Use of Aqueous Extract and Essential Oil of Citrus Aurantifolia Leaves in the Protection of Vegetables- Juniper Publishers

 

Nutrition and Food Science- Juniper Publishers

Summary

Our study is devoted to the valorization of the essential oil and the aqueous extract of Citrus aurantifolia leaves as biopesticides. The extraction of oil from the leaves was produced by hydrodistillation. The aqueous extract of the leaves was obtained by maceration. The insecticidal activity of the essential oil and the aqueous extract of the leaves of the plant was tested by spraying on two plots containing 10 Ndrowa eggplant plants. (Solanum aethiopicumm gilo) each. Leaf oil extraction yields 1.02%. On the plants sprayed with essential oil and aqueous extract of lemon tree leaves, it was observed a very significant reduction in insect pests of eggplant crops (less than 13% and 2% respectively for plots B and C). The havoc on the parties respectively with the aqueous extracts and the essential oil of the leaves of the lemon tree. The damage to plants in the treated plots was 13% and 3% for plots B and plots C respectively. Regarding the fruit conditions of Ndrowa eggplants, the frequencies of good fruits were 96%, 87% and 75% respectively for plots A, B and C. Regarding yield, plots treated with essential oil (C) and the aqueous extract (B) of lemon leaves were respectively 44% and 38% compared to 18% for the control plot (A). These oils are therefore better agents for protecting and preserving vegetables and fruits. Further study would be necessary to determine effective doses by working on a large population of insects and eggplant plants.

Keywords:Essential oil, Ndrowa eggplant, Citrus aurantifolia, Hydrodistillation, Insect, Solanum Aethiopicumm gilo

Introduction

Agriculture is one of the main sectors of activity which contributes to the socio-economic development of populations (more than 52%) in Africa [1]. Côte d’Ivoire, a country in West Africa, is an agricultural country. Its economy is mainly based on agriculture. Alongside cash crops, food crops including market garden products occupy an important place in the daily diet of populations [2,3,4]. Market gardening plays a key role in most nutrition and poverty reduction programs, fight against poverty and contribute significantly to family income [5,6]. However, the cultivation of food crops is experiencing increasing difficulties which are affecting its level of production. These include diseases and parasites (insects, fungi, viruses) which affect yield [7,8,9]. The fight against crop pests until now has been carried out using chemicals from plants of different crops [10,11]. Unfortunately, the use of pesticides in agriculture is not without consequences. The environment can be contaminated by these substances [12]. They lead to the destruction of useful species and constitute a major risk of human and animal poisoning [13,14]. Today, chemical pesticides which are undeniably effective reveal their limits through perverse effects on the ecosystem, fauna, flora [15,16]. Furthermore, the handling of chemicals by populations without any prior training are factors that expose not only the health of the consumer but also that of the producer [15]. It is therefore necessary to seek alternatives to the use of synthetic products [17]. The use of pesticidal plants is likely to significantly reduce pests and the need for synthetic pesticides [18]. Indeed, many plants are known and used for their biocidal activities (toxic, repellent, anti-feedant) against a wide range of pests. They can be used in the form of plant extracts for foliar protection [19]. Essential oils or whole plants are also used in stored food attics [20].

It is for this reason that in Ivory Coast, like many countries, studies are being carried out to find alternatives to chemical pesticides. Our study is part of the valorization of natural substances in the treatment of agricultural products against parasites harmful to market gardening crops.

The main objective is to bring food crop producers in rural areas to the use of biopesticides as alternatives to chemicals in crop pest control. It is with this in mind that our research aims to contribute to the management of pest parasites in eggplant crops by promoting the leaves of Citrus aurantifolia, a plant resource available in all rural areas of Côte d’Ivoire. This specifically involves validating the effectiveness of the aqueous extract and essential oil of Citrus aurantifolia leaves on the main pest parasites encountered on eggplant cultivation and evaluating the effect of the extracts on eggplant yield.

Materials and Methods

Study site

The test was conducted in Yamoussoukro (Lakes Region), located between 6°15-7°35 N and 4°40 and 5°40 W and 95 m altitude. The soil of the experimental plot is ferrallitic and has a sandy texture. It is highly desaturated, poor in exchangeable bases, particularly phosphorus, and comes from tertiary sands [7]. The soil is a ferralitic, gravelly and gravelly soil, more or less deep, rejuvenated, clayey-sandy (Ekou and Djidji, 1997). The climate is the Baoulean climate and straddles the pre-forest savannah and the rainforest. The terrain is generally very uneven. The distribution of rainfall is variable and is between 900 and 1100 mm 3. The average temperature is 26°C [21]. The locality has an equatorial climate with two rainy seasons (March to July and September to October) and two dry seasons (November to March and July to September). This hot and humid climate is conducive to the proliferation of fungal diseases and insect pests of vegetable plants.

Cultivation practices

Ndrowa seeds (Solanum aethiopicumm gilo) were germinated in a nursery on a small plot of 2 m² after plowing the soil. After sowing, the plot was regularly watered. After 40 days in the nursery, the plants were transplanted into three different plots of 25 m² each separated by 100 meters. To do this, the plots were cleared, plowed and watered. During this operation, the soil was enriched with a mineral fertilizer based on NPKs, at a rate of 1 g/30 m2 [22] and disinfected with the different solutions using a 2 L manual pressure sprayer. After transplanting, the plot was regularly watered every morning during the short dry season from July to September. In each plot, 10 eggplant plants (plants are approximately 15 cm high with at least three leaves) were transplanted 0.5 m × 1 m apart.

The transplants were made on July 20, 2021. A week later, the transplanting of the plants, fertilizer was again brought to the different plots. Herbs were removed throughout the experiment. From sowing to the end of observations lasted 4 months including 3 months, one week of flowering and 3 weeks of fruit harvest.

Observations and measurements

In each plot, observations focused on the following parameters: sensitivity to bacterial wilt, the level of attack on the plants, namely attacks on leaves, buds and fruits, the presence of insects, caterpillars…., the total number of fruits harvested, the average weight of the fruit.

The vegetative development of the plants was noted visually on some parameters: Susceptibility to bacterial wilt was assessed by weekly counting of all withered plants from the period of transplanting the plants until the end of the observation. The cumulative rate of wilted plants per week per plot was calculated.

To assess the damage caused by pests, a weekly count of all attacked plants (plants, leaves, buds and fruits) was carried out from the appearance of the attacks. Fruit attacks concerned fruit bores, attacks on leaves and buds concerned shredding and rolling. The cumulative rate of attacked games has been determined. The number of fruits per plant as well as the average weight of the fruit were measured on a scale. Observations relating to the number of insects were carried out during three periods (one week after the second treatment, during the flowering period and during the harvest period). The count is carried out for one week in each period. Data on pests were taken in the mornings between 6:30 a.m. and 9:30 a.m. for three days at different periods (P1, P2, P3) (Fauquet et al., 1987).

Preparation of biopesticide products

Citrus leaves aurantifolia were recovered from citrus trees aurantifolia present in the villages of Yamoussoukro. The aqueous extract was obtained by maceration of 100 g of dried leaf powder of citrus aurantifolia in one liter of water by maceration. Thus, the collected and dried leaves were ground to obtain a fine powder, then this ground material was soaked in distilled water for 24 hours. Finally, this ground material was filtered to obtain aqueous extracts. As for the essential oil of lemon leaves, it was obtained by hydrodistillation in an abininc from the fresh leaves of citrus aurantifolia.

