Introduction

Several scoring systems have been established to identify upper gastrointestinal bleeding (UGIB) patients at high risk of adverse outcomes. Recently, focus have been posed in the Shock Index since the NCEPOD reported this use to assess bleeding severity and found an association with mortality. Moreover, they report that there was inconsistent use of recognized scoring systems in their examined cases of upper GI bleeding and postulated their use (1).
After this, Stanley and colleagues examine the performance of SI in comparisons with preexisting scores predicting UGIB outcomes in a cohort of 3012 patients and reported that SI was inferior to existing pre‐endoscopy scores (2). Recently, other study positioned SI as the best ones to predict 30, 180 and 360-day mortality in UGIB patients over 65 years, generating the controversy (3).
We aim to compare the performance of SI versus previous scores and versus traditional vital constants to predict outcomes in UGIB.

Aims & Methods

We aim to compare the performance of SI versus previous scores and versus traditional vital constants to predict outcomes in UGIB.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’ between 2013-2020.
Main outcomes were intervention (a composite endpoint including need of transfusion, endoscopy therapy, interventional radiology or surgery) and in-hospital mortality.
Scores calculated were SI, MAP(ASH), ABC, Glasgow-Blatchford score (GBS), AIMS65 and Rockall score. We also included pulse and blood pressure (BP) in the comparison.
MedCalc was used to calculate ROC Curve of scores in determining outcomes.

Results

AUROCs are shown in the table. Comparisons of ROC curves for relevant outcomes show all the pre-existing scores superior to SI with statical difference. In relation to vital signs, only for intervention SI was superior to pulse with statical difference. For mortality, no differences were found between SI and vital signs.

AUROC (95%CI)	Need of intervention	In-hospital mortality
Pulse	0.538 (0.590 - 0.643)	0.618 (0.591 - 0.645)
Systolic Blood Pressure	0.645 (0.511 - 0.565)	0.587 (0.559 - 0.614)
Shock Index	0.626 (0.596 - 0.655)	0.612 (0.582 - 0.642)
MAP(ASH)	0.789 (0.764 - 0.813)	0.758 (0.731 - 0.784)
ABC	0.723 (0.695 - 0.749)	0.804 (0.779 - 0.828)
Glasgow-Blatchford score	0.780 (0.754 - 0.805)	0.708 (0.680 - 0.736)
AIMS65	0.682 (0.654 - 0.710)	0.738 (0.710 - 0.765)
Rockall score	0.760 (0.734 - 0.785)	0.743 (0.715 - 0.769)

Conclusion

In view of our results, we have to conclude, as Stanley et al. (2), that Shock Index is inferior to pre-existing scores in predicting outcomes in UGIB. In comparison to vital signs Shock Index not offer any advantages with the exception to pulse for intervention. Therefore, we maintain our previous recommendation (4) to use MAP(ASH), or failing that ABC, for predicting intervention and mortality in UGIB since it is easier to calculate with an excellent performance.

References

1. National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Time to Get Control? A review of the care received by patients who had a severe gastrointestinal haemorrhage. 2015. http://www.ncepod.org.uk/2015gih.html. Accessed May 10, 2017.
2. Saffouri E, Blackwell C, Laursen SB, Laine L, Dalton HR, Ngu J, Shultz M, Norton R, Stanley AJ. The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2020 Jan;51(2):253-260. doi: 10.1111/apt.15541. Epub 2019 Oct 23. PMID: 31642558.
3. Dogru U, Yuksel M, Ay MO, Kaya H, Ozdemır A, Isler Y, Bulut M. The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study. Sao Paulo Med J. 2022 Jul-Aug;140(4):531-539. doi: 10.1590/1516-3180.2021.0735.13102021. PMID: 35544884; PMCID: PMC9491474.
4. Jimenez-Rosales R, Lopez-Tobaruela JM, Lopez-Vico M, Ortega-Suazo EJ, Martinez-Cara JG, Redondo-Cerezo E. Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding. Journal of Clinical Medicine. 2023; 12(3):1085.

