Introduction

Upper gastrointestinal bleeding (UGIB) continues to pose a significant threat to patients presenting at the emergency department, especially if the patients present with hemodynamic instability. There are still some uncertainties in the guidelines about the stepwise assessment and management for those patients before undergoing endoscopy.

Aims & Methods

Our study aims to report practice patterns to better understand the pre-endoscopic assessment for patients presenting with acute UGIB. This is an international online survey that included a prospective two-phase data collection. The distribution was conducted from April 2023 to November 2023. The target population was active physicians with clinical practices focusing on the management of patients with UGIB. Study data were collected and managed using Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey included four main sections (demographics and clinical practice, definition of hemodynamic instability, pre-endoscopy assessment, and optimal time for endoscopy) with a total of 33 relevant questions. The survey was endorsed by several national and international gastroenterology societies. The primary analysis was a descriptive assessment of individual survey response items in different domains. Descriptive statistics were reported as proportions. Secondary analysis evaluated differences in survey responses according to the years of clinical experience, type of practice location, and the estimated number of UGIB patients presented annually.

Results

In total, 533 clinicians completed our survey from 50 countries. Over half of the respondents work at university-based hospitals (54.6%) and have over 100 UGIB patients hospitalized annually (67.7%). In terms of clinical experience, 55.7% reported less than 10 years and 44.3% with more than 10 years. In 29.1% of the hospitals, there was no specific protocol or guideline for the initial assessment of patients with suspected UGIB, and in 44.7%, there were no emergency on-call interventional radiology services for such cases. Among the respondents, 39.6% do not use any risk stratification scores at the time of patient presentation. Both 0.9% saline (40.9%) and balanced crystalloid fluid (39.5%) were almost equally chosen as initial fluid resuscitation. However, the rate of fluid resuscitation was dependent on the hemodynamic status of 40.2% of the answers. In 40.7% of the answers, clinicians do not use any major hemorrhagic protocol for patients with severe ongoing bleeding and at risk of exsanguination. Prokinetics were generally little or never used prior to endoscopy in patients with UGIB (34.3%) or even in those with known gastric emptying problems (27.6%). The most chosen optimal time for endoscopy was within 24 hours for stable patients with non-variceal bleeding and within 12 hours for variceal bleeding. If patients were unstable but responding to resuscitation, the most chosen time was within 6 hours regardless of the source of bleeding and within 2 hours for those with persistent hemodynamic instability.

Conclusion

Adherence to international gastroenterology guidelines is low. There is a significant variability in different assessment approaches among respondents. Based on our data, the optimal time for endoscopy seems to be dependent on the hemodynamic status of patients with acute UGIB in both variceal and non-variceal bleeding. Our study highlights opportunities for improving consistency in reporting data and identifies potential areas for research.

Introduction

In Japan, more than ten years have passed since direct oral anticoagulants (DOACs) was released in 2011. The differences between DOACs and warfarin (VKA) have gradually become clearer, and many studies have been reported regarding the differences in gastrointestinal bleeding risk ^(1)(2)(3). However, there are few reports that examine the prevalence of gastric mucosal injury or ulcers rather than the risk of bleeding.

Aims & Methods

The aim of this study is to reveal the clinical features about patients with gastric ulcer taking anticoagulants (DOACs or VKA). This study is a retrospective cross-sectional study conducted in a single hospital. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2015 and December 2022. We focused on subjects who took anticoagulants (DOACs or VKA), and compared the prevalence of gastric ulcer between subjects taking DOAC and those taking VKA. Subjects taking anticoagulants were limited to those taking that anticoagulant as the only anti-thrombotic agents. This study was conducted separately for subjects taking antacids (P-CAB or PPI) and those not taking antacids (NO P-CAB, NO PPI and NO H2RA). Statistical analyses were performed by Fisher’s exact test.