For each of the cultivation plots, eight treatments based on plant extracts and essential oils were compared to the untreated control. Three universal manual pressure sprayers, brand DCRAFT, with a capacity of 2 liters, were used. One was used to apply the essential oil of citrus aurantifolia at a rate of 3 ml/l of water to the plants in plot C, the second to apply aqueous extracts of citrus aurantifolia leaves at a rate of 100 g /l of water on the plants of plot B. The third to be used for the application of liquid soap water on plot A. 1 liter of water was added to each mixture then 10 ml of liquid soap was added respectively to the different mixtures of leaves and essential oil of lemon tree leaves allowing them to attach to the leaves, stems, buds and fruits of the plants. So that the treatment is homogeneous and with the aim of reaching a large population of pests. All parts of the plant including leaves, buds, twigs, branches and fruits were sprayed (Bhyan et al., 2007). Furthermore, the jets were oriented so as to cover the lower and upper surfaces of the leaves of each plant, also targeting the underside of the leaves where pests tend to hide. Treatments began on crops just before transplanting, then every week after transplanting, until 14 days before the first harvest.

Data analysis

Data entered into the Microsoft Excel spreadsheet. Graphical representation and data processing were carried out using Excel software. Data were analyzed with Graph Pad Prism 8.0 software. The differences between the means were determined using the Newman- Keuls test at the 5% threshold.

Results

Plant-destroying parasites identified on the plots

The results of the parasites encountered are presented by the figures (Figure 1/A, B, C, D, E, F, G, H). The pests encountered in the different plots are beetles, jassid beetles, caterpillars, whiteflies, orthoptera and aphids (Figure 1). The whiteflies encountered are whiteflies and blackflies. The aphids encountered are the genera Aphis, Myzus , Mcrosiphum . The orthopterans encountered are grasshoppers, locusts and crickets. Beetles include beetles, weevils, ladybugs and black ground beetles. Caterpillars are the most numerous pests with a frequency of 22%. They are followed by whiteflies and beetles (19%), then aphids (17%) (Figure 1A).

The last groups of parasites encountered in the plots are orthoptera and jassids with respective frequencies of 12% and 11%. The beetles experienced considerable growth (p ˂ 0.05) from the first period p1 (15%) to the third period p3 (23%). On the other hand, aphids, whiteflies and caterpillars experienced a non-significant regression from period p1 to period p3 (p˃ 0.05) (Figure 1/C,D,E,F,G). Regarding the presence of parasites on each of the plots, on plot A, which is the control plot, the different parasites were strongly encountered during the three periods with frequencies very significantly higher (p ˂ 0.0001) than those of plots B and C treated respectively with the aqueous extract of the leaves of C. aurantifolia and the essential oil of the leaves of the plant.

On plot B, the frequencies of parasites found on site were less than 13% during all periods. Orthoptera are the parasites most encountered in this plot with frequencies of 12.7%, 6.83% and 3.8% respectively at the different periods p1, p2 and p3.

As for plot C, parasite frequencies were less than 2%. Jassids and aphids were absent during the p1 period on this plot.

A : Frequency of insects encountered on the sites B : Distribution of insects according to the period C : Distribution of pucerons on the plots D : Distribution of caterpilla on the plots E : Distribution of beetles on the plots F : Distribution of whiteflies on the plots G : Distribution of orthoptera on the plots H : Distribution of jassids on the plots

Effects of aqueous extract and essential oil of Citrus aurantifolia against parasite attacks

The yield of essential oil extraction from Citrus leaves aurantifolia by hydrodistillation was 1.02%. The results of insect pest attacks on crops in the different sites are presented in Figure 2 (Figure 2/A, B, C, D). The control plot was the plot which followed a lot of attacks (p˂0.0001) during this experiment with a frequency of 87% compared to 10% and 3% respectively for plot B and plot C. The plot was significantly less attacked (p˂0.05) compared to plot C (Figure 2/A). Regarding plot A, the majority of attacks were leaf attacks with a frequency of 64%. After the leaves, come the attacks of the buds and the fruits with respective frequencies of 23% and 10%. Problems linked to eggplant plants represent the lowest attacks (Figure 2/B). In plots B and C, attacks are dominated by damage to leaves and buds. These ravages are followed by attacks on the fruits with frequencies of 17% and 8% respectively for plot B and plot C. Attacks on the feet were very rarely observed in plots B and C (4% and 2% respectively). Wilted plants were not observed in these two plots (Figure 2/C, D). Statistical analyzes revealed a strong significance between attacks on leaves and buds compared to attacks on fruits and then on eggplant plants.

A : Distribution of insect damage on plots B : Insect damage on plot A C : Insect damage on plot B D : Insect damage on plot C

Effects of aqueous extracts of leaves and essential oil of leaves of citrus aurantifolia on the yield of different plots

On control plot A, the fruits were 75% in good condition (skin and interior) compared to 87% and 96% respectively for the fruits of plots B and plot C. the analyzes showed a small significant difference (p˂ 0.05) between the good condition of the fruits of plot A and the two other plots treated with C. aurantifolia leaves (Figure 3). Statistical analyzes also showed strong significant differences (p˂0.0001) between good and bad fruits in all plots.

In terms of yield, plot C had the best yield (44%), followed by plot B with a yield of 38%. The lowest yield was observed in plot A (18%). Statistical analyzes showed a significant difference (p˂0.001) between the yield of the control plot A and the two other treated plots (plot B and C) (Figure 4).

In terms of average weight of eggplants, the values are between 98 g and 104 g. Statistical analyzes show no significant difference (p˃0.05) between the average weights of eggplants from the different plots (Figure 5).

Discussion

Plots treated with aqueous extract and essential oil of C. aurantifolia were very lightly infested by eggplant insects at all periods. Its broad spectrum of action on parasites on sites shows that it is not selective [23]. However, the essential oil has been shown to be very effective against insects on different sites during all periods. In addition, during the first period, the essential oil was very repellent against aphids and jassids (0%) [24]. These results are similar to those of Gnago et al. [25], who showed that neem seed extract behaves as a repellent. The leaves of C. aurantifolia exhibited high pesticidal activity by effectively reducing the populations of whiteflies, beetles, caterpillars, orthoptera, aphids and jassids as well as reducing the incidence and severity of pest pests. leaves, buds and fruits. This plant would therefore have repellent and anti-appetizing properties (Nevala, 2000). The leaves would therefore contain compounds that deter feeding, repellent, inhibit oviposition and growth regulatory activities against a wide variety of crop pests [26]. The aqueous extract and essential oil of lemon leaves were able to reduce the presence and activities of insects on the plots and therefore allowed a good yield, because there is a positive correlation between the incidence and severity of crop damage and the pest population at the sites [27]. This suggests that the aqueous extract and essential oil of lemon leaves can be used as a good pesticide to protect vegetable crops. Compounds from the leaves of C. Aurantifolia have regulatory effects (antibioses/ anticenoses ) on insects [28]. Similarly, Amtul [29] reported that A. indica contains compounds that act as inhibitors of the digestive enzyme alpha-amylase in beetles. Indeed, numerous studies have shown the effects of pesticidal plants on vegetable crop aggressors. Okereke et al. [2] showed that the application of aqueous extracts of Azadirachta indica on tomato plants infected by Sclerotium rolfsii Saccardo helps reduce the severity of the disease and obtain better growth of the plants. Kankam and Sowley [30] demonstrated that amending chili plants infested with A. indica induces a significant drop in nematode populations resulting in better growth of treated plants. Echereobia et al. (2010) showed that aqueous extracts of Piper guineense induced repellent activity on arthropod pests. Kambou and Guissou [31] also noted that spicy substances (Sinapis nigra, Mochiah et al. [19] showed that Allium and C. papaya extracts led to a considerable reduction in okra and eggplant pests. Bolou et al. [32] demonstrated that the essential oil of X. aethiopic fruits strongly inhibited the mycelial growth of S. rolfsii, resulting in a considerable reduction in the incidence of the disease on treated tomato plants.