Introduction

Upper gastrointestinal bleeding(UGIB) is a common condition that entails morbidity and mortality. Therefore, an early prediction of negative outcomes would be clinically relevant selecting patients who might benefit from a closer follow up. In this way, several pre-endoscopic scoring systems have been developed for risk assessment in the emergency room(1).
One of the limitations of scoring systems is that sensitivity and specificity alone (usually combined in the receiver operator characteristic curve) may help comparing the accuracy of different systems but cannot be used to accurately estimate the probability for an individual patient. A more appropriate approach is to establish the post‐test probability considering the expected pre‐test probability of poor outcomes in the population(2).

Aims & Methods

Given the absence of previous similar studies in UGIB, we aim to investigate the role of the most common pre-endoscopy scoring systems in modifying the pre-test probability of adverse outcomes.
Retrospective analysis of a prospective registry of UGIB patients admitted to 'Virgen de las Nieves University Hospital' (2013-2024). The outcomes included were intervention (composite endpoint including need of transfusion, endoscopy therapy, interventional radiology or surgery) and in-hospital mortality.
Pre-endoscopy scores analyzed were MAPASH,ABC and GBS as they have demonstrated their utility in predicting adverse events. The thresholds used for the definition of low-risk patients(test negative) were ABC≤3,MAPASH≤2 and GBS≤1(3).
First, the prevalence of the main outcomes was calculated to obtain the pre‐test probability. Next, characteristics of different scoring systems were used to obtain the likelihood ratio(LR) and to estimate the post‐test probability using an online calculator (http://araw.mede.uic.edu/cgi-bin/testcalc.pl).

Results

1649 UGIB patients were included.
Prevalence of intervention(pre-test probability) was 75%.
The sensitivity and specificity of MAPASH were 71.4% and 78.4%,respectively. +LR and -LR 3.31 and 0.36,respectively. Post‐test probability was 91% when positive and 52% when negative.
The sensitivity and specificity of ABC were 68.1% and 66.8%,respectively. +LR and -LR 2.05 and 0.48,respectively. Post‐test probability was 86% when positive and 59% when negative.
The sensitivity and specificity of GBS were 98.8% and 8.7%,respectively. +LR and -LR 1.08 and 0.14,respectively. Post‐test probability was 76% when positive and 29% when negative.
Prevalence of in-hospital mortality(pre-test probability) was 11%.
The sensitivity and specificity of MAPASH were 90.1% and 44.8%, respectively. +LR and -LR 1.63 and 0.22,respectively. Post‐test probability was 17% when positive and 3% when negative.
The sensitivity and specificity of ABC were 95.9% and 44.8%,respectively. +LR and -LR 1.74 and 0.09,respectively. Post‐test probability was 18% when positive and 1% when negative.
The sensitivity and specificity of GBS were 99.4% and 3.6%,respectively. +LR and -LR 1.03 and 0.17, respectively. Post‐test probability was 11% when positive and 2% when negative.

Conclusion

While MAPASH and ABC effectively prioritize high-risk patients for intervention, their ability to rule out intervention in low-risk patients is limited. Additionally, they are more useful excluding mortality among low-risk patients than accurately predicting fatal outcomes. GBS,in contrast, are useful identifying low risk patients for intervention and mortality.
Given these findings, clinicians should interpret these scores with caution and incorporate additional clinical parameters into decision-making.

References

1. Boustany A, Alali AA, Almadi M, Martel M, Barkun AN. Pre-Endoscopic Scores Predicting Low-Risk Patients with Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. J Clin Med. 9 de agosto de 2023;12(16).
2. Capurso G, Ponz de Leon Pisani R, Lauri G, Archibugi L, Hegyi P, Papachristou GI, et al. Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta‐analysis with pre and post‐test probability assessment. United European Gastroenterol J. 27 de septiembre de 2023;11(9):825-36.
3. Jimenez-Rosales R, Lopez-Tobaruela JM, Lopez-Vico M, Ortega-Suazo EJ, Martinez-Cara JG, Redondo-Cerezo E. Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding. J Clin Med. 30 de enero de 203;12(3):1085.

