Introduction
Upper gastrointestinal bleeding(UGIB), both variceal(VB) and nonvariceal(NVB), is a prevalent cause of hospitalization, readmission, and poor outcomes among patients with cirrhosis. However, studies typically focus on VB given its association with higher morbidity and mortality rates(1) although some other studies comparing VB and NVB among patients with cirrhosis reported no difference in outcomes(2). On the other hand, literature is controversial about NVB outcomes between cirrhosis and non-cirrhosis(3,4). Despite this, the existing literature of NVB in cirrhosis is less robust (few prospective studies with no differentiation between compensated and decompensated cirrhosis).
Aims & Methods
Aim: To compare outcomes between VB and NVB among patients with cirrhosis and between NVB patients with (compensated and decompensated) and without cirrhosis. Therefore, we sought to explore predictors of mortality in NVB patients.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’(2013-2020).
VB was defined as esophageal or gastric varices as source of bleeding. NVB was defined as all other etiology(including portal-hypertensive gastropathy)
Patients with a Child-Pugh A and B(score 5-9) have compensated cirrhosis and those with class C cirrhosis(score 10-15) have decompensated cirrhosis.
The primary outcome of our study was in hospital and delayed mortality. Secondary outcomes included intervention, length of hospital stay, rebleeding and delayed UGIB.
Statistical analysis was performed by SPSS. Categorical variables were compared using χ2 test. Continuous variables using Student’s t-test or Mann-Whitney U-test. Multivariate logistic regression analysis was performed to identify independent risk factors for mortality.
Results
We included 1345 UGIB patients, 319 had cirrhosis, 190 VB (59.6%) and 129 NVB (40.4%). There were no differences in relevant outcomes between VB y NVB in cirrhosis except for need of endoscopy therapy (74.2% vs.41.4%, p<0.001)
In the whole cohort, 1139 where NVB: 1011 non-cirrhotic (88.8%), 129 cirrhotic (11.2%): 81 compensated and 21 decompensated (26 without information).
Main outcomes between non-cirrhotic and compensated/decompensated cirrhotic with NVB are shown in the table.
| Outcomes | Non-cirrhotic | Compensated | Descompensated | p |
| Reebleding | 9% | 7.4% | 23.8% | 0.047 (for descompensated) |
| Nº RBC | 2.6 | 2.88 | 5.33 | 0.034 (for descompensated) |
| Endoscopy therapy | 39.1% | 37.5% | 52.4% | n.s (0.443) |
| Surgery | 4.8% | 1.2% | 0% | n.s (0.203) |
| Interventional radiology | 1.1% | 1.2% | 0% | n.s (0.883) |
| Lenght hospital stay | 8.59 | 8.55 | 12.33 | 0.022 (for descompensated) |
| In-hospital mortality | 7.2% | 13% | 45% | <0.001 (for descompensated) |
| Delayed-6months UGIB | 6.1% | 10.8% | 11.1% | n.s. (0.210) |
| Delayed-6months mortality | 8.8% | 18.5% | 14.3% | 0.013 (for compensated) |
Independent risk factors for in-hospital mortality were age (HR 1.08,95%CI 1.01-1.61,p=0.049), misbalance of chronic condition (HR 11.33,95%CI 2.26-56.71,p=0.003) and Child-Pugh score (HR 1.88,95%CI 1.18-2.99,p=0.008).
Conclusion
In our study we show that, at the end, prognosis depends on basal status, namely being compensated or decompensated, and is not only about have or not to have cirrhosis or about VB or NVB. Patients with decompensated cirrhosis have worse outcomes in terms of higher rates of rebleeding, number of packet blood cell transfused, length of hospital stay and in-hospital mortality. After performed multivariate analysis, Child-Pugh score remains as an independent risk factor for mortality, indicating that liver function deterioration marks the evolution.
References
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- Rudler M, Rousseau G, Benosman H, Massard J, Deforges L, Lebray P, Poynard T, Thabut D. Peptic ulcer bleeding in patients with or without cirrhosis: different diseases but the same prognosis? Aliment Pharmacol Ther. 2012 Jul;36(2):166-72.
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