Variability in the management of nonvariceal upper gastrointestinal bleeding in Europe: an observational study

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB. Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups. Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review. A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.

Time to endoscopy for acute upper gastrointestinal bleeding: Results from a prospective multicentre trainee-led audit

Background

Endoscopy within 24 h of admission (early endoscopy) is a quality standard in acute upper gastrointestinal bleeding (AUGIB). We aimed to audit time to endoscopy outcomes and identify factors affecting delayed endoscopy (>24 h of admission).

Methods

This prospective multicentre audit enrolled patients admitted with AUGIB who underwent inpatient endoscopy between November and December 2017. Analyses were performed to identify factors associated with delayed endoscopy, and to compare patient outcomes, including length of stay and mortality rates, between early and delayed endoscopy groups.

Results

Across 348 patients from 20 centres, the median time to endoscopy was 21.2 h (IQR 12.0-35.7), comprising median admission to referral and referral to endoscopy times of 8.1 h (IQR 3.7-18.1) and 6.7 h (IQR 3.0-23.1), respectively. Early endoscopy was achieved in 58.9%, although this varied by centre (range: 31.0-87.5%, p = 0.002). On multivariable analysis, lower Glasgow-Blatchford score, delayed referral, admissions between 7:00 and 19:00 hours or via the emergency department were independent predictors of delayed endoscopy. Early endoscopy was associated with reduced length of stay (median difference 1 d; p = 0.004), but not 30-d mortality (p = 0.344).

Conclusions

The majority of centres did not meet national standards for time to endoscopy. Strategic initiatives involving acute care services may be necessary to improve this outcome.

A New Scoring System to Predict Poor Clinical Outcomes in Acute Nonvariceal Upper Gastrointestinal Bleeding Patients with High-Risk Stigmata

AIMS

To explore the risk factors for rebleeding in acute nonvariceal upper gastrointestinal bleeding patients with high-risk stigmata after endoscopic hemostasis and to develop a new scoring system for them.

METHODS

A retrospective single-center study was conducted from January 2012 to June 2017. The logistic regression model was used to explore risk factors of poor clinical outcomes. Accuracy of new scoring systems was compared with Rockall score (RS) and Glasgow-Blatchford score (GBS) using receiver operating characteristics curve.

RESULTS

Two hundred nine patients were included. In multivariate regression analysis, systolic blood pressure, endoscopic hemostasis method, hemoglobin, blood urea nitrogen, and serum creatinine were identified as indicators for rebleeding. New scoring systems with 4 variables and 5 variables based on these 5 risk factors were chosen. The 4-variable scoring system outperformed GBS in predicting rebleeding while 5-variable scoring system outperformed RS and GBS in predicting rebleeding significantly. Score 2 was identified as the best cut-off of these 2 scoring systems.

CONCLUSIONS

Systolic blood pressure, endoscopic hemostasis method, hemoglobin, blood urea nitrogen, and serum creatinine were all associated with poor clinical outcomes. The new scoring systems had greater accuracy than RS and GBS in predicting rebleeding. Further external validation should be performed to verify the results.

Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.

Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study

OBJECTIVE

Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care.

MATERIAL AND METHODS

This population-based cohort study included all emergency EGDs for PUB in adults during 2012-2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model.

RESULTS

Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR = 1.51 (95% CI = 1.25-1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR = 1.22 (95% CI = 0.55-2.71). The prevalence of anaesthesia care varied between the hospitals, median = 78.9% (range 6.9-98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity.

CONCLUSIONS

Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.

Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.

Adherence to guidelines: a national audit of the management of acute upper gastrointestinal bleeding. The REASON registry

OBJECTIVES

To assess process of care in nonvariceal upper gastrointestinal bleeding (NVUGIB) using a national cohort, and to identify predictors of adherence to 'best practice' standards.

METHODS

Consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding across 21 Canadian hospitals were reviewed. Data regarding initial presentation, endoscopic management and outcomes were collected. Results were compared with 'best practice' using established guidelines on NVUGIB. Adherence was quantified and independent predictors were evaluated using multivariable analysis.

RESULTS

Overall, 2020 patients (89.4% NVUGIB, variceal in 10.6%) were included (mean [± SD] age 66.3±16.4 years; 38.4% female). Endoscopy was performed in 1612 patients: 1533 with NVUGIB had endoscopic lesions (63.1% ulcers; high-risk stigmata in 47.8%). Early endoscopy was performed in 65.6% and an assistant was present in 83.5%. Only 64.5% of patients with high-risk stigmata received endoscopic hemostasis; 9.8% of patients exhibiting low-risk stigmata also did. Intravenous proton pump inhibitor was administered after endoscopic hemostasis in 95.7%. Rebleeding and mortality rates were 10.5% and 9.4%, respectively. Multivariable analysis revealed that low American Society of Anesthesiologists score patients had fewer assistants present during endoscopy (OR 0.63 [95% CI 0.48 to 0.83), a hemoglobin level <70 g⁄L predicted inappropriate high-dose intravenous proton pump inhibitor use in patients with low-risk stigmata, and endoscopies performed during regular hours were associated with longer delays from presentation (OR 0.33 [95% CI 0.24 to 0.47]).