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGI) represents a significant gastrointestinal disorder with elevated mortality rates (1). Non-steroidal anti-inflammatory drugs (NSAIDs) have been firmly established as a risk factor for NVUGI, yet their precise impact on clinical outcomes remains insufficiently defined (2,3). Conversely, proton pump inhibitors (PPIs) have shown efficacy in reducing the incidence of NVUGI associated with NSAIDs. However, the extent of their influence on the clinical outcomes of NVUGI remains inadequately substantiated. Therefore, it is necessary to study the impact of these drugs on the clinical outcomes of patients with NVUGI.

Aims & Methods

The primary objective of our study is to compare the outcomes of NVUGI patients using NSAIDs with or without PPIs against those who did not use either medication. We conducted a retrospective analysis at a Spanish tertiary hospital, encompassing NVUGI cases from 2013 to 2022. NVUGI was defined as hematemesis or melena accompanied by a two-point decrease in hemoglobin or hemodynamic instability. Key clinical outcomes included the necessity for intervention (endoscopic, radiological, or surgical) and in-hospital mortality. Additionally, we compared baseline characteristics and pertinent clinical results such as rebleeding and delayed cardiovascular events. Statistical analysis was performed using SPSS.

Results

​A total of 1200 cases were included, with 6.6% undergoing concomitant treatment with PPIs and NSAIDs, and 15.7% utilizing NSAIDs alone. Patients who took NSAIDs alone were younger (57 years vs. 66 in both other groups) and had a lower rate of comorbidities. Table 1 presents risk scores and outcome comparisons among the three groups. Statistical differences were observed, revealing lower acute mortality (9.6% vs. 7 vs. 2.8%, p=0.011) and reduced need for intervention (74% vs. 69.6 vs. 57.8%, p<0.001) in the group using NSAIDs alone. In multivariate analysis, MAP(ASH) > 2 (OR: 8, CI: 3-21, p<0.001) and ASA > 2 (OR: 4.4, CI: 1.7-11.4, p:0.002) emerged as independent risk factors for acute mortality, with an elevated MAP(ASH) score (OR: 8.8, CI: 5.9-13, p<0.001) being the sole independent factor explaining the need for intervention.

	Naive	NSAIDs and PPIs	NSAIDs without PPIs	P
ASA 3-4	596 (64,3%)	50 (63,3%)	63 (33,7%)	<0,001
MAPASH>2	448 (59,3%)	39 (65%)	52 (34,4)	<0,001
Need for intervention	691 (74%)	55 (69,6%)	108 (57,8%)	<0,001
Rebleeding	96 (10,3%)	9 (11,4%)	6 (3,2%)	0,008
Acute mortality	86 (9,6%)	5 (7%)	5 (2,8%)	0,011
Mortality at 6 months	77 (8,8%)	7 (9,3%)	7 (3,8%)	0,075
Delayed Cardiovascular event	77 (8,7%)	3 (3,9%)	4 (2,2%)	0,004
Delayed rebleeding	145 (16,4%)	15 (19,5%)	6 (3,3%)	<0,001

Conclusion

Patients abstaining from NSAIDs or those concurrently undergoing PPI therapy exhibited a higher incidence of intervention or acute mortality compared to those solely using NSAIDs. Through multivariate analysis, our study indicates that bleeding severity and baseline comorbidities, expressed by elevated MAP(ASH) scores and ASA classification, are pivotal factors influencing the clinical outcomes of NVUGI. In summary, the use of NSAIDs or PPIs to safeguard against gastrointestinal lesions induced by these drugs did not demonstrate a discernible impact on the short-term outcomes of patients with non-variceal upper gastrointestinal bleeding.

