Management of upper gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis: a prospective, multicenter, observational study

Abstract

BackgroundUpper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective.We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes.MethodThis was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included.ResultsIn total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs.ConclusionMost of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-017-0425-6) contains supplementary material, which is available to authorized users.

Profile and Outcome of Patients with Upper Gastrointestinal Bleeding Presenting to Urban Emergency Departments of Tertiary Hospitals in Tanzania

“…We observed that age above 40 years was an independent predictor of mortality. This has also been noted in prior studies both in HIC and LMIC [1,5,13,14].…”

“…within 24 h of ED presentation. Compared with studies from HIC, patients in our study were of younger age, with the median age being 42 years [1,13,14,22]. We observed that age above 40 years was an independent predictor of mortality.…”

“…Similarly, the Glasgow-Blatchford among patients in our study was much higher compared to a British study carried out between the years 2008-2009, where the majority of patients had a GBS score ≤ 2 [24]. Severe anemia (Hb < 8 g/dl) was observed in over a half of our patients while in studies conducted in HIC, less than one-third of the patients had a Hb count suggestive of severe anemia [13,14,25].…”

“…The mortality observed in our study is much higher compared to developed countries [1,13,14]. Factors contributing to the high observed mortality rate include; higher disease severity, disposition status and gaps in management of these patients.…”

“…Rather than being due to alcoholic liver disease as in high income countries (HIC's), varices in sub-Saharan Africa result from Schistosoma-related portal hypertension [5,8,12]. This is in contrast to HIC where erosive gastritis has been commonly implicated [1,13,14]. Other potential contributors to the higher mortality may be the severity of disease presentation, as there is little primary care in these settings, and many patients seek care very late in their disease.…”