Predictors of in-hospital mortality in a cohort of elderly Egyptian patients with acute upper gastrointestinal bleeding

Management Outcomes of Variceal Bleeding in Northern Tanzania: Insights From a Single-Center Retrospective Analysis

Aims

Due to the expensiveness and unavailability of endoscopy management in Tanzania, the management outcomes of variceal bleeding are unknown. The objective of this study was to assess the management outcomes of patients with variceal bleeding.

Methods

This was a retrospective study conducted between April 2012 and April 2022. The study enrolled all patients diagnosed with variceal bleeding aged 18 years and older. Socio-demographic and clinic characteristics, treatment modalities, and outcomes were collected. Statistical analysis was done using a chi-square test. Multivariable logistic regression was used to determine factors associated with rebleeding and mortality. A p-value of ≤ 0.05 was considered statistically significant.

Results

A total of 534 patients were enrolled based on diagnostic endoscopy findings. Esophageal varices were identified in 88.9% of patients, gastric varices in 0.9%, and 10.1% had both. Conservative treatment was given to 77.5% of patients, and endoscopic treatment was performed in 22.5%: endoscopic variceal ligation (17.6%), endoscopic injection sclerotherapy (4.3%), and both (0.6%). Rebleeding occurred in 40.1%, and factors associated with rebleeding were patients without insurance (p = 0.037), without comorbidities (p = 0.042), with non-communicable diseases (p = 0.039), and with chronic infections (p = 0.035). In-hospital mortality was 8.1%, and factors associated with mortality were a shorter length of stay (p = 0.045), patients without comorbidities (p = 0.041), and grade II esophageal varices (p = 0.043).

Conclusion

This study shows a high rate of variceal bleeding among patients treated conservatively. Mortality and rebleeding rates in our setting remain high, which appears to be due to the expensiveness and unavailability of endoscopic treatment. Available endoscopic interventions will be vital in improving the outcomes of patients with variceal bleeding.

Optimal endoscopy timing in elderly patients presenting with acute non-variceal upper gastrointestinal bleeding

BACKGROUND

To evaluate the optimal endoscopy time in elderly patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) based on clinical outcomes.

METHODS

Patients over 65 years of age presenting with NVUGIB are three patient groups based on endoscopy timing: very early endoscopy (< 12 h), early endoscopy (12-24 h) and late endoscopy (> 24 h). Endoscopic intervention was undertaken during the first 12 h for patients who had unstable hemodynamic settings, ongoing bleeding, or a low hematocrit despite transfusion. The clinical outcomes investigated were: The primary endpoint was 30-day mortality, with the need for endoscopic intervention, rebleeding, and length of hospital stay considered as secondary endpoints.

RESULTS

The study population was 468, 260 of whom were ≥ 65 years. Based on the timing of endoscopy, very early endoscopy (within 12 h) was performed in 180 (69.2%) patients aged > 65 years and 150 (72.1%) younger patients (p > 0.05). Early endoscopy (12-24 h) was performed in patients aged > 65 years and younger patients 53 (20.4%) vs. 41 (19.7%), respectively, while late endoscopy (24-48 h) was performed in 27 (10.4%) vs. 17 (8.2%) patients, respectively (p > 0.05, for all parameters). The clinical results of subgroups based on endoscopy time in the ≥ 65 population and comparisons between groups. When groups were compared, it was found that the very early endoscopy group had a considerably lower likelihood of need for surgical/radiological intervention than the late endoscopy group [3 (1,7) vs. (3,7), p = 0.016], and 30-day mortality rates by the endoscopy timing were statistically significantly different in the very early group (15.6%), early endoscopy group (7.5%), and late endoscopy group (29.6%) (p < 0.05, for all groups). Endoscopy time within 24-48 h (late) (OR: 3.133, 95%Cl: 1.127-8.713, p: 0.029) was an independent predictor of rebleeding during the hospital stay.

CONCLUSIONS

Early endoscopy may benefit the management of acute UGIB, especially in the elderly population with high comorbidities and the severity of bleeding.