References

1. Lakatos L, Gonczi L, Lontai L, Izbeki F, Patai A, Racz I, et al. Incidence, predictive factors, clinical characteristics and outcome of non-variceal upper gastrointestinal bleeding – a prospective population-based study from hungary. Journal of Gastrointestinal and Liver Diseases. 2021 Sep 1;30(3):327–33.
2. Durak MB, Şimşek C, Yüksel İ. Clinical Outcomes of Older Patients with Non-Variceal Upper Gastrointestinal Bleeding Taking Anti-Thrombotic or Non-Steroidal Anti-Inflammatory Agents. Turkish Journal of Gastroenterology. 2023 Sep 1;34(9):918–24.
3. Åhsberg K, Höglund P, Kim WH, Von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol. 2010 Dec;45(12):1404–15.

Introduction

Several scoring systems have been established to identify upper gastrointestinal bleeding (UGIB) patients at high risk of adverse outcomes, being the best ones MAP (ASH) and ABC (1). Traditional scores(Glasgow-Blatchford, Rockall, AIMS65) were validated and compared mostly in nonvariceal-UGIB. On the contrary, MAP (ASH) and ABC included variceal bleed (VB) in their validation and comparison cohorts.
Also, to determine the prognosis of liver cirrhosis there are two frequently used scores, Child-Pugh score (CP) and MELD, and recently, ALBI score. Previous studies have reported the ability of these in predicting VB outcomes. A recent metanalysis show MELD and CP performed better predicting mortality than traditional scores (2). But there are no studies comparing liver scores with MAP (ASH) or ABC.

Aims & Methods

To compare the predictive value of MAP (ASH) and ABC scores vs. liver scores stratifying outcomes of VB.
Retrospective analysis of a prospective registry of UGIB patients admitted to ‘Virgen de las Nieves University Hospital’ (2013-2020). VB was defined as that coming from gastric or esophageal varices. Main outcomes were in-hospital (intervention,rebleeding, misbalance of chronic condition, mortality) and delayed-6months (UGIB, cardiovascular, mortality) ones. Intervention is a composite endpoint including need of transfusion, endoscopy therapy, interventional radiology or surgery. Statistical analysis was performed by SPSS and MedCalc.

Results

We included 1345 UGIB patients, 241 with VB, mean age 60.70+/-12.62, 26.1% females. Main differences between deaths and survivors were hepatocellular carcinoma, (57.1%vs.16.1%,p=0.001, OR 6.97,95%CI 2.28-21.34), misbalance of chronic condition (40.7% vs. 5.5%, p<0.001, OR 11.83,95 % CI 5.15-27.22), intervention (21.1% vs. 3%, p=0.013, OR 8.56,95 % CI 1.14-64.49), rebleeding (50%vs.12.7%, p<0.001, OR 6.88, 95% CI 3.12-15.20) and length hospital stay (15.91vs.9.23,p=0.031). In the multivariate analysis, misbalance of chronic condition was an independent risk factor for mortality (OR 4.23, 95 % CI 1.11-16.06, p=0.034).
Comparisons of ROC curves for relevant outcomes are shown in the table, with statiscal differences only for intervention (MAP(ASH) >CP, p=0.0195), misbalance of chronic condition (MAP(ASH) >ALBI, p=0.023; ABC > CP, p=0.020; ABC > ALBI, p=0.001) and delayed UGIB/liver mortality (MELD > Child, p=0.042).