The high N’drowa yields obtained in plots B and C can be explained using different factors. First, the good vegetative development linked to the low sensitivity of these plants to bacterial wilt allowed many plants to return to production. Then, the low presence of pests on the treated sites and the very reduced number of attacks on buds, leaves and fruits. However, the yield of plot A would be linked on the one hand to the ravages of plants, buds and leaves by pests. Also, it would be linked to rotting or perforation of fruits by insect pests (caterpillars, aphids) [33]. Asare-Bediako et al. (2014) showed that extracts of A. indica, C. papaya , Allium sp . , Capsicum sp . minimized the severity of whitefly damage and increased the yield of treated plots. Adesina et al., [34] showed that the use of aqueous extracts of Loncarpous cyanescens and Dalbergia lactea reduced the ravages of leaf beetles in okra cultivation. Habou et al. [35] showed that the application of Jatropha sp. on cowpea pests made it possible to reduce the abundance of thrips and bugs and the severity of their attacks, thus increasing yield.

Furthermore, the use of biopesticides is gaining ground as these plants provide alternative means of controlling crop pests, also preserve the ecosystem [36]. Natural products from plants can also increase yields with a cost/benefit ratio comparable to that of synthetic pesticides [37]. Thus, the improvement in the yield of treated plants could be due to the release of nutrients (nitrogen, phosphorus) by the leaves for significant vegetative growth and better fruit development. Also, these properties would be due to the presence of secondary metabolites such as saponins, polyesters and phenols which would influence the metabolism of the plant and allow an improvement in plant growth and yield [38]. These results are similar to those obtained by Habou et al. [39,40,41,42] who in open fields, curcas oil significantly reduced the number of cowpea pests.

Conclusion

Plant pesticides are far from quickly replacing synthetic pesticides, particularly in large crops. In market gardening, however, they can be an alternative solution and contribute to preserving the health of populations. Pesticidal plant extracts are less dangerous than synthetic pesticides due to their fairly rapid decomposition and low polluting action. They also make it possible to keep the pest population below the harmful threshold and reduce the use of synthetic pesticides used on market gardening. The aqueous extract and the essential oil of the leaves of C. aurantifolia have proven to be powerful pesticides by the considerable reduction in the presence of pests and damage on treated crop plots but also in the good yield of eggplants observed in this study. It would therefore be necessary to explore the capabilities of biopesticides (notably lemon leaves) to control pests of vegetable crops and to optimize their use. We must encourage the use of plant pesticides by producers and raise awareness about the enhanced safety of products treated with plant-based pesticides and their long-term benefits.

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Typhlitis (Neutropenic Enterocolitis): A Multidisciplinary Approach- Juniper Publishers

 

 Reviews and Research- Juniper Publishers

Abstract

Typhlitis, or neutropenic enterocolitis, is a life-threatening gastrointestinal complication that predominantly affects immunocompromised patients, particularly those undergoing intensive chemotherapy for hematologic malignancies. The pathophysiology of typhlitis is characterized by mucosal injury, bacterial translocation, and systemic inflammatory response, often resulting in sepsis and multi-organ failure if not promptly managed. Early diagnosis relies on clinical suspicion supported by imaging modalities such as computed tomography (CT) to identify hallmark features including bowel wall thickening and pneumatosis intestinalis. Management primarily involves aggressive supportive care, including bowel rest, fluid resuscitation, and broad-spectrum antibiotics targeting gram-negative bacilli, gram-positive cocci, and anaerobes. Surgical intervention is reserved for patients with complications such as bowel perforation, necrosis, or uncontrolled hemorrhage, with right hemicolectomy and ileostomy being the preferred procedures in severe cases. Despite advances in antimicrobial therapy and critical care, the prognosis remains guarded, particularly in patients with profound and prolonged neutropenia. Long-term management focuses on recurrence prevention through prophylactic antibiotics, gut microbiome modulation, and personalized oncologic treatment strategies to minimize further mucosal injury. Emerging research on microbiome-targeted therapies holds promise for reducing gastrointestinal complications in neutropenic patients. A multidisciplinary approach is essential for optimizing outcomes and improving survival in affected individuals.

Keywords:Typhlitis; Neutropenic enterocolitis; Chemotherapy; Immunosuppression; Bacterial translocation; Surgical management; Gut microbiome; Multidisciplinary approach

Keywords:ALL: Acute Lymphocytic Leukemia; ANC: Absolute Neutrophil Count; CT: Computed Tomography; FMT: Fecal Microbiota Transplantation; GS: General Surgery; NPO: Nothing by Mouth; NSAIDs: Non-Steroidal Anti-Inflammatory Drugs; PTE: Pulmonary Thromboembolism

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Introduction

Typhlitis, also known as neutropenic enterocolitis, is a life-threatening inflammatory and infectious process that primarily affects the cecum and proximal colon in immunocompromised patients. It is most commonly observed in individuals with profound neutropenia, particularly those undergoing intensive chemotherapy for hematologic malignancies. The condition is characterized by transmural inflammation, often complicated by bacterial translocation, ischemia, and, in severe cases, perforation, leading to significant morbidity and mortality [1]. The relevance of typhlitis is particularly pronounced in oncology, hematology, and post-transplant settings, where aggressive immunosuppressive therapies predispose patients to gastrointestinal complications [2]. It is frequently reported in patients with acute leukemia, lymphoma, and those receiving bone marrow transplantation, as these populations experience prolonged and severe neutropenia. The increasing use of high-dose chemotherapy and novel immunotherapies has also increased awareness of this condition in recent years [2]. Epidemiologically, typhlitis has been reported in approximately 5-10% of patients receiving intensive chemotherapy, with the highest incidence observed in those with acute myeloid leukemia (AML) and recipients of hematopoietic stem cell transplants [3]. The mortality rate varies widely, ranging from 20% to 50%, depending on the severity at presentation and the presence of complications such as perforation, sepsis, or multiorgan failure. Rapid recognition and intervention are critical, as delays in diagnosis or inadequate management can lead to catastrophic outcomes. A multidisciplinary approach is essential to optimize treatment and improve survival rates. Given the highrisk nature and potential fatality of typhlitis, a comprehensive understanding of its pathophysiology, early diagnostic markers, and evidence-based treatment strategies is imperative for improving patient outcomes [4]. This review explores the current insights into the diagnosis, management, and prevention of typhlitis, emphasizing the need for multidisciplinary collaboration in high-risk populations.