At admission hemodynamic instability is associated with increased mortality and rebleeding rate in acute gastrointestinal bleeding: a systematic review and meta-analysis

BACKGROUND

Acute gastrointestinal bleeding (GIB) is a life-threatening event. Around 20-30% of patients with GIB will develop hemodynamic instability (HI).

OBJECTIVES

We aimed to quantify HI as a risk factor for the development of relevant end points in acute GIB.

DESIGN

A systematic search was conducted in three medical databases in October 2021.

DATA SOURCES AND METHODS

Studies of GIB patients detailing HI as a risk factor for the investigated outcomes were selected. For the overall results, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated based on a random-effects model. Subgroups were formed based on the source of bleeding. The Quality of Prognostic Studies tool was used to assess the risk of bias.

RESULTS

A total of 62 studies were eligible, and 39 were included in the quantitative synthesis. HI was found to be a risk factor for both in-hospital (OR: 5.48; CI: 3.99-7.52) and 30-day mortality (OR: 3.99; CI: 3.08-5.17) in upper GIB (UGIB). HI was also associated with higher in-hospital (OR: 3.68; CI: 2.24-6.05) and 30-day rebleeding rates (OR: 4.12; 1.83-9.31) among patients with UGIB. The need for surgery was also more frequent in hemodynamically compromised UGIB patients (OR: 3.65; CI: 2.84-4.68). In the case of in-hospital mortality, the risk of bias was high for 1 (4%), medium for 13 (48%), and low for 13 (48%) of the 27 included studies.

CONCLUSION

Hemodynamically compromised patients have increased odds of all relevant untoward end points in GIB. Therefore, to improve the outcomes, adequate emergency care is crucial in HI.

REGISTRATION

PROSPERO registration number: CRD42021285727.

One in four patients with gastrointestinal bleeding develops shock or hemodynamic instability: A systematic review and meta-analysis

BACKGROUND

Hemodynamic instability and shock are associated with untoward outcomes in gastrointestinal bleeding. However, there are no studies in the existing literature on the proportion of patients who developed these outcomes after gastrointestinal bleeding.

AIM

To determine the pooled event rates in the available literature and specify them based on the bleeding source.

METHODS

The protocol was registered on PROSPERO in advance (CRD42021283258). A systematic search was performed in three databases (PubMed, EMBASE, and CENTRAL) on 14th October 2021. Pooled proportions with 95%CI were calculated with a random-effects model. A subgroup analysis was carried out based on the time of assessment (on admission or during hospital stay). Heterogeneity was assessed by Higgins and Thompson's I2 statistics. The Joanna Briggs Institute Prevalence Critical Appraisal Tool was used for the risk of bias assessment. The Reference Citation Analysis (https://www.referencecitationanalysis.com/) tool was applied to obtain the latest highlight articles.

RESULTS

We identified 11589 records, of which 220 studies were eligible for data extraction. The overall proportion of shock and hemodynamic instability in general gastrointestinal bleeding patients was 0.25 (95%CI: 0.17-0.36, I2 = 100%). In non-variceal bleeding, the proportion was 0.22 (95%CI: 0.14-0.31, I2 = 100%), whereas it was 0.25 (95%CI: 0.19-0.32, I2 = 100%) in variceal bleeding. The proportion of patients with colonic diverticular bleeding who developed shock or hemodynamic instability was 0.12 (95%CI: 0.06-0.22, I2 = 90%). The risk of bias was low, and heterogeneity was high in all analyses.

CONCLUSION

One in five, one in four, and one in eight patients develops shock or hemodynamic instability on admission or during hospitalization in the case of non-variceal, variceal, and colonic diverticular bleeding, respectively.

Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis

BACKGROUND

The optimal timing of esophagogastroduodenoscopy (EGD) and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding (NVUGIB) remains an area of active research.

AIM

To identify independent predictors of outcomes in patients with NVUGIB, with a particular focus on EGD timing, anticoagulation (AC) status, and demographic features.