AUROC (95%CI) Intervention	MAP(ASH) 0.744* (0.674 - 0.806)	ABC 0.701 (0.628 - 0.767)	MELD 0,622 (0,546 - 0.693)	Child-Pugh 0.582 (0.506 - 0.655)	ALBI 0.668 (0.594 - 0.737)
Rebleeding	0.553 (0.477 - 0.627)	0.522 (0.446 - 0.597)	0.602 (0.526 - 0.674)	0.546 (0.470 - 0.620)	0.543 (0.467 - 0.617)
Misbalance chronic condition	0.721* (0.649 - 0.785)	0.770* (0.702 - 0.830)	0.692 (0.619 - 0.759)	0.662 (0.587 - 0.730)	0.612 (0.536 - 0.684)
In-hospital mortality	0.678 (0.604 - 0.747)	0.677 (0.604 - 0.747)	0.734 (0.662 - 0.798)	0.741 (0.669 - 0.804)	0.677 (0.602 - 0.746)
UGIB in-hospital mortality	0.656 (0.568 - 0.736)	0.633 (0.545 - 0.714)	0.770 (0.689 - 0.838)	0.774 (0.694 - 0.842)	0.711 (0.626 - 0.786)
Other cause in-hospital mortality	0.751 (0.666 - 0.823)	0.762 (0.666 - 0.823)	0.696 (0.607 - 0.774)	0.722 (0.635 - 0.798)	0.638 (0.547 - 0.721)
Delayed cardiovascular events	0.634 (0.553 - 0.709)	0.534 (0.452 - 0.614)	0.566 (0.484 - 0.645)	0.588 (0.506 - 0.666)	0.658 (0.506 - 0.666)
Delayed UGIB	0.534 (0.453 - 0.615)	0.582 (0.501 - 0.660)	0.536 (0.455 - 0.616)	0.516 (0.434 - 0.596)	0.519 (0.437 - 0.599)
Delayed Mortality	0.581 (0.499 - 0.659)	0.683 (0.603 - 0.755)	0.555 (0.473 - 0.635)	0.617 (0.535 - 0.694)	0.676 (0.596 - 0.749)
Delayed UGIB and liver mortality	0.600 (0.340 - 0-824)	0.733 (0.468 - 0-914)	0.850* (0.596 - 0-974)	0.542 (0.289 - 0-780)	0.650 (0.386 - 0-860)

Conclusion

In our study, MAP (ASH) and ABC scores performed better at prediction intervention and misbalance of chronic condition. On the other hand, MELD is superior to CP in predicting delayed UGIB and liver mortality. None of them performs well in predicting rebleeding or other delayed outcomes. Although we see some differences in AUROCs for the other outcomes, no statical differences were found. Therefore, MAP (ASH) and ABC have a good performance not only in patients with UGIB but also in VB.
Independent risk factor for in-hospital mortality was misbalance of chronic condition, showing once again that it is not UGIB itself what determines the evolution if not the imbalance that it produces.

References

1. Jimenez-Rosales R, Lopez-Tobaruela JM, Lopez-Vico M, Ortega-Suazo EJ, Martinez-Cara JG, Redondo-Cerezo E. Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding. Journal of Clinical Medicine. 2023; 12(3):1085.
2. Yang L, Sun R, Wei N, Chen H. Systematic review and meta-analysis of risk scores in prediction for the clinical outcomes in patients with acute variceal bleeding. Ann Med. 2021 Dec;53(1):1806-1815.

Introduction

Antithrombotic drugs (AT) pose an increased risk of upper gastrointestinal bleeding (UGIB), and their discontinuation carries the risk of thromboembolic events, presenting a challenge for clinicians (1,2). Clinical practice guidelines advocate for a restrictive approach, recommending non-discontinuation and/or early reintroduction based on the drug and its indication (3).
Despite available literature, controversy persists regarding the outcomes of patients with UGIB on antithrombotic therapy, both in the short and long term, as well as the potential impact of drug discontinuation (4,5).

Aims & Methods

Aim:
To determine the impact of ATs on in-hospital and delayed outcomes. Also, to determine whether suspension and resumption influenced delayed outcomes.
Methods:
Prospective registry analysis of UGIB patients between 2013-2021. Anticoagulants and antiplatelets were classified as AT drugs. Outcomes examined included in-hospital mortality and delayed-6 months cardiovascular, bleeding and mortality events.

Results

1345 patients were included, with 21.7% on anticoagulants and 19.1% on antiplatelets.
Patients on ATs were older (73 vs. 59 years; p<0.0001) and had a higher rate of comorbidities, has longer delay of endoscopic performance (11±11h vs. 9.6±8h; p=0.027), with gastric erosions being more usual (14.2% vs.9.1%; p=0.006). Table shows main outcomes.