Pathophysiology

Typhlitis is a potentially life-threatening condition that primarily affects people with lowered immune systems and individuals undergoing cancer chemotherapy [1-6]. The condition is characterized by inflammation of the cecum and potentially other parts of the intestinal tract, resulting from a complex interplay involving neutropenia, mucosal injury, and bacterial translocation.

Role of Neutropenia in Susceptibility to Bacterial Translocation

Neutropenia is marked by a drastic reduction in the number of neutrophils, a type of white blood cell vital for the body’s innate immune response [6]. This condition significantly distorts the immune defense mechanism, increasing infection susceptibility [6]. The gastrointestinal tract (GIT), which harbors a diverse band of commensal and pathogenic bacteria, becomes a potential source of systemic infection [6,7]. In a healthy immune system, neutrophils contain and regulate the gut microbiota effectively. However, during neutropenia, this containment is disrupted, facilitating the translocation of bacteria across the intestinal mucosa into the bloodstream with evidence of low neutrophil counts < 500 cell/microliter, elevated C-reactive (CRP), and erythrocyte sedimentation rate (ESR) [6-9]. The gut microbiota is not just localized; it interacts with various body systems, including the skin, oral cavity, lungs, vagina, and even the brain [6-8]. It effectively enhances the production of key immune components such as immunoglobulin A (IgA), antimicrobial peptides (AMPs), and several innate and adaptive immune cells, which are essential for maintaining gut health and overall immunity [6, pg2].

Mucosal Injury Due to Chemotherapy and Gut Microbiota Alterations

Chemotherapy often induces mucositis, which damages the intestinal epithelium and contributes to diminished secretion of digestive fluids [7,8]. This damage leads to a decreased population of good gut microbiota, compromising the gut’s barrier function and increasing the actions of inflammatory mediators such as cytokines and chemokines [7]. Wei, Wen, & Xian expanded that “Specific toll-like receptors (TLRs) located on immune cells identify the cell wall components of bacteria, including peptidoglycan, which is recognized by TLR-2, lipopolysaccharides (LPS) detected by TLR-4, flagellin by TLR-5, and unmethylated DNA (CpG DNA) through TLR-9” [7]. The injury caused by mucositis is progressive by dysbiosis, which occurs due to an imbalance in gut microbiota, negatively enhancing chronic inflammation and weakening mucosal integrity [7,8]. The altered composition of microbiota, combined with a diminished ability for epithelial regeneration, creates a permissive environment for bacterial invasion [7,8]. This invasion not only “disrupts immunological homeostasis but can also have profound impacts on mental health, linking gut and brain function through the brain-gut axis” [6-8] (Figure 1).

Bacterial Invasion and Ischemic Damage

Bacterial translocation [BT] triggers an inflammatory process that can lead to ischemic damage within the intestinal wall [7]. This ischemic process, on the other hand, arises due to impaired blood flow, exacerbating tissue necrosis and disrupting the gut’s morphological structure and function [7-8,10]. In the bloodstream, BT can trigger sepsis-a life-threatening systemic inflammatory cascade that can further compromise organ function [8,10]. Also, the proliferation exacerbations caused by bacterial invasion lead to intestinal perforation, where holes are formed in the intestinal wall, significantly increasing the risk of life-threatening complications, such as peritonitis and organ failure/s [10,11]. The mortality risk associated with typhlitis is substantial, underscoring the importance of early recognition, aggressive management, and preventive strategies in immunocompromised patients [11].

Clinical manifestations

The most common symptoms seen in neutropenic enterocolitis (NE) include fever and abdominal pain (often RLQ, but can be diffuse), in addition to nausea, vomiting, diarrhea, peritonitis, and abdominal distention [12,13]. Bowel wall thickening on imaging can help narrow the differential [14]. Though not as common, patients may also exhibit a palpable boggy cecum, melena, or hematochezia [13,15]. Abdominal compartment syndrome has also been reported in the setting of ascites [16]. Without symptomatic resolution and early diagnosis, progressive decline in the form of life-threatening complications, including sepsis, acute respiratory distress syndrome (ARDS), intraabdominal abscesses, pneumatosis intestinalis, bowel necrosis, perforation, hemorrhage, and multi-organ failure, can occur [12,17]. At-risk immunocompromised populations include those undergoing organ transplantation, those receiving chemotherapy treatment for hematological malignancies or solid tumors, and immunosuppressive conditions such as AIDS [18]. For those receiving chemotherapy, symptoms can occur anywhere between ten days to two weeks after treatment [13,15].

Diagnostic Approach

Laboratory Findings

Laboratory findings in typhlitis are crucial for diagnosing and managing the condition, often revealing signs of infection and inflammation. A key feature is neutropenia, typically observed in patients with chemotherapy or hematologic malignancies, where neutrophil counts are significantly low, sometimes below 500 cells/μL. Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are common, indicating systemic inflammation. In some cases, pancytopenia is seen, where reductions occur across all blood cell types, including red blood cells and platelets, especially in patients with severe bone marrow suppression. Additionally, lactate dehydrogenase (LDH) levels may rise due to tissue damage, and electrolyte imbalances such as hyponatremia and hypokalemia may occur due to gastrointestinal losses [19-23]. Procalcitonin (PCT) levels have been extensively studied as a biomarker for bacterial infections and sepsis, particularly in the context of febrile neutropenia and other severe infections. However, the specific relationship between PCT levels and typhlitis (neutropenic enterocolitis) remains less welldocumented in the literature [24]. While there is no direct evidence linking procalcitonin levels specifically to typhlitis, the elevated PCT levels observed in severe bacterial infections and sepsis suggest that it could serve as a valuable marker in the diagnosis and management of typhlitis in neutropenic patients [24]. The presence of these lab findings, combined with clinical symptoms like abdominal pain and fever and imaging showing bowel wall thickening, aids in diagnosing typhlitis. CRP levels, in particular, can be valuable for monitoring the severity of inflammation. The severity and duration of neutropenia directly correlate with the symptoms and outcomes of typhlitis, as neutrophil recovery is essential for resolution [21-24]. Differentiating typhlitis from other conditions is important, and stool studies are essential to rule out infections like Clostridioides difficile (C. difficile). Key tests for C. difficile include Nucleic Acid Amplification Tests (NAAT), Glutamate Dehydrogenase (GDH) Antigen Test, and Toxin A and B Enzyme Immunoassay (EIA). Additionally, routine stool cultures and NAATs are necessary for detecting other enteric pathogens such as Salmonella, Shigella, and Campylobacter [25]. Blood cultures are also vital in diagnosing and treating typhlitis, as neutropenic patients are at a high risk of bacteremia. Blood cultures should be collected before initiating antibiotics to ensure accurate pathogen identification, allowing for more targeted antimicrobial therapy, improving patient outcomes, and reducing complications [25].

Imaging Modalities

Imaging studies play a crucial role in diagnosing and managing typhlitis, with several modalities available depending on clinical circumstances and institutional capabilities. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast is the gold standard for diagnosing typhlitis [12,17,26]. CT imaging typically reveals characteristic findings such as circumferential bowel wall thickening of the cecum and ascending colon, often exceeding 5 mm. The thickening may be asymmetric and can involve other colon or small intestine segments in more severe cases [26]. CT can also identify pneumatosis intestinalis, which appears as gas within the bowel wall, indicating advanced disease with mucosal disruption. In cases where perforation has occurred, CT can detect pneumoperitoneum (free air in the peritoneal cavity), an ominous sign that typically necessitates urgent surgical intervention. Additional findings may include pericecal fat stranding, cecal distention, and pericolonic fluid collections or abscesses, all of which help assess the disease’s extent and severity [26,27].