METHODS

A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database. Patients were stratified by EGD timing relative to hospital admission (≤ 24 h, 24-48 h, 48-72 h, and > 72 h) and then by AC status (yes/no). The primary outcome was all-cause inpatient mortality. Secondary outcomes included healthcare usage.

RESULTS

Of the 1082516 patients admitted for NVUGIB, 553186 (51.1%) underwent EGD. The mean time to EGD was 52.8 h. Early (< 24 h from admission) EGD was associated with significantly decreased mortality, less frequent intensive care unit admission, shorter length of hospital stays, lower hospital costs, and an increased likelihood of discharge to home (all with P < 0.001). AC status was not associated with mortality among patients who underwent early EGD (aOR 0.88, P = 0.193). Male sex (OR 1.30) and Hispanic (OR 1.10) or Asian (aOR 1.38) race were also independent predictors of adverse hospitalization outcomes in NVUGIB.

CONCLUSION

Based on this large, nationwide study, early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage, irrespective of AC status. These findings may help guide clinical management and would benefit from prospective validation.

Bleeding, Hemorrhagic Shock, and the Global Blood Supply

Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.

Use of endoscopic band ligation alone and in combination with nonselective beta blockers for prevention of variceal bleeding in ascites patients on the liver transplant waiting list

Objective: to conduct a comparative analysis of the effectiveness of two methods – endoscopic band ligation (EBL) alone and in combination with nonselective beta blockers (NSBB) – used for prevention of variceal bleeding (VB); to evaluate their impact on patient survival in severe ascites during long-term stay on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of two groups of patients with decompensated liver disease, ascites and varices included in the LTWL, who received EBL (n = 41, group 1) and EBL + NSBB (n = 45, group 2). Results. The groups being compared did not differ in demographics, clinical parameters, MELD and Child–Turcotte–Pugh scores. There were no significant differences in the incidence of severe ascites, particularly diuretic-resistant ascites. The study groups did not differ in the incidence of mediumand large-sized varices. Incidence of bleeding did not differ in both groups. Overall mortality was significantly higher in the EBL + NSBB group than in the EBL group. Patient survival was lower, while mortality was higher in the EBL + NSBB group. The combined therapy group had a significantly higher number of acute kidney injury (AKI) than the EBL group. Conclusion. The compared methods are equivalently effective in preventing VB in patients with decompensated cirrhosis with a prolonged stay on the waiting list. Survival rate is significantly lower, while mortality is significantly higher in the EBL + NSBB group than in the EBL group.

Association of ABO Blood Type with Bleeding Severity in Patients with Acute Gastroesophageal Variceal Bleeding

Background and Objectives: ABO blood types have been implicated as potential risk factors for various hemorrhagic diseases. No study has investigated the association between gastroesophageal variceal bleeding and ABO blood types. We aimed to evaluate the impact of ABO blood types on mortality and bleeding risk in acute gastroesophageal variceal bleeding. Materials and Methods: This is a retrospective observational study. Patients presenting with acute gastroesophageal varices bleeding diagnosed by endoscopy were enrolled, and were divided by blood type into a type O group and non-type O group. The outcomes were death within 30 days and the proportion of further bleeding. We used generalized linear mixed-effects models to analyze the outcomes. Results: A total of 327 patients and 648 records of emergency room visits were included. The 30-day mortality was 14.8% (21 of 142 patients) in the type O group, and 16.2% (30 of 185 patients) in the non-type O group (p = 0.532). Further bleeding within 30 days occurred in 34 cases (12.6%) in the type O group, and in 26 cases (6.9%) in the non-type O group (p = 0.539). Conclusions: There was no significant difference in blood transfusion volume in 24 h, recurrent bleeding rates, or mortality between patients with blood type O and those with non-type O.

Upper gastrointestinal bleeding in patients 80 years old and over. A comparison with younger patients and risk factors analysis for in-hospital and delayed mortality

INTRODUCTION

Outcomes in old patients with upper gastrointestinal bleeding (UGIB) have been scarcely studied. Our aim was to compare very old individuals (>80 years old) with younger patients with UGIB, and to identify risk factors for the main outcomes.