	Non-AT (n=839)	AT (n=506)	P	Aspirin (n=195)	Thienopyridine (n=29)	Double antiaggregating (n=24)	VKA (n=179)	NACO (n=49)
Endoscopy therapy	48.3%	38.5%	0.001	75 (38.5%)	12 (41.4%)	7 (29.2%)	62 (34.6%)	20 (40.8%)
Rescue therapy	6.1%	3.8%	0.083	8 (4.1%)	17 (58.6%)	0	4 (2.2%)	1 (2%)
Rebleeding	10.5%	9.7%	0.702	20 (10.3%)	1 (3.4%)	18 (75%)	12 (6.7%)	4 (8.2%)
Transfusion	56.3%	66.2%	0.000	127 (65.1%)	17 (58.6%)	0	115 (64.2%)	41 (83.7%)
In-hospital mortality	12%	8%	0.028	14 (7.2%)	0	1 (4.2%)	13 (7.3%)	1 (2%)
Delayed cardiovascular event	3.4%	13.7%	0.000	18 (9.2%)	5 (17.2%)	1 (4.2%)	31 (17.3%)	12 (24.5%)
Delayed hemorrhagic event	12.9%	22.9%	0.000	43 (22.1%)	5 (17.2%)	6 (25%)	41 (22.9%)	12 (24.5%)
Delayed mortality	6%	9.4%	0.034	17 (8.7%)	2 (6.9%)	2 (8.3%)	19 (10.6%)	4 (8.2%)

AT suspension <72h was associated with increased in-hospital mortality (14.9% vs. 2.3%; p=0.001), especially <24h (20.9% vs. 2.6%; p<0.0001).
Delayed mortality was higher in patients on ATs who suspended them more than 7 days (17% vs.8.7%; p= 0.033), with no differences when last <72h. Suspension/reintroduction have no effect on other delayed outcomes.
Multivariate analysis identified ASA≥3 (HR 12.20;95%CI 3.69-56-92; p<0.001), disseminated malignancy (HR 4.73; 95%CI 1.92-11.42; p=0.001) and rebleeding (HR 19.25; 95%CI 9.07-43.04) as independent risk factors for in-hospital mortality, with AT therapy (HR 0.27; 95%CI 0.13-0.55; p<0.001), NSAIDS (HR 0.26; 95%CI 0.07-0.75; p=0.023), endoscopic therapy (HR 0.49; 95%CI 0.24-0.96; p=0.040) and hemoglobin levels being protectives factors HR 0.80; 95%CI 0.69.0.93; p=0.004).
Logistic regression analysis for delayed mortality showed that age (HR 1.04; 95%CI 1.02-1.07; p=0.001), disseminated malignancy (HR 3.49; 95%CI 1.81-7.86; p=0.004), esophageal varices HR 3.34; 95%CI 1.62-6-64; p=0.001), ischemic heart disease (HR 2.44; 95%CI 1.10-5.19; p=0.023) and a being an inpatient (HR 1.92; 95%CI 1.00-3.98; p=0.042) were independent risk factors for the outcome.

Conclusion

Despite increased comorbidities and older age, patients with AUGIB on ATs had lower in-hospital mortality, with no differences in other relevant outcomes. In fact, our results suggest that AT treatment provides a survival benefit, possibly related to a higher risk of bleeding in milder lesions.
Regarding delayed mortality, it was higher in patients on AT, determined by the comorbidity leading to their prescription.
Interestingly, early resumption of AT was associated with higher in-hospital mortality, while reintroduction after 7 days increased delayed one.

References

1. Lanas A, Carrera-Lasfuentes P, Arguedas Y, et al. Risk of upper and lower gastrointestinal bleeding in patients taking nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. Clin Gastroenterol Hepatol 2015;13:906-12 e2.
2. Chan FK, Leung Ki EL, Wong GL, et al. Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal Hemorrhage. Gastroenterology 2016;151:271-7.
3. Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021;53:300-332.
4. Dunne PDJ, Laursen SB, Laine L, et al. Previous Use of Antithrombotic Agents Reduces Mortality and Length of Hospital Stay in Patients With High-risk Upper Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2019;17:440-447 e2.
5. Marmo R, Occhipinti V, Zullo A, et al. Improved Survival for Patients With Acute Upper Gastrointestinal Bleeding While on Antithrombotic Therapy: A Multicenter Prospective Cohort Study. J Clin Gastroenterol 2023;57:278-284.

