Introduction

Non-variceal upper gastrointestinal bleeding (nvUGIB) mortality has improved but remains high. Guidelines on nvUGIB often focusing on pre- and endoscopic management. However, more data on causes of death are needed, because non-bleeding specific mortality is unlikely to be improved by interventional advances.

Aims & Methods

The aims of this retrospective analysis of a single tertiary center registry of patients with nvUGIB were to assess causes of death in patients with nvUGIB and characterize this cohort. All hospitalized patients evaluated for suspected non-variceal UGIB (i.e., patients undergoing endoscopy) at our endoscopy unit between January 2018 and October 2020, either due to presentation for nvUGIB or with a suspected bleeding episode during hospitalization for any reason, were included in a prospective registry. Data on pre-endoscopic signs/symptoms of UGIB, epidemiological data, laboratory values, and medications were extracted from the electronic health record. Endoscopy reports were individually searched and relevant data including the most likely culprit lesion in the opinion of the endoscopist as well as respective hemostatic treatment extracted.

Results

Among 1135 patients – 41.7% women, mean age 70.4 (±15.7) years, median length of stay 8 (IQR 4;16) days – 92 (8.1%) died during hospitalization and were further analyzed. Mean age was 73.2 (±12.9) years, 44.5% were women, 36% of patients were on anticoagulation, 27% on antiplatelet therapy, and 9% on both. The median Charlson comorbidity index was 5 (IQR 3;6.8), the CHA2DS2-VASc-Score 3 (IQR 2;5). However, the median AIMS65 score was only 2 (IQR 1;2). Median time from admission to death was 17 (IQR 6.5;30) and from endoscopy to death 11 (IQR 4;21.5) days. The most common sources of bleeding as determined by endoscopy reports were: uncertain (24%), peptic ulcer (21%), esophagitis (14%), and non-peptic ulcers (9%). Adherence to guideline-based endoscopic peptic ulcer management recommendations was 70%. Radiological intervention for bleeding was performed in 1%, surgical intervention in 8.7%. Patients who died were older (73.2 vs. 70 years, p=0.0336), had lower hemoglobin nadirs (7.1 vs. 7.8 g/dL, p<0.0001), high c-reactive protein levels (p<0.0001) and creatinine (p<0.01), had longer lengths of stay (LOS) (median LOS 17 vs. 8 days, p<0.0001), and longer times from admission to endoscopy (median 3 days vs. 1 day, p<0.0001). However, sex was not associated with mortality (p=0.58). Looking at bleeding in association with causes of death, mostly (n=55, 59.8%), bleeding was categorized as a bystander. Only 32.6% of causes of death were judged as directly due to or likely associated with the bleeding episode, and these patients had a higher AIMS65 (p=0.0301). Only 12% died due to an unmanageable bleeding (or change to best supportive care). Overall, the following major groups of causes of death were identified: malignancy (18.5%), multi-organ failure (17.4%), infection/sepsis (15.2%), bleeding-associated (15.2%), cardiovascular (13.0%), and others (23.9%).

Conclusion

UGIB mortality remains relatively high despite management advances. However, only a minority of patients die due to UGIB and even among those most deaths are related to sequelae of the bleeding instead of unmanageable bleeding. Patients who die are older, likely sicker, and suffer from many comorbidities. Based on these data, it is uncertain whether focusing on endoscopic management improvements will significantly change UGIB-related mortality. Possibly, the focus should be shifted to improving general/internal medicine or geriatric care.

Introduction

Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common emergency with high morbidity and mortality. Lactate levels and comorbidity indices, such as the Charlson Comorbidity Index (CCI), have shown promise in predicting patient outcomes. While these parameters individually provide valuable prognostic insights, their collective utility in predicting mortality among NVUGIB patients has not been explored.

Aims & Methods

The data for this study were collected from hospital records of patients admitted to Hitit University Hospital with NVUGIB between June 2021 and June 2024.
Demographic information, including age, gender, chronic illnesses, current medications, and history of previous gastrointestinal bleeding, was retrieved from computer database. Clinical data, such as outcomes (discharge or death), reasons for mortality, length of hospital stay were documented. Laboratory parameters, including lactate levels were recorded. Additionally, CCI and Glasgow Blatchford Score (GBS) were calculated for each patient.
Patients were stratified based on mortality status, which was considered the primary outcome. The associations between mortality and potential predictive factors were statistically analyzed. To improve mortality prediction, parameters that were significant in the logistic regression analysis were combined and assessed independently.