METHODS

A single-centre prospectively collected database was analysed. Descriptive, inferential and multivariate logistic regression models were performed. Main clinical outcomes were in-hospital and delayed 6-month mortality.

RESULTS

698 patients were included, 143 very old and 555 aged <80. Old patients differed from younger ones in comorbidities (85.9% vs. 62%, P < .0001), oral anticoagulants (32.3% vs. 12.7%; P < .0001), and antiplatelets intake (32.3% vs. 21.2%; P < .007). No differences were found in the need for endoscopic interventions, blood unit transfusions, hospital stay, in-hospital rebleeding and mortality. Among very old patients, creatinine levels were higher in those who died compared with the ones who survived (1.92 ± 1.46 vs. 1.25 ± 0.59 mg/dL; P = .002), they had lower haemoglobin levels (8.1 ± 1.4 vs. 9.1 ± 2.4 g/dL; P = .04) and longer hospital stays (17.75 ± 15.5 vs. 8.1 ± 8.4 days; P < .0001). Logistic regression showed creatinine levels (OR: 2.42; 95% CI: 1.24-4.74; P = .01), cirrhosis (OR: 2.88, 95% CI: 1.88-17.34; P = .04) and being an impatient (OR: 3.90; 95% CI: 1.11-20; P = .035) were independent risk factors for mortality in older patients. They had an increased delayed 6-month mortality compared with younger patients (17.5% vs. 8%, P = .001).

CONCLUSIONS

Creatinine levels, cirrhosis or the onset of UGIB while being an inpatient were independent risk factors for mortality in very old patients. Delayed mortality was higher among them, mostly caused by cardiovascular events and neoplasms, but not in-hospital mortality.

Clinical judgment model-based nursing simulation scenario for patients with upper gastrointestinal bleeding: A mixed methods study

Assisting patients with upper gastrointestinal bleeding is a crucial role for nurses, and as future nurses, students should demonstrate sound clinical judgment. Well-structured, high-quality simulations are useful alternatives to prepare students for clinical practice. However, nursing simulation scenarios focused on enhancing clinical judgment in managing upper gastrointestinal bleeding are limited. This study aims to develop, apply, and evaluate an effective nursing simulation scenario for patients with upper gastrointestinal bleeding based on Tanner’s clinical judgment model using a mixed methods study design. A high-fidelity patient simulation was conducted among 80 undergraduate nursing students divided into a simulated control group (n = 39) and an experimental group (n = 41). Subsequent student performance evaluations used questionnaires and video recordings. After scenario simulations, the students showed a statistically significant increase in theoretical knowledge (p = 0.001) and clinical performance skills (p < 0.001), but there was no significant increase in self-confidence (p = 0.291). According to the video analysis, the “noticing” clinical judgment phase was the most frequently observed phase, while “reflection” was the least frequently observed phase. Additionally, “education” was the most frequently observed nursing domain, and “anxiety” was the least frequently observed domain. Although further simulation repetitions are required to reinforce students’ self-confidence when caring for patients with upper gastrointestinal bleeding, the scenario was deemed effective. Moreover, emphasis should be placed on developing various scenarios to strengthen students’ clinical judgment skills, especially “reflecting” and “emotional care.”

Secure intravariceal sclerotherapy with red dichromatic imaging decreases the recurrence rate of esophageal varices: A propensity score matching analysis

BACKGROUND

Red dichromatic imaging (RDI) is next-generation image-enhanced endoscopy technique released in July 2020. We previously reported that RDI can predict esophageal varices (EV) depth and decrease their recurrence rate by accurate intravariceal injections during endoscopic injection sclerotherapy (EIS) using unreleased prototype RDI endoscope. In this study, we analyzed whether RDI improves the overall survival (OS) rate and whether it is more accurate independent predictor of EV recurrence than white light imaging (WLI), using propensity score matching.

METHODS

A total of 179 patients were enrolled. Patients were matched for age, platelet count, liver function, EV size, luminal diameter, and EV depth using propensity score matching, and 78 patients (RDI, 39; WLI, 39) were finally matched. Primary endpoints were OS and recurrence rates. Secondary endpoints were success rate of intravariceal injection, operating time, incidence of adverse events (AEs), and predictors associated with OS and recurrence rates.

