Dig Dis Sci DOI 10.1007/s10620-015-3549-4
CORRESPONDENCE
Upper GI Bleeding Caused by Severe Esophagitis or Esophageal Ulcers? Yusuf Serdar Sakin • Murat Kekilli Ahmet Uygun • Sait Bagci
•
Received: 13 December 2014 / Accepted: 19 January 2015 Ó Springer Science+Business Media New York 2015
To the Editor, We read with great interest the recently published article by Guntipalli et al. [1]. They aimed to show the rates of gastrointestinal bleeding in erosive esophagitis. They indicate that this study described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. We thank Guntipalli et al. for this study, but think there are some controversial situations that need to be clarified. They mention that they designed the groups as those having esophagitis or having other primary bleeding lesions, including gastric ulcer, duodenal ulcer, portal hypertensive gastropathy, Mallory-Weiss tear, esophageal varices, gastric cancer, or a primary source of bleeding not from the esophagus based on retrospective data analysis. They indicated in this article that they found esophagitis as a cause of nearly 25 % of severe bleeding in their hospital. But in our current practice, we do not observe esophagitis as a cause of severe upper gastrointestinal bleeding at that rate. Consistently, in a recent study, Kim et al. [2] found esophageal ulcers at 2.1 % and esophagitis at 8.1 % as a cause of all of upper gastrointestinal system bleeding. Second, it is known that mucosal lesions such as erosions are confined to the mucosa, and severe hemorrhage occurrence is unlikely. In contrast, ulcers extend into the submucosa,
Y. S. Sakin (&) A. Uygun S. Bagci Department of Gastroenterology, Gulhane Military Medical Academy, Ankara, Turkey e-mail: [email protected] M. Kekilli Department of Gastroenterology, Ankara Training and Research Hospital, Ankara, Turkey
and deeper and severe bleeding results when ulcers erode into the vessels below the mucosa [3]. However, in this study, the rate of esophageal ulcers in the esophagitis group was not mentioned. The authors also indicated that erosive esophagitis was determined based on the Los Angeles (LA) Classification. However, the LA classification, which is a popular modern system for grading the severity of reflux esophagitis, avoids the problem of distinguishing erosions from ulcerations by referring to both as mucosal breaks [4]. Thus, it is difficult to distinguish between ulcer and erosion with this classification. In contrast, the Savary-Miller classification includes ulcers and other complications [5]. Although it has limitations, it would be better to identify the reason for gastrointestinal bleeding, whether it is from erosion or its complications. Thus, as a result, we think that the rate of esophageal peptic ulcers might be distinguished from erosion to determine the exact rate of esophagitis in severe gastrointestinal bleeding.
Reply We thank Dr. Sakin and colleagues for their inquiry about the distinction between esophageal erosions and ulcers in our study [1]. We believe that there are several important points raised here. First, it should be emphasized that severe mucosal injury causing esophagitis and ulceration of the esophagus likely spans a continuum of inflammatory injury to the esophagus. In this context, in which there is injury to the mucosa, in our clinical experience, whether a patient has clinical bleeding or not is determined by a number of variables. In particular, these include underlying bleeding tendencies (including the use of anticoagulants or antiplatelet agents, which may predispose to bleeding) and the severity of the mucosal injury. Developing ulcerative
123
Dig Dis Sci
disease likely simply indicates more long-standing injury; moreover, there are almost certainly many patients with esophagitis and esophageal ulcers who do not bleed and do not come to clinical attention—so that what actually caused the bleeding to become clinically evident is unclear. We also emphasize that in the esophagus, the distinction between a very severe erosion and an ulcer is difficult, if not impossible, to make endoscopically. In our patients, 9/60 (15 %) with LA grade D esophagitis had an esophageal ulcer (3 had stigmata of recent bleeding), 2/24 (8 %) with LA grade C esophagitis had an esophageal ulcer (both had stigmata of recent bleeding), and 1/22 (5 %) with LA grade B esophagitis had an esophageal ulcer (no stigmata). No LA grade A patients had esophageal ulcers. Thus, overall, 12/119 (10 %) of our patients had esophageal ulceration, including 5 (4 % overall) with stigmata of hemorrhage. Finally, we would point out that severe esophagitis was identified in 119 of 1,515 patients (7.9 %); this frequency is very close to that previously reported for esophagitis in a large academic medical center [2] (156/ 1,929, 8.1 %; if esophagitis plus esophageal ulceration are considered to be part of the same pathophysiologic process, then in the latter study, the frequency of inflammatory injury to the esophageal mucosa as a cause of upper gastrointestinal bleeding would be 196/1,929, 10.2 %). Thus, we believe that together these studies emphasize that esophagitis commonly causes upper gastrointestinal bleeding. Prathima Guntipalli, MD, and Rebecca Chason, BA.