Introduction

In patients with upper gastrointestinal bleeding (UGIB), the European Society of Gastrointestinal Endoscopy (ESGE) recommends adopting the following definitions regarding the timing of upper GI endoscopy: urgent (6-12h), early (≤24h), and delayed (>24h) (1). There is no consensus definition of emergent endoscopy, but previous publications use the timeline of <6h (2).
Early endoscopy is associated with better outcomes, and guidelines suggest that it should be performed within this time frame (1).
Last ESGE guideline about variceal bleeding (VB) suggests performing urgent endoscopy in this context (3). This is based on a meta-analysis showing lower overall mortality when endoscopy was performed <12h compared to >12h (4). Surprisingly, ESGE concludes that the optimal timing in this setting is controversial due to a lack of high-level evidence. In fact, except for this study, all the others examining this aspect show that performing endoscopy before 12h does not provide benefits (5,6).

Aims & Methods

We aim to compare whether urgent endoscopy (6-12h) provides benefits to VB and explore predictors for mortality.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to 'Virgen de las Nieves University Hospital' (2013-2020). VB was defined as that coming from gastric or esophageal varices. Endoscopy timings were defined according to ESGE: emergent (<6h), urgent (6-12h), early (≤24h) and delayed (>24h) (1).
Main outcomes were in-hospital (endoscopy therapy, transfusion, rebleeding, misbalance of chronic condition, hospital stay, and mortality) and delayed-6 months (bleeding, cardiovascular events, mortality). Statistical analysis was performed using SPSS.

Results

1459 UGIB patients were collected, 216 with VB.
Statistical differences in main outcomes are shown in Table 1 (each letter in the subscript denotes column proportions that do not differ significantly from each other). No differences were found for the other outcomes.

Timing (% patients)	<6h (39.7%)	6-12h (28.8%)	12-24h (17.4%)	24h (2.7%)	p
Endoscopy therapy	85.1% a	63.5% b	65.8% b	66.7% b	0.014
Misbalance of chronic condition	48.3% a	30.2% b	23.7% b	50% a	0.026
Rebleeding	22.1% a	7.9% b	7.9% b	16.7% a	0.037
In-hospital mortality	27.4% a	13.6% b	11.1% b	50% a	0.025

We also compared basal characteristics and found differences in MAP(ASH) score≥2 (92.3% vs. 66.7% vs. 77.4% vs. 75%; p=0.003) and GBS≥12 (69% vs. 44.4% vs. 52.6% vs. 83.3%; p= 0.011).
Independent risk factors for in-hospital mortality were MAP(ASH)≥2 (1.26, 95% CI 1.03-1.54), misbalance of chronic condition (OR 9.92, 95% CI 3.56-27.61, p=0.000), and rebleeding (OR 3.95, 95% CI 1.45-10.79, p=0.007). The timing of endoscopy performing was not an independent prognostic factor for mortality.
We also conducted subgroup analysis to assess whether performing endoscopy before 12h provides benefits in other UGIB patients, without finding differences for patients with non-variceal bleeding or in those at higher risk of poor outcomes (GBS≥12, MAP(ASH)≥2, ASA≥3).

Conclusion

Our study highlights, in line with the majority of available ones (5,6), that endoscopy before 12h does not provide a benefit in patients with VB. This necessitates a reconsideration of the ESGE recommendation. Patients with endoscopy performed before 6 or after 24h have poor outcomes. However, multivariate analysis shows that the timing of endoscopy is not an independent prognostic factor for mortality. On the other hand, the decompensation of basal chronic disease and the severity of bleeding (determined by MAP(ASH) and rebleeding) are the determinants of patient outcomes.