Results

A total of 390 patients with acute upper gastrointestinal bleeding were initially assessed. Of these, 180 patients were excluded due to missing data, leaving 210 patients included in the final study cohort. Key variables such as age, CCI, GBS, length of hospital stay, and mortality status were presented. Laboratory findings upon admission and the etiological distribution of gastrointestinal bleeding sources were also detailed.
Variables significantly associated with mortality in the univariate analysis include age, CCI, GBS, urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and lactate levels. In the logistic regression analysis, significant predictors of mortality were CCI (OR: 1.318, p=0.001) and lactate levels (OR: 1.575, p=0.003). GBS was not a predictor for mortality (p=0.468). CCI plus lactate levels were significantly higher in deceased patients compared to survivors (12.96 vs.7.31, p<0.001).
The correlation coefficients (r) showed significant positive correlations between the combination of lactate levels and CCI with GBS (r=0.498, p<0.001), length of stay (r=0.213, p=0.014), age (r=0.634, p<0.001) and urea levels (r=0.417, p<0.001). No significant correlation was found with AST or ALT.
ROC curves for lactate levels, CCI and CCI plus lactate levels predicting mortality showed that the area under the curve (AUC) for lactate was 0.704 (95% CI: 0.577–0.830, p=0.002) with a cut-off value of 1.83, yielding a sensitivity of 76% and a specificity of 52%. For CCI, the AUC was 0.769 (95% CI: 0.670–0.869, p<0.001) with a cut-off value of 6.5, showing a sensitivity of 76% and a specificity of 70%. And for the ‘CCI plus lactate’ level, the AUC was higher as 0.799 (95% CI: 0.703–0.895, p<0.001) with a cut-off value of 8.3, showing a sensitivity of 88% and a specificity of 62%.

Conclusion

Both lactate levels and the CCI are valuable tools for predicting mortality in NVUGIB patients. Our findings support the use of these parameters collectively to improve risk stratification. Combining lactate levels and CCI offers the advantage of better predicting mortality and improving sensitivity compared to using lactate levels or CCI alone.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.

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.

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

1. Farooq U, Tarar ZI, Franco D, Kamal F, Abegunde AT. Comparison of outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis: Insights from a Nationwide Inpatient Sample. Ann Gastroenterol. 2022 Nov-Dec;35(6):618-626.
2. Ardevol A, Ibañez-Sanz G, Profitos J, Aracil C, Castellvi JM, Alvarado E, Cachero A, Horta D, Miñana J, Gomez-Pastrana B, Pavel O, Dueñas E, Casas M, Planella M, Castellote J, Villanueva C. Survival of patients with cirrhosis and acute peptic ulcer bleeding compared with variceal bleeding using current first-line therapies. Hepatology. 2018 Apr;67(4):1458-1471.
3. 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.
4. Lecleire S, Di Fiore F, Merle V, Hervé S, Duhamel C, Rudelli A, Nousbaum JB, Amouretti M, Dupas JL, Gouerou H, Czernichow P, Lerebours E. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol. 2005 Apr;39(4):321-7.

Introduction

Non-variceal upper gastrointestinal bleeding can usually be controlled endoscopically; however, if endoscopic hemostasis fails, it can pose a life-threatening risk. Trans-arterial embolization is a less invasive, safe, and effective rescue therapy that can serve as an alternative to surgery. Identifying factors influencing rebleeding after trans-arterial embolization in advance could lead to more efficient and safer patient management. Therefore, we aim to investigate these factors.

Aims & Methods

We retrospectively investigated 167 patients treated with TAE between January 2008 and June 2023. All patients underwent emergent endoscopy prior to TAE. Re-bleeding was defined as the presence of melena, hematemesis, or hematochezia with a fall in hemoglobin levels (> 0.8 g/dl) or shock after TAE. The primary outcomes was 30-day re-bleeding rate.