While CT remains the primary imaging tool, ultrasonography provides a valuable alternative, particularly in pediatric populations, pregnant patients, or settings where CT may not be readily available. Ultrasound findings in typhlitis include cecal wall thickening (typically appearing as a hypoechoic rim surrounding the cecum), decreased peristalsis, and increased echogenicity of pericecal fat. The non-invasive nature and absence of radiation exposure make ultrasound an attractive option for initial evaluation and follow-up studies. However, its accuracy is operator-dependent and may be limited by patient factors such as obesity or excessive bowel gas [27,28]. Magnetic resonance imaging (MRI) represents another alternative imaging modality that may be considered in select cases. MRI offers excellent soft tissue contrast without radiation exposure, making it suitable for patients who require repeated imaging studies. With high sensitivity, it can detect bowel wall thickening, mucosal enhancement, and pericolonic inflammation. However, the longer acquisition times, higher cost, and limited availability compared to CT or ultrasound restrict its routine use in the acute setting. Nevertheless, MRI may be particularly valuable in patients with renal insufficiency who cannot receive iodinated contrast agents for CT studies [27-31]. The choice of imaging modality should be tailored to the individual patient’s clinical situation, considering factors such as disease severity, comorbidities, and local resources. Regardless of the modality, prompt imaging is essential for early diagnosis and appropriate management of typhlitis.

Differential Diagnosis

The most common symptoms of Neutropenic enterocolitis (NE) are abdominal pain, diarrhea, and fever [32]. Nausea, vomiting, and abdominal distension are also common symptoms. Abdominal pain can be localized in the lower right quadrant or can be more diffuse. Tenderness on palpation can be found at the RLQ [33]. Typhlitis frequently mimics appendicitis on presentation, and the main difference is that appendicitis has leukocytosis and Typhlitis has neutropenia [34,35]. When comparing NE with Clostridioides difficile (C. difficile), colitis is a cause of diarrhea in hospitalized patients and using antibiotics like cephalosporins, Clyndamycin, and penicillin, among others. C. Difficile is one of the most common causes of nosocomial infections. C. difficile infection is usually suspected when hospitalized patients develop diarrhea, abdominal pain, and fever, but patients can develop dehydration, loss of appetite, and nausea as well [36].

Cytomegalovirus (CMV) is a member of the herpesvirus family and forms latent infection after the resolution of the primary infection. After the primary CMV infection, CMV remains in host cells, and CMV replication is controlled by the immune system in immunocompetent patients [37]. Immunodeficiency is the leading risk factor for invasive CMV diseases. Invasive CMV mostly affects the gastrointestinal tract in immunocompromised patients. Clinical manifestation of CMV colitis in immunocompromised patients varies and depends on the site of involvement, which could cause odynophagia, abdominal pain, hematochezia, and fever [38,39]. Inflammatory bowel disease (IBD), which comprises Crohn’s disease (CD) and ulcerative colitis (UC), is a chronic, systemic, autoimmune disease. Both may present with abdominal pain, diarrhea, rectal bleeding, or muscle spasms in the region of the pelvis and weight loss [40]. Ischemic colitis (IC), characterized by insufficient blood supply and oxygen delivery to the colon, is the most common form of bowel ischemia [41]. The severity of IC depends on the degree of parietal involvement, ranging from superficial mucosa inflammation to full-thickness transmural necrosis, a life-threatening condition that requires surgery [42]. Because of the overlapping symptoms of NE with many abdominal pathologies, this is an entity that should be considered in any differential for a patient with febrile RLQ pain, not just those with obvious immunosuppression.

Management Strategies: Internal Medicine and Surgery Perspectives

Supportive Care

The cornerstone of managing typhlitis begins with aggressive supportive care measures implemented immediately upon diagnosis. Bowel rest is essential to minimize intestinal peristalsis and reduce the risk of perforation in the compromised bowel wall. This typically involves establishing nothing-by-mouth (NPO) status until clinical improvement is observed. In patients presenting significant abdominal distention or radiographic evidence of ileus, nasogastric tube placement for intestinal decompression becomes necessary to relieve pressure on the affected bowel segments and reduce the risk of aspiration [43]. Fluid resuscitation represents another critical component of supportive care, as many patients present with significant volume depletion due to decreased oral intake, diarrhea, and third-spacing into the bowel wall and peritoneal cavity. Careful attention to fluid balance with isotonic crystalloid solutions helps maintain adequate tissue perfusion while preventing fluid overload. Concurrent with volume resuscitation, vigilant monitoring and correction of electrolyte abnormalities, particularly hypokalemia and hypomagnesemia which may result from gastrointestinal losses, is essential for preventing cardiac arrhythmias and optimizing intestinal function [44]. Pain management warrants special consideration in patients with typhlitis. Opioid analgesics are generally preferred for their efficacy and relatively favorable safety profile in this context. Importantly, non-steroidal anti-inflammatory drugs (NSAIDs) should be strictly avoided due to their association with increased risk of gastrointestinal mucosal damage and bleeding, which could exacerbate the already compromised intestinal mucosa in neutropenic patients. Additionally, NSAIDs may mask fever, an important clinical indicator of treatment response or disease progression. The administration of opioids should be balanced against their potential to exacerbate ileus, with careful titration and adjunctive measures such as stool softeners employed when necessary [45].

Antibiotic Therapy

Prompt initiation of empirical broad-spectrum antibiotic therapy is imperative in managing typhlitis given its potentially rapid progression and the immunocompromised state of affected patients. The selection of antimicrobial agents should provide comprehensive coverage against gram-negative bacilli (including Pseudomonas aeruginosa), gram-positive cocci, and anaerobic organisms, which commonly constitute the polymicrobial intestinal flora that may translocate across the damaged intestinal barrier [46]. Monotherapy options with excellent broad-spectrum coverage include piperacillintazobactam, meropenem, or imipenem-cilastatin. These betalactam antibiotics with beta-lactamase inhibitors or carbapenems provide robust activity against the typical pathogens encountered in typhlitis and are often preferred as first-line agents due to their excellent tissue penetration and proven efficacy in neutropenic infections. Alternatively, combination therapy with cefepime plus metronidazole offers comparable coverage, with cefepime targeting gram-negative and gram-positive aerobes while metronidazole provides dedicated anaerobic coverage [47]. For patients with prolonged neutropenia (typically exceeding 7-10 days), persistent fever despite appropriate antibacterial therapy, or those receiving intensive chemotherapy regimens associated with severe mucosal damage, consideration should be given to adding antifungal coverage. Candida species, particularly Candida albicans, may contribute to the pathogenesis of typhlitis in these high-risk individuals. Echinocandins (e.g., caspofungin) or lipid formulations of amphotericin B are typically recommended in this scenario due to their broad antifungal spectrum and favorable safety profile [48]. Antibiotic therapy should be continued until neutrophil recovery (absolute neutrophil count >500 cells/μL) and resolution of clinical symptoms, including defervescence, abdominal pain improvement, and normalization of gastrointestinal function. This typically requires a minimum of 10-14 days of treatment, though the duration may be extended based on clinical response and the presence of complications [49- 50].