123
Division of Digestive and Liver Diseases and Department of Internal Medicine and Parkland Memorial Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA. Alan Elliott, MS. Department of Statistical Science, Southern Methodist University, Dallas, TX, USA. Don C. Rockey, MD. Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, MSC 623, Charleston, SC 29425, USA. Tel.: 843-792-2914; E-mail: [email protected] Conflict of interest
None.
References 1. Guntipalli P, Chason R, Elliott A, Rockey DC. Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome. Dig Dis Sci. 2014;59:2997–3003. 2. Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding. J Clin Gastroenterol. 2014;48:113–118. 3. Swain CP, Storey DW, Bown SG, et al. Nature of the bleeding vessel in recurrently bleeding gastric ulcers. Gastroenterology. 1986;90:595–608. 4. Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of esophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45:172–180. 5. Genta RM, Spechler SJ, Kielhorn AF. The Los Angeles and Savary–Miller systems for grading esophagitis: utilization and correlation with histology. Dis Esophagus. 2011;24:10–17.
CORRESPONDENCE
Upper GI Bleeding Caused by Severe Esophagitis or Esophageal Ulcers? Yusuf Serdar Sakin • Murat Kekilli Ahmet Uygun • Sait Bagci
•
Received: 13 December 2014 / Accepted: 19 January 2015 Ó Springer Science+Business Media New York 2015
To the Editor, We read with great interest the recently published article by Guntipalli et al. [1]. They aimed to show the rates of gastrointestinal bleeding in erosive esophagitis. They indicate that this study described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. We thank Guntipalli et al. for this study, but think there are some controversial situations that need to be clarified. They mention that they designed the groups as those having esophagitis or having other primary bleeding lesions, including gastric ulcer, duodenal ulcer, portal hypertensive gastropathy, Mallory-Weiss tear, esophageal varices, gastric cancer, or a primary source of bleeding not from the esophagus based on retrospective data analysis. They indicated in this article that they found esophagitis as a cause of nearly 25 % of severe bleeding in their hospital. But in our current practice, we do not observe esophagitis as a cause of severe upper gastrointestinal bleeding at that rate. Consistently, in a recent study, Kim et al. [2] found esophageal ulcers at 2.1 % and esophagitis at 8.1 % as a cause of all of upper gastrointestinal system bleeding. Second, it is known that mucosal lesions such as erosions are confined to the mucosa, and severe hemorrhage occurrence is unlikely. In contrast, ulcers extend into the submucosa,
Y. S. Sakin (&) A. Uygun S. Bagci Department of Gastroenterology, Gulhane Military Medical Academy, Ankara, Turkey e-mail: [email protected] M. Kekilli Department of Gastroenterology, Ankara Training and Research Hospital, Ankara, Turkey
and deeper and severe bleeding results when ulcers erode into the vessels below the mucosa [3]. However, in this study, the rate of esophageal ulcers in the esophagitis group was not mentioned. The authors also indicated that erosive esophagitis was determined based on the Los Angeles (LA) Classification. However, the LA classification, which is a popular modern system for grading the severity of reflux esophagitis, avoids the problem of distinguishing erosions from ulcerations by referring to both as mucosal breaks [4]. Thus, it is difficult to distinguish between ulcer and erosion with this classification. In contrast, the Savary-Miller classification includes ulcers and other complications [5]. Although it has limitations, it would be better to identify the reason for gastrointestinal bleeding, whether it is from erosion or its complications. Thus, as a result, we think that the rate of esophageal peptic ulcers might be distinguished from erosion to determine the exact rate of esophagitis in severe gastrointestinal bleeding.