CONCLUSION

There was variability between the process of care and 'best practice' in NVUGIB. Certain patient and situational characteristics may influence guideline adherence. Dissemination initiatives must identify and focus on such considerations to improve quality of care.

Emergency diagnosis of upper gastrointestinal bleeding by detection of haemoglobin in nasogastric aspirate

OBJECTIVE

To determine the accuracy of the Faecal Occult Blood-Transferrin test (FOB-T; Certest Biotec, San Mateo de Gállego, Spain) for detection of blood in nasogastric aspirate, and its emergency diagnostic value for upper gastrointestinal bleeding (UGIB).

METHODS

Nasogastric aspirate was collected from patients with haematemesis on admission to hospital. Haemoglobin was quantified on admission and after 12 h. FOB-T test was used to assess each nasogastric aspirate sample for the presence of haemoglobin and transferrin.

RESULTS

Of 64 patients included in the study, 28 (43.8%) were hospitalized for UGIB based on physical examination, haemoglobin level. 24 were confirmed with endoscopy findings. Four were excluded from study due to lack of endoscopic confirmation. The remaining 36 patients had no clinical evidence of UGIB. FOB-T test findings were positive in 26/60 patients, including all 24 patients with UGIB. The FOB-T test had sensitivity 100%, specificity 94.4%, positive predictive value 92.3% and negative predictive value 100% for UGIB.

CONCLUSIONS

A negative FOB-T test may be sufficient to exclude the possibility of UGIB without other diagnostic tests.

Bleeding and starving: fasting and delayed refeeding after upper gastrointestinal bleeding

CONTEXT

Early refeeding after nonvariceal upper gastrointestinal bleeding is safe and reduces hospital stay/costs.

OBJECTIVES

The aim of this study was obtaining objective data on refeeding after nonvariceal upper gastrointestinal bleeding.

METHODS

From 1 year span records of nonvariceal upper gastrointestinal bleeding patients that underwent urgent endoscopy: clinical features; rockall score; endoscopic data, including severity of lesions and therapy; feeding related records of seven days: liquid diet prescription, first liquid intake, soft/solid diet prescription, first soft/solid intake.

RESULTS

From 133 patients (84 men) Rockall classification was possible in 126: 76 score ≥5, 50 score <5. One persistent bleeding, eight rebled, two underwent surgery, 13 died. Ulcer was the major bleeding cause, 63 patients underwent endoscopic therapy. There was 142/532 possible refeeding records, no record 37% patients. Only 16% were fed during the first day and half were only fed on third day or later. Rockall <5 patients started oral diet sooner than Rockall ≥5. Patients that underwent endoscopic therapy were refed earlier than those without endotherapy.

CONCLUSIONS

Most feeding records are missing. Data reveals delayed refeeding, especially in patients with low-risk lesions who should have been fed immediately. Nonvariceal upper gastrointestinal bleeding patients must be refed earlier, according to guidelines.

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

BACKGROUND

The modern management of acute non-variceal upper gastrointestinal bleeding is centred on endoscopy, with recourse to interventional radiology and surgery in refractory cases. The appropriate use of intervention to optimize outcomes is reviewed.

METHODS

A literature search was undertaken of PubMed and the Cochrane Central Register of Controlled Trials between January 1990 and April 2013 using validated search terms (with restrictions) relevant to upper gastrointestinal bleeding.

RESULTS

Appropriate and adequate resuscitation, and risk stratification using validated scores should be initiated at diagnosis. Coagulopathy should be corrected along with blood transfusions, aiming for an international normalized ratio of less than 2·5 to proceed with possible endoscopic haemostasis and a haemoglobin level of 70 g/l (excluding patients with severe bleeding or ischaemia). Prokinetics and proton pump inhibitors (PPIs) can be administered while awaiting endoscopy, although they do not affect rebleeding, surgery or mortality rates. Endoscopic haemostasis using thermal or mechanical therapies alone or in combination with injection should be used in all patients with high-risk stigmata (Forrest I-IIb) within 24 h of presentation (possibly within 12 h if there is severe bleeding), followed by a 72-h intravenous infusion of PPI that has been shown to decrease further rebleeding, surgery and mortality. A second attempt at endoscopic haemostasis is generally made in patients with rebleeding. Uncontrolled bleeding should be treated with targeted or empirical transcatheter arterial embolization. Surgical intervention is required in the event of failure of endoscopic and radiological measures. Secondary PPI prophylaxis when indicated and Helicobacter pylori eradication are necessary to decrease recurrent bleeding, keeping in mind the increased false-negative testing rates in the setting of acute bleeding.

CONCLUSION

An evidence-based approach with multidisciplinary collaboration is required to optimize outcomes of patients presenting with acute non-variceal upper gastrointestinal bleeding.