Surgical Considerations (GS focus)

Typhlitis, also known as neutropenic enterocolitis, can be challenging to diagnose and to treat for most physicians, since there is a high mortality seen in these patients, and there are controversial opinions on its form of treatment. Initially, established management of the disease is recommended to follow a thorough electrolyte follow-up, bowel rest with nasogastric suction, total parenteral infusion, and blood transfusions depending on the patient’s hemodynamic status. Surgical intervention is only given in extreme cases, such as the patient presenting with signs and/or symptoms of necrosis, perforation, and persistent bleeding.The mortality rate has been reported to range from 50% to 100% in patients that have not been treated and require surgical intervention. Physicians don’t typically select abdominal surgery as their first choice to treat this disease because of exhaustive complications in patients with neutropenia [51-53]. Patients who happen to experience severe systemic symptoms, such as sepsis, or as well with those who evidently have signs of perforation, obstruction, massive bleeding, or abscess formation, require surgery effective immediately. All the necrotic tissue must be removed, typically through right hemicolectomy, ileostomy, and mucous fistula. In patients who carry a less severe case, a divided ileostomy may also be implemented. If this necrotic area is not excised, particularly in patients who are severely immunocompromised, it can be fatal. With prompt identification, typhlitis and its underlying causes risk of complications can be minimized with early preventive measures in a timely manner [52- 55]. The most common diagnosis prompting surgical consultation in neutropenic patients is neutropenic enterocolitis, followed by small bowel obstruction, Clostridium difficile infection, diverticulitis, appendicitis, cholecystitis, pseudo-obstruction, splenic rupture, and an unclear diagnosis. Neutropenic enterocolitis is a common complication of cytotoxic chemotherapy, and most of the patients with this specific pathology must be further evaluated for possible malignancies. There are certain diseases linked that predispose to have neutropenic enterocolitis, such as ALL (acute lymphocytic leukemia), being ranked as the highest risk. Patients mostly get treated with a right hemicolectomy, and although there have been reports of successful recovery, still surgery is not the first approach to treatment [53-56].

Although most patients get treated successfully with conservative management, those who had clinical signs of bowel perforation and/or peritonitis were submitted to surgery. Some of the other indications to surgery were the inability to diagnose bowel perforation, other pathologies such as appendicitis, and patients who were hemodynamically unstable (mostly due to life threatening hemorrhage). Most studies suggest a right hemicolectomy with a defunctioning ileostomy indication in the area where necrosis of the colon has occurred, in comparison to primary anastomosis which had a higher rate of complications in neutropenic patients. Another procedure that could be implemented in pancolonic disease is defunctioning ileostomy, but carries a heavier risk of prolonged postoperative sepsis in patients with poor neutrophil counts [54-59]. Clinical signs such as abdominal pain and fever in patients with typhlitis can serve as very important health indicators for physicians to suspect this pathology. Diagnosing this disease as early as possible and giving the right treatment can be lifesaving and enhance the prognosis. However, supportive care still remains the primary form of treatment and surgery must be needed to survive in minimal cases [59].

Prognosis and Long-Term Management

Typhlitis, or neutropenic enterocolitis, is a severe and potentially life-threatening complication observed in immunocompromised patients, particularly those undergoing chemotherapy for hematologic malignancies. The prognosis of typhlitis is influenced by several key factors, including the severity of neutropenia, the timeliness of intervention, and the patient’s response to therapy. Severe neutropenia, particularly an absolute neutrophil count (ANC) of less than 500 cells/μL, is associated with an increased risk of bacterial translocation, sepsis, and mortality (Gorschlüter et al., 2005). Early recognition and aggressive management with broad-spectrum antibiotics, bowel rest, and supportive care are essential to improving outcomes. Delayed intervention has been correlated with increased morbidity and higher rates of surgical intervention due to complications such as bowel perforation or necrosis (Rodríguez-Villar et al., 2021). The response to initial therapy, including clinical improvement and resolution of neutropenia, plays a crucial role in determining patient outcomes. Poor response or persistent symptoms despite appropriate treatment is indicative of a worse prognosis and often necessitates escalation of care [60].

The risk of recurrence of typhlitis is a major concern, particularly in patients undergoing multiple cycles of chemotherapy. Recurrent episodes have been reported in patients with continued myelosuppression and mucosal injury due to repeated cytotoxic exposure. The incidence of recurrence can be as high as 20-30% in high-risk populations, necessitating tailored preventive strategies (Rodríguez-Villar et al., 2021). Prophylactic antibiotics, particularly fluoroquinolones, have been explored as a potential preventive measure in patients with prolonged neutropenia or a history of typhlitis. While some studies suggest that prophylaxis reduces the incidence of febrile neutropenia and bacterial infections, concerns regarding antimicrobial resistance and microbiome dysbiosis warrant cautious use (Freifeld et al., 2011). Future research is needed to determine optimal patient selection criteria for prophylactic antibiotic therapy [61].

The gut microbiome has emerged as a crucial factor in the pathophysiology and prevention of typhlitis. Chemotherapyinduced mucosal injury, coupled with the broad-spectrum antibiotic use often required in neutropenic patients, can lead to significant alterations in gut microbiota composition. This dysbiosis has been linked to an increased risk of gastrointestinal infections and inflammation, contributing to the development of enterocolitis (Taur et al., 2014). Strategies to modulate the gut microbiome, including probiotic supplementation, prebiotic use, and fecal microbiota transplantation (FMT), are being investigated as potential interventions to restore intestinal homeostasis. Preliminary data suggest that preserving a diverse and healthy microbiota may reduce the incidence of gastrointestinal complications in neutropenic patients, but large-scale clinical trials are needed to confirm these findings and establish standardized protocols for microbiome-targeted therapies [62]. In conclusion, the prognosis of typhlitis is dependent on early recognition, timely intervention, and the severity of neutropenia. Recurrent episodes are a significant concern, particularly in patients undergoing multiple chemotherapy cycles, highlighting the need for effective preventive strategies. While prophylactic antibiotics may be beneficial in select high-risk patients, concerns about antimicrobial resistance must be carefully considered. Emerging evidence on gut microbiome modulation presents a promising avenue for reducing typhlitis risk, though further research is required to integrate these strategies into clinical practice. A multidisciplinary approach involving oncologists, infectious disease specialists, and gastroenterologists is essential for optimizing long-term management and improving patient outcomes [63].

Conclusion

Typhlitis remains a critical and potentially fatal complication in immunocompromised patients, particularly those undergoing cytotoxic chemotherapy. Despite advances in supportive care and antimicrobial therapy, the condition continues to pose significant management challenges due to its rapid progression, high morbidity, and risk of recurrence. Early recognition through clinical suspicion and imaging is paramount in initiating timely interventions and reducing mortality. While most cases can be managed conservatively with bowel rest, broad-spectrum antibiotics, and fluid resuscitation, a subset of patients with severe complications such as bowel perforation, necrosis, or persistent sepsis requires surgical intervention. Right hemicolectomy with ileostomy remains the procedure of choice in such cases, though surgery is associated with increased perioperative risks in neutropenic individuals. Long-term management strategies emphasize recurrence prevention, including judicious use of prophylactic antibiotics and emerging microbiome-targeted therapies aimed at preserving intestinal integrity. Future research should focus on refining risk stratification models, optimizing prophylactic strategies, and exploring innovative microbiomemodulating interventions. Given the complexity of typhlitis, a multidisciplinary approach is crucial in improving patient outcomes and survival rates.