Reply We thank Dr. Sakin and colleagues for their inquiry about the distinction between esophageal erosions and ulcers in our study [1]. We believe that there are several important points raised here. First, it should be emphasized that severe mucosal injury causing esophagitis and ulceration of the esophagus likely spans a continuum of inflammatory injury to the esophagus. In this context, in which there is injury to the mucosa, in our clinical experience, whether a patient has clinical bleeding or not is determined by a number of variables. In particular, these include underlying bleeding tendencies (including the use of anticoagulants or antiplatelet agents, which may predispose to bleeding) and the severity of the mucosal injury. Developing ulcerative
123
Dig Dis Sci
disease likely simply indicates more long-standing injury; moreover, there are almost certainly many patients with esophagitis and esophageal ulcers who do not bleed and do not come to clinical attention—so that what actually caused the bleeding to become clinically evident is unclear. We also emphasize that in the esophagus, the distinction between a very severe erosion and an ulcer is difficult, if not impossible, to make endoscopically. In our patients, 9/60 (15 %) with LA grade D esophagitis had an esophageal ulcer (3 had stigmata of recent bleeding), 2/24 (8 %) with LA grade C esophagitis had an esophageal ulcer (both had stigmata of recent bleeding), and 1/22 (5 %) with LA grade B esophagitis had an esophageal ulcer (no stigmata). No LA grade A patients had esophageal ulcers. Thus, overall, 12/119 (10 %) of our patients had esophageal ulceration, including 5 (4 % overall) with stigmata of hemorrhage. Finally, we would point out that severe esophagitis was identified in 119 of 1,515 patients (7.9 %); this frequency is very close to that previously reported for esophagitis in a large academic medical center [2] (156/ 1,929, 8.1 %; if esophagitis plus esophageal ulceration are considered to be part of the same pathophysiologic process, then in the latter study, the frequency of inflammatory injury to the esophageal mucosa as a cause of upper gastrointestinal bleeding would be 196/1,929, 10.2 %). Thus, we believe that together these studies emphasize that esophagitis commonly causes upper gastrointestinal bleeding. Prathima Guntipalli, MD, and Rebecca Chason, BA.
123
Division of Digestive and Liver Diseases and Department of Internal Medicine and Parkland Memorial Hospital, University of Texas Southwestern Medical Center, Dallas, TX, USA. Alan Elliott, MS. Department of Statistical Science, Southern Methodist University, Dallas, TX, USA. Don C. Rockey, MD. Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, MSC 623, Charleston, SC 29425, USA. Tel.: 843-792-2914; E-mail: [email protected] Conflict of interest
None.
References 1. Guntipalli P, Chason R, Elliott A, Rockey DC. Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome. Dig Dis Sci. 2014;59:2997–3003. 2. Kim JJ, Sheibani S, Park S, Buxbaum J, Laine L. Causes of bleeding and outcomes in patients hospitalized with upper gastrointestinal bleeding. J Clin Gastroenterol. 2014;48:113–118. 3. Swain CP, Storey DW, Bown SG, et al. Nature of the bleeding vessel in recurrently bleeding gastric ulcers. Gastroenterology. 1986;90:595–608. 4. Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of esophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45:172–180. 5. Genta RM, Spechler SJ, Kielhorn AF. The Los Angeles and Savary–Miller systems for grading esophagitis: utilization and correlation with histology. Dis Esophagus. 2011;24:10–17.