Results

Total of 104 patients with non-variceal upper gastrointestinal bleeding were selected. Re-bleeding within a month after TAE was noted in 24 patients (23.1%). Patients with re-bleeding had significantly higher rates of thrombocytopenia (50.0% vs. 15.0%, p= 0.001) and coagulopathy (20.8% vs. 5.0%, p= 0.045) than those without re-bleeding. Additionally, 7-day mortality (16.7% vs. 2.5%, p=0.035), AIMS65 score (2.0 vs. 1.0, p=0.029), and ABC score (7.0 vs. 4.0, p=0.002) were significantly elevated in patients with re-bleeding. A multivariate logistic analysis showed thrombocytopenia (odds ratio: 5.44, 95% confidence interval: 1.84–16.92, p= 0.002) and an ABC score ≥ 6 (odds ratio: 2.87, 95% confidence interval: 1.02–8.66, p= 0.005) significantly increased the risk of re-bleeding after TAE.

Conclusion

TAE could be an effective and safe treatment for non-variceal upper gastrointestinal bleeding. However, thrombocytopenia and elevated ABC scores might be associated with a higher 30-day rebleeding rate after TAE. Therefore, patients with these risk factors should be carefully monitored and managed.

Introduction

Upper digestive hemorrhage (HDH) is a frequent reason for hospitalization in the emergency department. Schematically, they are divided into HDH of varicose origin and HDH of non-varicose origin.
Upper GI endoscopy must be performed as quickly as possible, under the best possible technical conditions.
The objective of our study is to evaluate the hemostatic endoscopic management of these hemorrhages in the emergency department.

Aims & Methods

This is a retrospective descriptive study covering a period of 26 months, from January 2022 to March 2024, and including all patients admitted in an emergency for upper digestive haemorrhage of non-variceal origin, identified during the endoscopy on-call duty at the "Médecine B" Hepato-gastroenterology and Proctology Department, CHU Ibn Sina.
All patients underwent clinical examination, blood count and oeso-gastro-duodenal fibroscopy (FOGD).
Patients admitted for HDH of varicose origin or with normal FOGD were excluded from our study.

Results

91 cases of HDH of non-varicose origin were diagnosed out of a total of 225 cases of HDH consulting the emergency department, with a prevalence of 40.44%.
The mean age of our patients was 54.8 years (20-84 years), with a male predominance of 70.3% and a sex ratio of M/F : 2.3.
11 patients (12.08%) had a history of smoking, 11 (12.08%) had heart disease on anticoagulants, 10 (11%) had taken NSAIDs, 8 (8.79%) had nephropathy at the hemodialysis stage, and 7 (8%) were hypertensive.
The mode of externalization of HDH was melena associated with hematemesis in 26 patients (28.6%), isolated melena in 44 (48.4%), hematemesis in 16 (17.6%) and rectal discharge in 5 (5.5%).
The main etiologies of HDH of non-varicose origin revealed by FOGD were: gastro-duodenal ulcer in 73 patients (80.2%), with Forrest Ib ulcer in 9 (12.3%), Forrest IIa in 4(5.4%), Forrest IIb in 4(5.4%), Forrest IIc in 13(17.8%) and Forrest III in 43(59%).
Of the 91 patients, 15(16.48%) had esophagitis, 5(5.5%) had gastric process, 1(1.09%) had duodenal process and 8 patients (8.8%) had angiodysplasia lesions.
All patients were treated with a loading dose of injectable PPI, followed by a maintenance dose.
Endoscopic haemostasis was required in 19 patients (20.8%), of whom 8 (8.7%) benefited from injection of adrenaline serum and placement of haemostatic clips, 2 patients (2.2%) from exclusive injection of adrenaline serum, 8 patients (8.7%) from exclusive placement of haemostatic clips and one patient (1.09%) benefited from per-endoscopic surgical suturing.
The mortality rate in our study was 3.2%.

Conclusion

HDH of non-varicose origin remains dominated by ulcerative origin. Impregnation with PPIs prior to FOGD and the possibility of endoscopic haemostasis reduce the mortality rate.