Original article
Alimentary tract
Outcomes and Role of Urgent Endoscopy in High-Risk Patients With Acute Nonvariceal Gastrointestinal Bleeding

https://doi.org/10.1016/j.cgh.2017.06.029Get rights and content

Background & Aims

We investigated clinical outcomes in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), and determined if urgent endoscopy is effective.

Methods

Consecutive patients with a Glasgow–Blatchford score greater than 7 who underwent endoscopy for acute nonvariceal UGIB at the emergency department from January 1, 2005, to December 31, 2014, were included. Urgent (<6 h) and elective (6–48 h) endoscopies were defined according to the time to endoscopy after the initial presentation. The primary outcomes were mortality and rebleeding within 28 days of admission.

Results

Among 961 patients, 571 patients underwent urgent endoscopy. The 28-day mortality rate was 2.5%, and the rebleeding rate was 10.4%. There were significant differences in mortality rate (1.6% vs 3.8%), the number of transfused packed red blood cells (2.6 ± 2.5 vs 2.3 ± 2.1 packs), need for intervention (69.5% vs 53.5%), and embolization (2.8% vs 0.5%), but no differences in rebleeding, intensive care unit admission, vasopressor use, and length of stay between the urgent and elective endoscopy groups. Mortality was associated with malignancy (odds ratio [OR], 3.58; 95% confidence interval [CI], 1.33–9.62), cirrhosis (OR, 4.67; 95% CI, 1.85–11.76), urgent endoscopy (OR, 0.36; 95% CI, 0.14–0.95), failed primary endoscopic treatment (OR, 15.03; 95% CI, 4.63–48.82), and rebleeding (OR, 2.77; 95% CI, 1.03–7.45). Rebleeding was associated with Forrest I ulcers (OR, 7.67; 95% CI, 2.71–21.69), Forrest II ulcers (OR, 2.34; 95% CI, 1.51–3.60), and coagulopathy (OR, 2.34; 95% CI, 1.51–3.60).

Conclusions

Urgent endoscopy was an independent predictor of lower mortality rate but was not associated with rebleeding in high-risk patients with acute nonvariceal UGIB.

Section snippets

Patient Selection

From January 1, 2005, to December 31, 2014, we included consecutive high-risk patients aged 18 years and older who underwent endoscopy for coffee-ground emesis, hematemesis, or melena, at the ED of a tertiary care center. High-risk patients were defined as those with a GBS greater than 7 at the initial ED presentation. Patients who had a GBS of 7 or less at ED presentation did not undergo endoscopy within 48 hours, and patients who had variceal bleeding, were transferred from other hospitals,

Patient Characteristics

A total of 961 patients were included. Table 1 shows the patient characteristics. Of the total patients, 571 (59.4%) underwent urgent endoscopy. Patients who underwent urgent endoscopy were older than patients who underwent elective endoscopy (58.3 ± 14.8 vs 55.2 ± 15.1 y; P = .001). Malignancy and cirrhosis were observed in 26.8% and 15.0% of patients, respectively; these comorbidities were not different between groups. Gastrointestinal cancer was the most common malignancy observed (in 195

Discussion

In this study, 28-day mortality was observed in 2.5% and rebleeding was detected in 10.4% of patients. Notably, urgent endoscopy was associated strongly with a lower mortality rate for high-risk patients. Approximately 60% of high-risk patients underwent urgent endoscopy. The urgent endoscopy group was more unstable hemodynamically with a higher incidence of shock, although there was no difference in GBS between groups. Nevertheless, the rebleeding rate was not different between groups, and the

Acknowledgments

The authors express their sincere gratitude to gastroenterologists Drs Hwoon-Yong Jung, Gin Hyug Lee, Ho June Song, Kee Don Choi, Do Hoon Kim, and Ji Yong Ahn for their tireless dedication and availability 24 hours a day, 7 days per week for the endoscopic procedures.

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    Conflicts of interest The authors disclose no conflicts.

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