Results

Of the 8,602 subjects analyzed, 522 subjects were taking anticoagulants, of which 103 were taking VKA (76 men, 27 women, mean age 73.1±12.0 years) and 297 were taking DOACs (205 men, 92 women, mean age 74.9±8.7 years). Among subjects taking DOACs, 33 subjects received Dabigatran, 93 received Edoxaban, 87 received Rivaroxaban, and 84 received Apixaban. The prevalence of gastric ulcer in subjects taking antacids was 6.7% (4/60) on VKA and 2.9% (5/170) on DOACs (p=0.24). The prevalence of gastric ulcer in subjects not taking antacids was 23.1% (9/39) on VKA and 5.4% (6/111) on DOACs (p=0.004).

Conclusion

Without concomitant use of antacids, subjects taking DOACs had a statistically significantly lower prevalence of gastric ulcers than those taking warfarin. These results suggest that DOACs are gentler on the gastric mucosa and user friendly than warfarin.

References

(1) Miller CS, et al. Clin Gastroenterol Hepatol. 15(11): 1674-1683, 2017
(2) Ray WA, et al. JAMA. 320(21): 2221-2230, 2018
(3) Ingason AB, et al. Ann Intern Med. 174(11): 1493-1502, 2021

Introduction

The optimal timing of endoscopy in acute upper gastrointestinal bleeding (AUGIB) management remains debated. We assessed time to endoscopy's impact on rebleeding and mortality based on patient characteristics and pre-endoscopic factors.

Aims & Methods

Data from 3,001 patients with AUGIB undergoing endoscopy within 48 hrs of referral from the prospective multicentre UK 2022 audit were analysed. Patients were categorised into 0-12 hrs, 12-24 hrs, and 24-48 hrs groups based on the time to endoscopy from referral. Regression analyses, adjusting for age, admission status (inpatient vs new admission), vital signs, symptoms, comorbidities, laboratory parameters, red blood cell transfusion, and pre-endoscopic management, assessed the association between endoscopy timing and rebleeding and mortality.

Results

Patients undergoing endoscopy within 0-12 hrs were younger, more likely to be haemodynamically unstable, and had a higher median Glasgow Blatchford Score (GBS) compared to those undergoing endoscopy in the 12-24 and 24-48 hrs groups. Despite a higher proportion receiving endotherapy (41% for the 0-12 hrs group, 28% for the 12-24 hrs group, and 17% for the 24-48 hrs group; p<0.001), the 0-12 hrs group had the highest rates of rebleeding (16%) and mortality (10%), compared to 9% rebleeding and 6% mortality in the 12-24 hrs group, and 7% rebleeding and 5% mortality in the 24-48 hrs group (p<0.001). The median length of stay was longer for the 0-12 hrs and the 24-48 hrs groups at 5 days, compared to 4 days in the 12-24 hrs group (p < 0.001). (see table)

Regression analysis indicated that, compared to the 12–24-hrs group, the 0–12 hrs group had higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69, p < 0.001), after adjusting for confounding variables. However, the 24–48 hrs group exhibited comparable odds of rebleeding (OR 0.93, 95% CI 0.60-1.45, p < 0.001) compared to the 12–24-hrs group. Regression analysis for mortality showed the 0-12 hrs group had higher odds of mortality compared to the 12-24 hrs group (OR 1.59, 95% CI 1.09-2.34, p = 0.001), while the 24-48 hrs group had similar odds of death (OR 0.74, 95% CI 0.43-1.23, p = 0.001).

Conclusion

The findings suggest a complex relationship between the timing of endoscopy and clinical outcomes in patients with AUGIB. Earlier endoscopy (0-12 hrs) may be associated with a higher risk of rebleeding, mortality and resource utilisation, while later endoscopy (24-48 hrs) may not be associated with increased adverse outcomes, but may lead to a longer hospital stay. Despite the initial severity of illness, early endoscopy may not translate to improved patient outcomes in AUGIB management. These results highlight the need for individualised management when determining the optimal timing of endoscopy in AUGIB.

Introduction

Upper gastrointestinal bleeding (UGIB) poses a significant threat in patients presenting to the emergency department, particularly in those with associated hemodynamic instability. Despite major advancements in medical and endoscopic therapeutic options, mortality rates have not shown a substantial decline over the years. This study aimed to assess clinical practice patterns in order to gain a clearer understanding of the pre-endoscopic assessment for patients with acute UGIB.

