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ARTICLES: M. J. O'Donnell, M. K. Kapral, J. Fang, G. Saposnik, J. W. Eikelboom, W. Oczkowski, J. Silva, L. Gould, C. D'Uva, F. L. Silver On behalf of the Investigators of the Registry of the Canadian Stroke Network Gastrointestinal bleeding after acute ischemic stroke Neurology 2008; 71: 650-655 [Abstract] [Full text] [PDF]

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Gastrointestinal bleeding after acute ischemic stroke

Usha K. Misra, Jayantee Kalita   (16 January 2009)

Reply from the authors

Martin J. O'Donnell, MB, PhD, Moira Kapral, MD, MSc, Frank Silver, MD   (16 January 2009)

Gastrointestinal bleeding after acute ischemic stroke 16 January 2009
Usha K. Misra, Professor & Head Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow- 226014, India, Jayantee Kalita Send Correspondence to journal: Re: Gastrointestinal bleeding after acute ischemic stroke drukmisra{at}rediffmail.com Usha K. Misra, et al.	We read with interest the paper by O’Donnell et al. who describe 1.5% patients with ischemic stroke who developed gastric hemorrhage and gastric hemorrhage that was related to recurrence of stroke, myocardial infarction, and venous thromboembolism during hospital stay. [1] It is unclear whether gastric hemorrhage was due to stroke or to antithrombotic and/or anticoagulant therapies which their patients might have received for myocardial infarction and venous thromboembolism. The timing of gastric hemorrhage following stroke may provide a clue about the etiology. In our study, 30% of patients with intracerebral hemorrhage developed gastric hemorrhage. [2] In a prospective study on intracerebral hemorrhage, 3.3% patients had gastric hemorrhage within 48 hours, 9.8% within 3-5 days and 20.8% after 5 days of stroke. Early bleeding is likely due to raised intracranial pressure and stress ulcers whereas later due to septicemia or systemic inflammatory response syndrome (SIRS). [3] In a multivariate analysis in intracerebral hemorrhage, gastric hemorrhage was related to septicemia/SIRS and size of hematoma. [3] A combination of anti-platelets such as aspirin and clopidogrel is known to produce high frequency of intracerebral hemorrhage. [4] Did this combination increase the risk of gastric hemorrhage and was the hemorrhage severe in the patients studied by O’Donnell et al.? In addition, was it measured in a qualitative or quantitative way? Another interesting difference was that 49% of O’Donnell et al.’s patients with gastric hemorrhage were women. We reported only 4.3% women in our study. [3] The gender difference in stress ulcer has not been investigated but peptic ulcer is more common in men than women (6.8% vs. 2.8%). [5] We encourage further evaluation of gender differences in gastric hemorrhage to determine potential social, cultural, and genetic components. References 1. O'Donnell MJ, Kapral MK, Fang J, et al. and Investigators of the Registry of the Canadian Stroke Network. Gastrointestinal bleeding after acute ischemic stroke. Neurology. 2008;71:650-655. 2. Misra UK, Kalita J, Pandey S, Mandal SK. Predictors of gastrointestinalbleeding in acute intracerebral haemorrhage. J Neurol Sci 2003;208:25–29. 3. Misra UK, Kalita J, Pandey S, Mandal SK, Srivastava M. A randomized placebo controlled trial of ranitidine versus sucralfate in patients with spontaneous intracerebral hemorrhage for prevention of gastric hemorrhage. J Neurol Sci. 2005;239:5-10. 4. Diener HC, Bogousslavsky J, Brass LM et al; MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364:331-337. 5. Raina I, Kemppainen H, Kaprio J, Koskernvuo M, Sourander L. Lifestyle, stress and genes in peptic ulcer disease. Arch Intern Med 1998;158:698–704. Disclosure: The authors report no disclosures.
Reply from the authors 16 January 2009
Martin J. O'Donnell, MB, PhD, McMaster University 70 Wing, Room 220, 711 Concession Street, Hamilton, Ontario, L8V 1C3, Canada, Moira Kapral, MD, MSc, Frank Silver, MD Send Correspondence to journal: Re: Reply from the authors odonnm{at}mcmaster.ca Martin J. O'Donnell, MB, PhD, et al.	We thank Drs. Misra and Kalita for their thoughtful comments. We agree that there is an apparent discrepancy between the frequency of gastrointestinal bleeding reported in our study and their previous studies. [1,2] Two key considerations may account for this difference. First, the patient populations are different. Patients with intracerebral hemorrhage are likely to be at greater risk of stress ulceration as they are more likely to be admitted to the intensive care unit, undergo major surgery, and more likely to have an underlying diathesis to bleeding compared to patients with ischemic stroke. [2] Second, we included registry data obtained by screening patient records for clinically documented gastrointestinal (GI) bleeding which likely resulted in underreporting of bleeding episodes, particularly minor bleeds. The comparative frequency of the more serious GI hemorrhages requiring transfusion (unlikely to be missed by chart review) was 36/6,853 (0.5%) in our study [1] and 1/51 (2.0%) in the cohort study by Misra et al. [2] Unfortunately, we were unable to comment on the etiologies of gastrointestinal bleeding since this information was not captured in our study. [1] We agree that further research is required to explore a potential gender effect. Disclosures: The Registry of the Canadian Stroke Network was funded by grants from the Canadian Stroke Network. Data collection was supported by the Ontario Ministry of Health and Long-term Care. Dr. Martin O'Donnell holds the William Walsh Endowed Research Chair in Internal Medicine and a Mentor-Mentee Award from the Canadian Institutes of Health Research. Dr. Moira Kapral is supported by the Canadian Stroke Network, the University Health Network Women's Health Program, and holds a New Investigator Award from the Canadian Institutes of Health Research. Dr. Frank Silver is supported by the Canadian Stroke Network.