References

1. Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332.
2. Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 2017 May;85(5):936-944.e3.
3. Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al.. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Nov;54(11):1094-1120.
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Introduction

Alcohol abuse is a significant risk factor for the development of hepatic cirrhosis, which can lead to upper gastrointestinal bleeding. In non-cirrhotic patients, alcohol has been studied as a risk factor for non-variceal upper gastrointestinal bleeding (NVUGI), particularly in cases of peptic ulcer bleeding (1). However, the clinical impact of alcohol abuse on outcomes remains unclear. Only one retrospective study has analyzed this, finding an increased risk of rebleeding and non-significant increased mortality among alcohol consumers (2). Nevertheless, this study included cirrhotic patients, who accounted for most of the mortality. There is currently no available data on the impact of alcohol on NVUGI outcomes in non-cirrhotic patients.

Aims & Methods

This study aims to determine the impact of alcohol consumption on clinical outcomes in NVUGI.
We conducted a retrospective analysis at a Spanish tertiary hospital, encompassing NVUGI cases from 2013 to 2022. Alcohol abuse was defined as daily alcohol intake exceeding 20g. Key clinical outcomes included the need for intervention (transfusion, endoscopic, radiological, or surgical) and in-hospital mortality. In addition, we compared baseline characteristics and assessed both acute and delayed 6 months outcomes, including rebleeding and delayed cardiovascular events. Statistical analysis was performed using SPSS.

Results

A total of 892 cases were included. The alcohol abuse group had a higher proportion of men (95.6% vs. 64.1%, p < 0.001) and were younger (median age of 56 years vs. 66 years, p < 0.001). Non-alcohol consumers had more comorbidities and a higher ASA comorbidity risk score (58% had ASA 3 or 4 vs. 46% in the other group, p = 0.015). Additionally, the MAP(ASH) score was higher in the first group (>2 in 54.5% vs. 46.3%, p = 0.030). We did not find any other differences between groups, neither in key outcomes nor in the remaining comparisons for the acute episode. However, delayed mortality (8,2% in group 1 vs 3,1% in group 2, p=0,046) and six months cardiovascular events (8,9% vs 2,3%, p=0,011) were more frequent in the non-alcohol group. In multivariate analysis, only ASA 3-4 (OR: 4.17, CI: 1.49-11.68, p= 0.006) and MAP(ASH) (OR: 7.61, CI: 2.54-22.8, p < 0.001) were found to be independent risk factors for acute mortality.

	No Alcohol	Alcohol	p
Age	66,75	56,88	<0,001
Sex	Men 464 (61,4%)	Men 130 (95,6%)	<0,001
Chronic obstructive pulmonary disease	75 (9,9%)	13 (9,6%)	0,896
Chronic renal disease	126 (16,7%)	6 (4,4%)	<0,001
Heart faliure	91 (12%)	6(4,4%)	0,009
High blood pressure	368(48,7%)	52 (38,2%)	0,071
Diabetes mellitus	182 (24,1%)	19 (14%)	0,009
Smooking	95 (12,6%)	69 (50,7%)	<0,001
MAPASH >2	334 (54,5%)	49 (43,4%)	0,030

Conclusion

Alcohol abuse is more common among younger individuals with fewer comorbidities. This consumption does not worsen clinical outcomes in non-cirrhotic NVUGI patients, with similar rates of need for intervention or mortality. Our results indicate that only comorbidities and bleeding severity (summarized as high ASA score and MAP(ASH)) score influence the outcomes. In summary, while alcohol consumption may increase the risk of NVUGI incidence, it does not impact acute outcomes.

References

1. Kelly JP, Kaufman DW, Koff RS, Laszlo A, Wiholm BE, Shapiro S. Alcohol consumption and the risk of major upper gastrointestinal bleeding. Am J Gastroenterol. 1995 Jul;90(7):1058-64.
2. Kärkkäinen JM, Miilunpohja S, Rantanen T, Koskela JM, Jyrkkä J, Hartikainen J, Paajanen H. Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding. Dig Dis Sci. 2015 Dec;60(12):3707-15