Aims & Methods

This study was an international online survey based on a prospective two-phase data collection approach, conducted between April 2023 and November 2023. The survey targeted practicing physicians actively involved in managing patients with UGIB. Data collection and management were performed through Research Electronic Data Capture (REDCap), an electronic data collection tool. The survey comprised four key domains: demographics and clinical practice, definitions of hemodynamic instability, pre-endoscopic assessment, and optimal timing of endoscopy, encompassing a total of 33 questions. The primary analysis provided a descriptive assessment of responses reported as proportions. Secondary analyses explored differences in responses based on years of clinical experience, practice setting, and the estimated annual number of UGIB cases encountered

Results

A total of 533 clinicians from 50 countries completed our survey. Among respondents, 54.6% work in university-based hospitals, and 67.7% reported managing over 100 UGIB patients annually. Regarding clinical experience, 55.7% have less than 10 years, with 44.3% with over 10 years of experience. Only 47.1% of respondents reported that their hospitals implement a triage system for UGIB patients. Additionally, 39.6% indicated that they do not use any risk stratification scores at the time of patient presentation. For initial fluid resuscitation, 0.9% saline (40.9%) and balanced crystalloid fluids (39.5%) were almost equally preferred. The rate of fluid resuscitation was reported to depend on the patient’s hemodynamic status by 40.2% of respondents. Most respondents indicated that hemodynamically unstable patients are primarily managed in the emergency department or intensive care unit. A total of 34.3% of respondents indicated that they do not routinely use prokinetics prior to endoscopy in UGIB patients, while 27.6% reported not commonly using them even in cases involving severe bleeding or known gastric emptying disorders. Proton pump inhibitors are administered prior to upper GI endoscopy in all cases by 70.4% of respondents, while vasoconstricting agents are used by 61% in cases of suspected variceal bleeding.

Conclusion

Our survey found considerable variability among respondents regarding the pre-endoscopic management of patients presenting with upper gastrointestinal hemorrhage. The overall adherence to international guidelines was low, which can potentially result in a significant negative impact on patient outcomes.

Introduction

Optimal timing of endoscopy in patients with acute variceal bleeding (AVB) remains unclear. Studies in patients with peptic ulcer bleeding (PUB) have indicated that urgent endoscopy <6 hours from presentation may be associated with worsened patient outcome. We aimed to analyse the association between timing of endoscopy and mortality in AVB.

Aims & Methods

Prospective multicenter cohort study based on data from the 2022UK Audit on Acute upper gastrointestinal bleeding. The association between timing of endoscopy and in-hospital mortality was evaluated using logistic regression analyses with adjustment for differences in patients’ characteristics and severity of bleeding.

Results

We included 401 AVB patients. Mean age was 58 years, 65% were males, 75% had known cirrhosis at time of presentation, mean Child-Pugh score was 8.2, 31% had other comorbidities, 13% had ongoing bleeding at time of endoscopy, 78% were treated with terlipressin, 75% were treated with antibiotics, and 12.6% died during hospital admission. Mortality rates were 22%, 17%, 11%, and 11% for patients undergoing endoscopy in the periods <6, <12, 6-24 and >24 hours from presentation. Patients undergoing endoscopy < 6 hours had lower blood pressure, higher heart rate, lower haemoglobin, and higher peak-lactate levels than patients undergoing later endoscopy (see table). However, even haemodynamically stable patients with systolic blood pressure above 100mmHg had high mortality rates (16%) when performing urgent endoscopy < 6 hours. When adjusting for differences in patients’ characteristics, and severity of bleeding, we did not find any association between timing of endoscopy and mortality (Odds ratio (95% confidence interval): 1.01 (0.99-1.03); p=0.17).

Table: Patient characteristics in relation to time of endoscopy (n=401)

Conclusion

AVB is associated with significant mortality, in particular in patients undergoing urgent endoscopy <6 hours from presentation, which may be explained by more severe bleeding. When taking differences in patients characteristics and severity of bleeding into consideration, endoscopy within 6-12 hours appears to be associated with similar outcomes to endoscopy undertaken 6-24 hours from presentation, despite less time to patient optimization before endoscopy. Thus, the association between timing of endoscopy and outcome may differ between patients with AVB and patients with PUB.

Disclosure

No conflicts of interest.