RESULTS

There was no difference in OS (P = .193), but the cumulative recurrence rate in the RDI group was significantly lower than in the WLI group (P = .002). Success rates of intrainjection, operating time, and incidence of AEs were better in the RDI group (p = 0.035, .026, and .0019, respectively). Independent predictors associated with recurrence rate by Cox proportional regression were RDI function and luminal diameter (P < .001 and .017, respectively).

CONCLUSION

RDI did not improve OS but decreased the recurrence rate. Independent predictors of recurrence rate were RDI and luminal diameter, resulting from secure intravariceal injections in EIS.

Complications and management of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices

OBJECTIVE

To report the complications and evaluate the risk factors of elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices in cirrhotic patients.

METHODS

A total of 583 elective endoscopic tissue adhesives procedures were performed in 439 patients in our hospital from January 2015 to December 2016. The clinical characteristics and complications were retrospectively collected and evaluated.

RESULTS

The median age was 56 ± 11 years, and 290 (66.1%) patients were male. The main etiology of liver cirrhosis was hepatitis virus (63.3%). Two hundred fifty-nine (59.0%) patients were classified as Child-Pugh Class A. Bleeding occurred in 44 patients (7.5%) during procedures. Two patients developed distant embolism (0.5%; one pulmonary, one cerebra). In perioperative period, fever was a common complication; however, only 16 cases had high fever and one case had sepsis. Bleeding was observed in 7 (1.2%) patients. Overall incidence of the major perioperative complication was 3.8%. The major postoperative complication rate was 10.4% (60/582, 26 rebleeds, 27 ascites increase, 12 new-onset portal vein thrombosis). The complication-related death was 1.6% (one death from embolism, five deaths from rebleeding, one death from refractory ascites). Injection point was the only factor related to the major perioperative complications [odds ratio (OR) = 1.581, 95% CI, 1.086-2.301; P < 0.05]. Etiology of cirrhosis and injection point were independent risk factors of major postoperative complications (OR = 1.830, 95% CI, 1.005-3.331, P = 0.048; OR = 1.373, 95% CI, 1.089-1.731, P = 0.007).

CONCLUSION

The incidence of complications after elective endoscopic cyanoacrylate injection with lauromacrogol for gastric varices was low. The injection point was the risk factor for both perioperative and postoperative complications.

C-reactive protein for simple prediction of mortality in patients with acute non-variceal upper gastrointestinal bleeding: A retrospective analysis

In upper gastrointestinal bleeding (UGIB), scoring systems using multiple variables were developed to predict patient outcomes. We evaluated serum C-reactive protein (CRP) for simple prediction of patient mortality after acute non-variceal UGIB.The associated factors for 30-day mortality was investigated by regression analysis in patients with acute non-variceal UGIB (N = 1232). The area under the receiver operating characteristics (AUROC) curve was analyzed with serum CRP in these patients and a prospective cohort (N = 435). The discriminant validity of serum CRP was compared to other prognostic scoring systems by means of AUROC curve analysis.Serum CRP was significantly higher in the expired than survived patients (median, 4.53 vs 0.49; P < .001). The odds ratio of serum CRP was 4.18 (2.10-9.27) in multivariate analysis. The odds ratio of high serum CRP was higher than Rockall score (4.15 vs 1.29), AIMS65 (3.55 vs 1.71) and Glasgow-Blatchford score (4.32 vs 1.08) in multivariate analyses. The AUROC of serum CRP at bleeding was 0.78 for 30-day mortality (P < .001). In the validation set, serum CRP was also significantly higher in the expired than survived patients, of which AUROC was 0.73 (P < .001). In predicting 30-day mortality, the AUROC with serum CRP was not inferior to that of other scoring systems.Serum CRP at bleeding can be simply used to identify the patients with high mortality after acute non-variceal UGIB.