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Therapeutic and Prognostic Factors of Upper Gastrointestinal Bleeding in the Intensive Care Unit in a Sub-Saharan African Country- Juniper Publishers

 

Anesthesia & Intensive Care Medicine- Juniper Publishers

Abstract

Background: The aim of our study was to determine the therapeutic and prognostic factors of upper gastrointestinal bleeding (UGB) in the ICU.

Patients and Methods: This was a retrospective descriptive study of records of patients admitted to the ICU from January 2012 to April 2017. Records of patients admitted to UGB in two intensive care units were included. The sampling was consecutive and non-exhaustive. Data were coded and analyzed using SPSS software.

Results: The sample size was 30 cases. The mean age was 55.3 ± 19.1 years. The sex-ratio was 2.3. Nineteen patients were seen more than 72 hours after the onset of bleeding (63.4%). The most frequent mode of revelation was hematemesis (50.7%). Endoscopy was performed in seven patients (23.3%). The management, in addition to resuscitation measures, consisted of parenteral administration of omeprazole. Haemostatic treatment was performed in one patient (3.4%). The mortality rate was 50%.

Conclusion: Upper gastrointestinal bleeding is an important cause of mortality in the ICU.

Keywords: Upper Gastrointestinal Bleeding; Management; Outcome; ICU

Introduction

Upper gastrointestinal bleeding (UGB) is one of the important medical emergencies worldwide, accounting for high morbidity and mortality [1-4]. It requires careful management regardless of the abundance of bleeding and the mode of revelation. Its management should be rapid and appropriate, often requiring endoscopic haemostasis. It remains, despite major advances in technology, a real vital threat. The prevalence of digestive haemorrhage varies from one country to another. UGB is defined as bleeding within the lumen of the gastrointestinal tract from any location between the upper oesophagus to the duodenum at the ligament of Treitz [5].

Critical care physicians are involved in the treatment of patients with gastrointestinal bleeding in several ways. First, patients outside the ICU suffering from gastro-intestinal tract bleeding with hypovolemic shock may need ICU treatment. Secondly, patients can develop gastrointestinal bleeding as a complication during their treatment in intensive care [6]. The global mortality ranges from 5% to 30%. According to French studies, the annual incidence of UGB is roughly estimated at about 100 to 150 episodes per 100,000 inhabitants [7]. The in-hospital mortality appeared to be around 10% in United Kingdom. In countries with limited resources and no endoscopic haemostasis, mortality from digestive haemorrhages is around 30%-40%. The aim of our study was to determine the therapeutic and prognostic factors of UGB in ICU in a low-income country.

Patients and Methods

This was a descriptive, retrospective study. It included records of patients admitted to two intensive care units from January 1st, 2012, to April 30th, 2017. It included the complete records of patients admitted to the intensive care unit for acute upper gastrointestinal bleeding in the intensive care units of the Yaoundé Central Hospital and the Yaoundé University Teaching Hospital. Data collection began after approval by the National Ethics Committee. Information was collected using a pre-established data sheet. The variables studied were socio-demographic data (age, sex), clinical data (pathological history, haemodynamic parameters, mode of bleeding, admission time, initial assessment of the bleeding, biological examinations, and endoscopic findings), therapeutic data (resuscitation measures, specific treatment) and prognostic data (prognostic scores, complications, evolution, death). Patients were stratified based on prognostic scores.

These were the Advanced Trauma Life Support Classification of the American College of Surgeons (ATLAS) and the preendoscopic Rockall score. Resuscitative measures consisted of IV fluids, oxygen therapy, intubation and mechanical ventilation and blood transfusion. Data collected was entered using CSPRO 6.3 software and analyzed using SPSS 21 software. Quantitative data was expressed as means, standard deviations for those following a nominal distribution and median and interquartile range for those with a non-nominal distribution. Categorical data were represented as numbers and percentages. The search for associations between qualitative variables was carried out using the Chi-square test or Fisher’s exact test. Medical confidentiality was respected. All information obtained was treated with utmost confidentiality.

Results

During the study period, fifty-five (55) cases of gastrointestinal bleeding were identified. A total of 32 cases with complete medical files were found from which two cases of lower gastrointestinal bleeding were excluded. This left us with a sample size of 30 patients. From 2012 to 2017, 3159 patients were admitted to the 2 intensive care units. The prevalence of upper gastrointestinal bleeding was 1.74%. The male gender was predominant, with a sex ratio of 2.3:1. The mean age was 55.3 ± 19.1 years, with extremes ranging from 16 to 82 years. The mean haemoglobin level on admission was 6.6 ± 1.9g/dl with extremes from 3.50 to 12.5g/dl. Nineteen patients were admitted to the intensive care unit more than 72 hours after the onset of bleeding (63.4%). The pre-endoscopic Rockall score was greater than 0 in 29 patients (96.7%).

UGB: Upper gastrointestinal bleeding.

HIV: Human Immunodeficiency Virus.

The ATLAS classification on arrival was greater than 1 in 28 patients (93.7%). Endoscopy was performed in seven patients (23.4%). It was performed more than 72 hours after the onset of bleeding. Forrest III ulcerative lesions were the most common (n=3, 42.8%). The management of UGB combined resuscitation and specific measures. IV fluids were administered to all patients. Oxygen was administered in 13 patients (43.3%). Three patients were intubated and put on mechanical ventilation (10%). A total of 26 patients (87.7%) received blood transfusions. Packed red blood cells were the most frequently administered blood product (n=14, 53.8%). Endoscopic haemostatic treatment was performed in one patient with an active Forrest Ib bleed (14.3%). It consisted of an adrenaline injection diluted at 1:10,000. All patients received parenteral omeprazole. Tranexamic acid was administered in seven patients (23.4%). The average length of hospital stay was 5.6 ± 4.9 days, with extremes ranging from 1 to 21 days. The death rate was 50% (Table 1-3).

