients with non-variceal upper gastrointestinal (GIT) bleeding regarding sex,hematemsis only,liver function tests,renal function tests and mortality. · There were statistically significant differences between the studied patients with non-variceal upper gastrointestinal (GIT) bleeding regarding increasing age, NSAIDs used whatever Selective or Non selective, decrease level of HB,WBCs,prolonged PTT, clinical presentation of hematemsis and melena, need for blood transfusion and rebleeding. 107 · There were non-significant differences between the studied patients with non-variceal upper gastrointestinal (GIT) bleeding regarding endoscopic findings, except for duodenal ulcer which exhibited a significant difference. Rebleeding was only demonestrated in groupD(12.5%)and groupE(25%). We could not demonestrate any mortality among studied patients in all groups throughout study period.