Comparison of various risk scores for the prognosis of hemorrhagic upper gastrointestinal mucosal disorder

Background

Various risk scores have been proposed that are useful for the management of upper gastrointestinal bleeding (UGIB), which is an important disease in emergency medicine. Few studies have examined the usefulness of Charlson Comorbidity index (CCI) in this disease, which evaluates the patient’s general condition by scoring the patient’s underlying disease. There have been no studies investigating the efficacy of CCI compared to other risk scores in the management of UGIB requiring endoscopic hemostasis.

Methods

In addition to the Glasgow-Blatchford score, AIMS65 score, and Rockall score, we investigated the efficacy of the outcome prediction obtained by the original CCI and the updated CCI, scored only with respect to the underlying disease. We also examined the cutoff value when using the risk score. This retrospective study included 265 patients with hemorrhagic upper gastrointestinal mucosal lesions who underwent emergency endoscopic hemostasis during a 6-year period between 2011 and 2016 in our hospital.

Results

The updated CCI and AIMS65 score correlated with prognosis in multivariate analysis (p = 0.002 and p = 0.003, respectively). In clinical practice, the prognosis might be worse if both updated CCI and AIMS65 score were 3 point or more.

Conclusion

In addition to the AIMS65 score, the updated CCI can be a useful tool for managing upper gastrointestinal mucosal disorder bleeding that requires endoscopic hemostasis.

Second urgent endoscopy within 48-hour benefits cirrhosis patients with acute esophageal variceal bleeding

Urgent endoscopy (UE) is important to the diagnosis and treatment of liver cirrhosis patients with esophageal variceal bleeding (EVB). It was reported that a second-look endoscopy may benefit acute upper gastrointestinal bleeding (UGIB) caused by peptic ulcer, while whether it could improve UGIB caused by liver cirrhosis associated EVB remains unclear. This study aimed to investigate the characteristics of second UE for liver cirrhosis with EVB and further examined the potential prognostic factors.Patients aged ≥18 years who underwent UE for EVB within 2 hours after the admission were included and divided into scheduled second-look group (n = 245) and uncontrolled bleeding group (n = 352) based on the indications for second UE within 48 hours after initial endoscopy. Demographic and clinical data were collected and analyzed. Univariate and multivariate analysis were used to identify the risk factors for prognosis. The value of different scoring system was compared.Statistical differences were found on history of bleeding and hepatocellular carcinoma, ascites, endoscopic type of bleeding, between scheduled second-look group and uncontrolled bleeding group. Univariate and multivariate logistic regression analysis confirmed that ascites, hemoglobin <60 g/L, AIMS65 score and failure to identify in initial UE were independent risk factors for bleeding uncontrolled after initial UE, and age, bilirubin level, initial unsatisfactory UE hemostasis, failure to identify bleeding on initial UE and tube/urgent TIPS suggested in initial UE were independent risk factors for 42-day mortality.A second-look UE could bring benefit for liver cirrhosis patients with EVB without increasing the complication rate.

Propranolol plus endoscopic ligation for variceal bleeding in patients with significant ascites: Propensity score matching analysis

The use of beta-blockers in decompensated cirrhosis accompanying ascites is still under debate. The aim of this study was to compare overall survival (OS) and incidence of cirrhotic complications between endoscopic variceal ligation (EVL) only and EVL + non-selective beta-blocker (NSBB) combination therapy in cirrhotic patients with significant ascites (≥grade 2).This retrospective study included 271 consecutive cirrhotic patients with ascites who were treated with EVL only or EVL + NSBB combination therapy as a primary prophylaxis of esophageal varices. The primary outcome was all-cause mortality. Propensity score matching was performed between the 2 groups to minimize baseline difference.Median observation period was 42.1 months (interquartile range, 18.4-75.1 months). All patients had deteriorated liver function: 81.1% Child-Pugh class B and 18.9% Child-Pugh class C. All-cause mortality was significantly higher in the EVL + NSBB group than in the EVL only group not only in non-matched cohort, but also in matched cohort (48.9% vs 31.2%; P = .039). More people died from hepatic failure in the EVL + NSBB group than that in the EVL only group (40.5% vs 20.0%; P = .020). However, the incidence of variceal bleeding, hepatorenal syndrome (HRS), or spontaneous bacterial peritonitis (SBP) was not significantly different between the 2 groups.The use of NSBB might worsen the prognosis of cirrhotic patients with significant ascites. These results suggest that EVL alone is a more appropriate treatment option for prophylaxis of esophageal varices than propranolol combination therapy when patients have significant ascites.