Discussion

The main limitation of our study was the sample size, owing to the retrospective nature of the study. Some records were not found, highlighting the difficulties of archiving in our context. Another limitation was the type of study: data was collected in two different ICU wards to increase our chances of getting cases of UGB. As a result, there is bound to be a selection bias due to the divergent practices that two different ICU wards may have. The prevalence of UGB in the ICU was 1.74%. This was like findings in literature. Cook et al. in England in 1995 found a prevalence of less than 2% [8]. The incidence of upper GI haemorrhage is estimated at 143 cases per 100,000 inhabitants in France and 150 cases per 100,000 inhabitants in the USA. In Africa, several studies have reported a hospital prevalence ranging from 2 to 17.7% [9]. Our series was predominantly male with a sex-ratio of 2.3. The mean age was 55.3 ± 19.1 years. This is consistent with data from several series studied [10-11]. Our older population is because the patients referred to the ICU were mostly high-risk, elderly patients with comorbidities. The most frequent modes of revelation of UGB were haematemesis (50.7%) and melaena (29.7%). Bleeding from the gastrointestinal tract may present in five ways:

1) Haematemesis

2) Melaena

3) Haematochezia

4) Occult gastrointestinal bleeding,

5) Features of blood loss

Or anemia such as light headedness, syncope, angina, or dyspnoea. UGB typically presents with symptoms of melaena (black, malodorous feces caused by altered haemoglobin), or haematemesis (coffee-ground appearing blood-stained vomitus, caused by blood interaction with gastric acid [12]. The management of UGB combined resuscitation and specific measures. The cornerstone of the treatment of UGIB in intensive care patients is good clinical care: restore circulation, oxygenation, and haemoglobin levels. In addition, clotting disorders should be treated to enhance clot formation and haemostasis. Usually, these measures are sufficient to stop bleeding. When bleeding persists, the next step is to obtain an endoscopic examination with or without endoscopic treatment. Rapid assessment, resuscitation and correction of coagulopathy should be undertaken, and investigation or definitive management urgently arranged. For UGB, endoscopy remains the cornerstone of investigation and treatment. Initial management of haemorrhage is common to any source and involves standard resuscitative measures.

Assessment of the patient’s airway and respiratory system is performed initially, with attention made to ensure adequacy of ventilation. The patient’s heart rate and blood pressure are recorded and wide bore peripheral venous access obtained (at least two 16 or 18- gauge intravenous cannulas) [13-14]. In all cases, patients who are in a state of hypovolemic shock need appropriate shock treatment with fluids, blood- and plasma transfusions and if needed, vasopressors. Blood loss was estimated to be greater than 500ml in 28 patients (93.7%). It was class 1 ATLS. The ATLS guidelines on haemorrhage severity and class of hypovolaemic (haemorrhagic) shock are useful tools in the estimation of blood loss in patients with significant gastrointestinal bleeding. A prompt fluid bolus of 500 ml of crystalloids is recommended for initial volume replacement. It may be prudent to adopt a policy of ‘permissive hypotension’ (maintaining blood pressure at a level required to maintain tissue perfusion and cognition) until definitive control of the source of bleeding can be established.

Blood transfusion was performed in 26 patients (87.7%). The most used blood product was packed red blood cells. Whole blood was used in 38.5% of cases. Transfusion management was in accordance with the international consensus [15]. However, there is still a high use of whole blood. This may be due to the unavailability of other labile blood products in our setting. Hospitals have a transfusion policy where, for stable patients, packed red blood cell transfusion is recommended below a threshold (typically Hb ≤ 7g/dl. When used, NICE guidelines recommend a transfusion target of Hb 8.0 g/dL in patients with cardiovascular disease and 7.0 g/dL in those without [16].

Studies have quantified massive (or major) gastrointestinal haemorrhage as requiring transfusion of at least four units of packed red blood cells. The NHS transfusion service defines it as loss of one blood volume in 24 hours (70 ml/kg), 50% of total blood volume within 3 hours, or blood loss more than 150 ml/minute. A clinical aid includes systolic blood pressure less than 90 mmHg or heart rate more than 110 beats per minute. Omeprazole administration protocols were disparate, depending on the practitioner. The recommended protocols were 80mg bolus and then 40mg/12 hours (73.3%), and 8mg/hr. with an electric syringe pump for 72 hours in one patient (3.3%). Most guidelines agree that following an endoscopic diagnosis of ulcerative disease with high-risk features, high dose proton pump inhibitor is recommended.

The European Society of Gastrointestinal Endoscopy (ESGE) recommends intravenous high dose proton pump inhibitor (omeprazole 80 mg) be given as a bolus on presentation followed by continuous infusion (omeprazole 8 mg/hr.) for all patients requiring admission. Tranexamic acid was used in 7 patients (23.3%). This drug is not recommended for the intensive care management of upper GIB. Tranexamic acid has traditionally been given to patients presenting with gastrointestinal haemorrhage. However, the landmark HALT-IT trial found no difference between tranexamic acid infusion and placebo for mortality, blood transfusion and re-bleeding. With only a very small increase in venous thromboembolism, most guidelines no longer recommend tranexamic acid for GI bleeding [17]. Approximately one in four patients benefited from endoscopy. The time to perform endoscopy was > 72 hours.

This was due to the low level of technical facilities in these two hospitals and the high cost of endoscopy in our setting. This was different from the international recommendations for the management of upper GIB which suggest that endoscopy should be performed within 24 hours of the clinical manifestations of the haemorrhage in a stable patient. Patients who are haemodynamically unstable and with evidence of active bleeding should undergo immediate endoscopy after initial resuscitative measures. All patients requiring admission should receive endoscopy within 24 hours. Even after a period of stabilization, if the patient further deteriorates, immediate repeat intervention is necessary. Ulcerative lesion was the main endoscopic lesion found. This is consistent with the study by Ankouane et al, which found a peptic ulcer lesion in 38% of patients. Bagny et al. in Togo reported an ulcer lesion in 26% of cases. This high prevalence of ulcerative lesions was explained by the fact that the patients were elderly subjects with comorbidities.

Peptic ulcer disease is the most common cause for upper GI bleeding and accounts for approximately 31% to 67% of presentations. Benign peptic ulcers are best assessed endoscopically where they are typically described as having smooth, rounded edges. The Forrest classification categorises ulcers into three classes, which helps guide management and stratifies risk in patients at high risk of re-bleeding and mortality. Any ulcer other than a 2c or 3 is considered high risk. Only one patient received perendoscopic haemostatic treatment. This result could be explained by the non-availability of an endoscopy unit in these two hospitals. This highlights the lack of infrastructure for the management of UGB. The death rate was 50%. This was due to the severity of the patients admitted to the intensive care unit. The pre-endoscopic Rockall score was greater than 0 in 29 patients (96.7%), indicating a high risk of mortality. The in-hospital mortality appeared to be around 10% in United Kingdom. In countries with limited resources and no endoscopic haemostasis, mortality from digestive haemorrhages is around 30% - 40%. Mortality related to UGB was 36.6% in Brazzaville.

It remains high between 17 and 40% in other African countries [18-19]. On the other hand, in the centres that perform endoscopic haemostasis, mortality is low [20-22]. It was of 3% in Gabon in 2018, around 5% in France. The severity of bleeding is assessed by four main clinical factors and the haematocrit. The clinical factors are tachycardia greater than 110 beats per minute, systolic hypotension less than 80mmHg, tachypnoea greater than 20 cycles and the presence of skin mottling. Several scoring systems rate the severity of illness and their prognostication of patients who present with bleeding outside the ICU. A recent study showed that the AIMS65 and Glasgow- Blatchford scores performed better than the pre-endoscopic Rockall score and pre-endoscopi. Baylor score. There is an association between endoscopy performed more than 24 hours after admission and increased risk of mortality. In multivariate analysis, the risk factors for mortality were age between 30 and 60 years old, male sex and late hospitalization. The high mortality rate in our series is probably related to the lack of endoscopic haemostasis.

Conclusion

The prevalence of UGB in the ICU is low. Males predominate. The management was based on emergency measures and specific treatment. Mortality is high. The reduction of the mortality rate in ICU requires considering the identified risk factors and the acquisition of endoscopic haemostasis equipment.

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