Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Sediment and organic matter properties, and molecular formula from sampling locations in the Northern Black Sea

Remineralization of organic matter in reactive marine sediments releases nutrients and dissolved organic matter (DOM) into the ocean. Here we focused on the molecular-level characterization of DOM by high-resolution Fourier transform ion cyclotron resonance mass spectrometry (FT-ICR-MS) in sediment pore waters and bottom waters from contrasting redox regimes in the northern Black Sea with particular emphasis on nitrogen-bearing compounds to derive an improved understanding of the molecular transformations involved in nitrogen release. The number of nitrogen-bearing molecules is generally higher in pore waters than in bottom waters. This suggests intensified degradation of nitrogen-bearing precursor molecules such as proteins in anoxic sediments: No significant difference was observed between sediments deposited under oxic vs anoxic conditions (average O/C ratios of 0.55) suggesting that the different organic matter quality induced by contrasting redox conditions does not impact protein diagenesis in the subseafloor. Compounds in the pore waters were on average larger, less oxygenated, and had a higher number of unsaturations. Applying a mathematical model, we could show that the assemblages of nitrogen-bearing molecular formulas are potential products of proteinaceous material that was transformed by the following reactions: (a) hydrolysis and deamination, both reducing the molecular size and nitrogen content of the products and intermediates; (b) oxidation and hydration of the intermediates; and (c) methylation and dehydration.

Physical properties of sediment core AND-2A

Whole-core measurements of Wet Bulk Density (WBD), compressional (P)-wave velocity (Vp), and Magnetic Susceptibility were measured at a sampling interval of 1 or 2 centimetres (cm) throughout the AND-2A drill core for initial core characterisation and on-site correlation with seismic modeling to predict target-reflector depth. Measurements were made using a GEOTEK (Multi-Sensor-Core-Logger MSCL). Density and velocity standards were measured together with core runs of 3-6 metres (m) (and occasionally up to 18 m) throughout the entire depth range to monitor data quality. Drift of the magnetic susceptibility sensor was also monitored and corrected where necessary. These physical properties show a large range of values, reflecting the different nature of the various lithologies including extremely high velocity and density values in individual clasts, and the effects of cementation on porosity. A downcore increase in WBD and Vp occurs in the upper 200 m, however, no systematic trend exists at greater depths although large fluctuations on a m-decimetre- (dm) scale occur. Magnetic susceptibility is generally low (<100 x 10-5 SI), however, four intervals of high (>600 x 10-5 SI) susceptibility occur at 560, 800, 980 and 1 080 mbsf, indicating a relatively greater contribution of volcanic-derived material to the core site in the lower half of the AND-2A core.

Porosity and sound velocity measured in sediment core CIROS-1

The CIROS-1 drillhole, which in 1986 reached a depth of 700 m below the seafloor, is still the only deep hole that can provide information on the velocity structure of the upper crust in McMurdo Sound and the Ross Sea, Antarctica. A careful review and quality control of the downhole logging data of CIROS-1 resulted in a new porosity depth function that is consistent with porosity data from the MSSTS-1 and CRP-1 drillholes. Using existing porosity-velocity equations, it was possible for the first time to obtain reliable velocity information for the upper 700 m of strata off the Victoria Land coast. The calculated synthetic seismograms, based on downhole velocity and density data, fit very well with the existing seismic lines IT90A-71, PD90-12, and NBP9601-89. The quality of the correlation confirms that the average velocity of the top 700 m of strata is about 2 000-2 300 m/s, and not 2 800-3 000 m/s, as was previously assumed. In consequence, these distinctly lower velocities result in shallower depths for the seismic unconformities V3/V4 andV4/V5 and thus may have important implications for further drilling off Cape Roberts.

Dinoflagellate cysts analyses from sediment cores of the Po River discharge plume over the last two centuries

To obtain insight into the natural and/or human-induced changes in the trophic state of the distal portion of the Po River discharge plume over the last two centuries, high temporal resolution dinoflagellate cyst records were established at three sites. Cyst production rates appear to reflect the natural variability in the river's discharge, whereas cyst associations reflect the trophic state of the upper waters, which in turn can be related to agricultural development. The increased abundances of Lingulodinium machaerophorum and Stelladinium stellatum found as early as 1890 and 1920 correspond to the beginning of the industrial revolution in Italy and the first chemical production and dispersion of ammonia throughout Europe. After 1955, the increased abundances of these species and of Polykrikos schwartzii, Brigantedinium spp. and Pentapharsodinium dalei correspond to agriculturally induced alterations of the hypertrophic conditions. A slight improvement in water quality can be observed from 1987 onward.

Age model and stable isotopes of sediment core RC17-177

A careful comparison is made between the most detailed records of sea level over the last glacial cycle, and two high-quality oxygen isotope records. One is a high-resolution benthonic record that contains superb detail but proves to record temperature change as well as ice volume; the other is a planktonic record from the west equatorial Pacific where the temperature effect may be minimal but where high resolution is not available. A combined record is generated which may be a better approximation to ice volume than was previously available. This approach cannot yet be applied to the whole Pleistocene. However, comparison of glacial extremes suggests that glacial extremes of stages 12 and 16 significantly exceeded the last glacial maximum as regards ice volume and hence as regards sea level lowering. Interglacial stages 7, 13, 15, 17 and 19 did not attain Holocene oxygen isotope values; possibly the sea did not reach its present level. It is unlikely that sea level was glacio-eustatically higher than present by more than a few metres during any interglacial of the past 2.5 million years.

Interim manual for clinical practice guideline development /

"May 1991."

Sediment toxicity in U.S. coastal waters.

"Donna D. Turgeon ... [et al.]"--P. 1.

Dynamic modeling and monitoring of water, sediment, nutrients, and pesticides in agricultural watersheds during storm events /

"Contract report 655"--Cover.

Evaluation of Illinois sieved stream sediment data, 1982-1995 : staff report /

At head of cover title: Illinois Environmental Protection Agency, Bureau of Land.

Evaluation of Illinois stream sediment data, 1974-1980 /

"IEPA/WPC/84-004."-- Cover.

Hydrology, nutrient, and sediment monitoring for Hurricane and Kickapoo Creek watersheds, water year 2000-2002 : pilot watershed program /

"Prepared for the Illinois Dept. of Natural Resources."

Illinois Conference on Soil Conservation and Water Quality : conference proceedings of November 9-10, 1983 at Holiday Inn East, Springfield, Illinois /

Includes bibliographical references.