In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered condition in the Gastroenterology field with a mortality rate of 10-14%. Despite recent newer innovations and advancements in endoscopic techniques and available medications, the mortality rate associated with AUGIB remained persistently elevated.

AIM

To explore mortality, characteristics and outcome differences between hospitalized patients who develop AUGIB while in-hospital, and patients who initially present with AUGIB.

METHODS

This is a retrospective of patients who presented to Northwell Health Staten Island University Hospital from October 2012 to October 2016 with AUGIB that was confirmed endoscopically. Patients were divided in two groups: Group 1 comprised patients who developed AUGIB during their hospital stay; group 2 consisted of patients who initially presented with AUGIB as their main complaint. Patient characteristics, time to endoscopy, endoscopy findings and interventions, and clinical outcomes were collected and compared between groups.

RESULTS

A total of 336 patients were included. Group 1 consisted of 139 patients and group 2 of 196 patients. Mortality was significantly higher in the 1st group compared to the 2nd (20% vs 3.1%, P ≤ 0.05). Increased length of stay (LOS) was noted in the 1st group (13 vs 6, P ≤ 0.05). LOS post-endoscopy, vasopressor use, number of packed red blood cell units and patients requiring fresh frozen plasma were higher in group 1. Inpatients were more likely to be on corticosteroids, antiplatelets and anticoagulants. Conversely, the mean time from bleeding to undergoing upper endoscopy was significantly lower in group 1 compared to group 2.

CONCLUSION

In-hospital AUGIB is associated with high mortality and morbidity despite a shorter time to endoscopy. Larger scale studies assessing the role of increased comorbidities and antithrombotic use in this setting are warranted.

Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania

Background

Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania.

Methods

This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality.

Results

During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32–64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3–4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7–29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8–22.8).

Conclusions

In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Acute upper gastrointestinal bleed: An audit of the causes and outcomes from a tertiary care center in eastern India

BACKGROUND/PURPOSE OF THE STUDY

Acute upper gastrointestinal (UGI) bleed is a life-threatening emergency carrying risks of rebleed and mortality despite standard pharmacological and endoscopic management. We aimed to determine etiologies of acute UGI bleed in hospitalized patients and outcomes (rebleed rates, 5-day mortality, in-hospital mortality, 6-week mortality, need for surgery) and to determine predictors of rebleed and mortality.

METHODS

Clinical and endoscopic findings were recorded in patients aged > 12 years who presented within 72 h of onset of UGI bleed. Outcomes were recorded during the hospital stay and 6 weeks after discharge.

RESULTS

A total of 305 patients were included in this study, mean age being 44 ± 17 years. Most common etiology of UGI bleed was portal hypertension (62.3%) followed by peptic ulcer disease (PUD) (16.7%). Rebleed rate within 6 weeks was 37.4% (portal hypertension 47.9%, PUD 21.6%, malignancy 71.4%). Five-day mortality was 2.3% (malignancy 14.3%, portal hypertension 3.2%); the in-hospital mortality rate was 3.0% (malignancy 14.3%, portal hypertension 3.2%, PUD 0.0%) and 4.9% at 6 weeks (malignancy 28.6%, portal hypertension 5.8%, PUD 0.0%). Surgery was required in 4.59% patients. On multivariate analysis, post-endoscopy Rockall score was significantly predictive of rebleed in both portal hypertension- and PUD-related rebleed. No factors were found predictive of mortality in multivariate analysis.

CONCLUSION

Portal hypertension remains the commonest cause of UGI bleed in India and carries a higher risk of rebleed and mortality as compared to PUD-related bleed. Post-endoscopy Rockall score is a useful tool for clinicians to assess risk of rebleed.