Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit
- Sarah A Hearnshaw1,
- Richard F A Logan2,
- Derek Lowe3,
- Simon P L Travis4,
- Mike F Murphy5,
- Kelvin R Palmer6
- 1Royal Victoria Infirmary, Newcastle upon Tyne, UK
- 2University of Nottingham, Nottingham, UK
- 3CEEU Royal College of Physicians of London, London, UK
- 4John Radcliffe Hospital, Oxford, UK
- 5NHS Blood and Transplant, Oxford, UK
- 6Western General Hospital, Edinburgh, UK
- Correspondence to Professor Richard F A Logan, Division of Epidemiology and Public Health, School of Community Health Sciences, University of Nottingham Medical School, Queen's Medical Centre, Nottingham NG7 2UH, UK;
Contributors Dr S Hearnshaw designed the study, ran the data collection, analysed the data and wrote the manuscript.
Mr D Lowe contributed to the design of the study, carried out the statistical analysis and co-wrote the manuscript.
Prof R Logan designed the study, advised on data analysis and contributed to the writing of the manuscript.
Dr S Travis contributed to the study design and writing of the manuscript.
Prof M Murphy designed the study and contributed to the writing of the manuscript.
Dr K Palmer designed the study, contributed to the writing of the manuscript and is the guarantor.
- Revised 27 October 2009
- Accepted 3 November 2009
- Published Online First 31 March 2010
Objectives To examine the use of endoscopy in the UK for acute upper gastrointestinal bleeding (AUGIB) and compare with published standards
To assess the organisation of endoscopy services for AUGIB in the UK
To examine the relationship between outcomes and out of hours (OOH) service provision.
Design Multi-centre cross sectional clinical audit.
Setting All UK hospitals accepting admissions with AUGIB.
Patients All adults (≥16 yrs) presenting with AUGIB between 1st May and 30th June 2007.
Data Collection A custom designed web-based reporting tool was used to collect data on patient characteristics, comorbidity and haemodynamic status at presentation to calculate the Rockall score, use and timing of endoscopy, treatment including endoscopic, rebleeding and in-hospital mortality. A mailed questionnaire was used to collect data on facilities and service organisation.
Results Data on 6750 patients (median age 68 years) were analysed from 208 hospitals. 74% underwent inpatient endoscopy; of these 50% took place within 24 h of presentation, 82% during normal working hours and 3% between midnight and 8 am. Of patients deemed high-risk (pre-endoscopy Rockall score ≥5) only 55% were endoscoped within 24 h and 14% waited ≥72 h for endoscopy. Lesions with a high risk of rebleeding were present in 28% of patients of whom 74% received endoscopic therapy. Further bleeding was evident in 13% and mortality in those endoscoped was 7.4% (95% CI 6.7% to 8.1%). In 52% of hospitals a consultant led out of hours (OOH) endoscopy rota existed; in these hospitals 20% of first endoscopies were performed OOH compared with 13% in those with no OOH rota and endoscopic therapy was more likely to be administered (25% vs 21% in hospitals with no OOH rota). The risk adjusted mortality ratio was higher (1.21, p=0.10, (95%CI 0.96 to 1.51)) in hospitals without such rotas.
Conclusions This audit has found continuing delays in performing endoscopy after AUGIB and underutilisation of standard endoscopic therapy particularly for variceal bleeding. In hospitals with a formal OOH endoscopy rota patients received earlier endoscopy, were more likely to receive endoscopic therapy and may have a lower mortality.
- gastrointestinal haemorrhage
- emergency medical services
- endoscopic procedures
Funding Dr S Hearnshaw was funded to conduct this study by NHS Blood and Transplant and the British Society of Gastroenterology. No participating hospitals were provided with funding.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.