Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study

Bjorkman, David J.; Zaman, Atif; Fennerty, M. Brian; Lieberman, David A.; DiSario, James A.; Guest-Warnick, Ginger

doi:10.1016/s0016-5107(04)01287-8

Cited by 180 publications

(105 citation statements)

References 28 publications

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“…The rebleeding rate observed in our patients (3.4%) was similar to that observed in the Italian PNED study (3.2%) and in other recent publications (17,18), but it was significantly lower than that reported in the Canadian RUGBE study (14.1%) (3,5,8). The divergence of our results from the ones of the Canadian study may be explained because a higher proportion of our patients received combined endoscopic therapy (adrenaline injection plus BICAP) than in the Canadian study; combined therapy has been shown to be superior to pharmacologic treatment for reduction of rebleeding in controlled trials (25)(26)(27). In addition, rebleeding was found to be an independent predictor of death in our study as equal as it has been described in other studies.…”

Section: Discussioncontrasting

confidence: 65%

Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding

González-González

Vázquez-Elizondo

García-Compeán

et al. 2011

Rev. esp. enferm. dig.

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Objective: to determine the independent predictors of in-hospital death of Hispanic patients with nonvariceal upper gastrointestinal bleeding (NVUGB).Experimental design: prospective and observational trial. Patients: in a period between 2000 and 2009, all patients with NVUGB admitted to our hospital were studied. Demographical and clinical characteristics, endoscopic findings and laboratory tests were evaluated. χ² and Mann-Whitney U analyses were performed for comparisons, and binary logistic regression was employed to identify independent predictors of in-hospital mortality.Results: 1,067 patients were included, 65% male with a mean age of 58.8 years. Mean number of comorbidities per patient was 1.6 ± 0.76. The most frequent cause of bleeding were gastric and duodenal ulcers (55.4%); 278 patients (25.8%) received endoscopic treatment of which 69.1% had combined therapy. Rebleeding occurred in 36 patients (3.4%) of which 50% died. Inhospital mortality was 10.2%, of which only 3.1% was associated to bleeding. When comparing causes of death among patients with and without comorbidities, only hypovolemic shock was found significative (48.3 vs. 25%; p = 0.020). Binary logistic regression found that the number of comorbidities, Rockall scale serum albumin < 2.6 g/dL on admission; rebleeding and length of hospital stay were independent risk factors of in-hospital mortality.Conclusion: the number of comorbidities, the Rockall scale score, an albumin level < 2.6 g/dL, the presence of rebleeding and hospital stay were predictors of in-hospital mortality in patients with UNVGB. INTRODUCTIONNon-variceal upper gastrointestinal bleeding (NVUGB) is a critical condition in which a mortality of 5 to 10% has been reported in different series of patients. This variability may be explained in part by the different clinical and demographic characteristics of the studied population (1,2). Recent prospective studies have identified different predictors of mortality; it is worth noting that the use of proton pump inhibitors (PPIs) significantly reduces mortality in patients both with and without high risk stigmata of rebleeding. Moreover, the use of endoscopic treatment has been demonstrated to reduce mortality in greater proportion than drug treatment (3-6). However, it has been shown that the risk factors, complications and mortality rates described in controlled trials are lower than those reported in patients who received their attention on "day-today conditions" in a tertiary care community hospital (7), which illustrates more accurately the actual conditions of medical care.The main objective of our study is to describe the clinical characteristics, endoscopic findings, and treatment used, as well as risk factors of complications and in-hospital mortality in Hispanic patients with NVUGB on "day-to-day conditions". Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleedingJosé Alberto González-González, Genaro Vázquez-Elizondo, Diego García-Compeán, Juan Obed Gaytán-Torres, Ángel Ricardo ...

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Section: Discussioncontrasting

confidence: 65%

Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding

González-González

Vázquez-Elizondo

García-Compeán

et al. 2011

Rev. esp. enferm. dig.

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“…In a second randomized trial comparing early endoscopy within 6 h vs. within 48 h in 93 patients with hemodynamic stabilization and absence of severe comorbidity, no signifi cant benefi ts were seen in clinical end points or in resource utilization ( 38 ). Although discharge without hospitalization was recommended in the 40 % of early endoscopy patients who met criteria for early discharge, this advice was followed in only 9 % , suggesting that the fi nancial benefi t of early endoscopy can only be realized if physicians use the results of endoscopy in making management decisions.…”

Section: Recommendationsmentioning

confidence: 98%

Management of Patients With Ulcer Bleeding

Laine

Jensen

2012

American Journal of Gastroenterology

651

547

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Ulcers are the most common cause of hospitalization for upper gastrointestinal bleeding (UGIB), and the vast majority of clinical trials of therapy for nonvariceal UGIB focus on ulcer disease. Th is guideline provides recommendations for the management of patients with overt UGIB due to gastric or duodenal ulcers. "Overt" indicates that patients present with symptoms of hematemesis, melena, and/or hematochezia. We fi rst discuss the initial management of UGIB in patients without known portal hypertension, including initial assessment and risk stratifi cation, pre-endoscopic use of medications and gastric lavage, and timing of endoscopy. We then focus on the endoscopic and medical management of ulcer disease, including endoscopic fi ndings and their prognostic implications, endoscopic hemostatic therapy, post-endoscopic medical therapy and disposition, and prevention of recurrent ulcer bleeding.Each section of the document presents the key recommendations related to the section topic, followed by a summary of the supporting evidence. A summary of recommendations is provided in Table 1 .A search of MEDLINE via the OVID interface using the MeSH term " gastrointestinal hemorrhage " limited to " all clinical trials " and " meta-analysis " for years 1966 -2010 without language restriction as well as review of clinical trials and reviews known to the authors were performed for preparation of this document. Th e GRADE system was used to grade the strength of recommendations and the quality of evidence ( 1 ). Th e quality of evidence, which infl uences the strength of recommendation, ranges from " high " (further research is very unlikely to change our confi dence in the estimate of eff ect) to " moderate " (further research is likely to have an important impact on our confi dence in the estimate of eff ect and may change the estimate) to " low " (further research is very likely to have an important impact on our confi dence in the estimate of eff ect and is likely to change the estimate), and " very low " (any estimate of eff ect is very uncertain). Th e strength of a recommendation is graded as strong when the desirable eff ects of an intervention clearly outweigh the undesirable eff ects and is graded as conditional when uncertainty exists about the trade-off s ( 1 ). In addition to quality of evidence and balance between desirable and undesirable eff ects, other factors aff ecting the strength of recommendation include variability in values and preferences of patients, and whether an intervention represents a wise use of resources ( 1 ). 2. Blood transfusions should target hemoglobin ≥ 7 g / dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease (Conditional recommendation). Management of Patients With Ulcer Bleeding3. Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care (Cond...

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“…Numerous studies have shown that early endoscopy is not often followed by early discharge of appropriate low-risk patients. Bjorkman et al [27] have shown that EGD within 6 h of presentation to the emergency department versus 48 h did not change hospital utilization of resources, the study's primary endpoint. In a recently published study, Chaparro et al [28] have formulated an early discharge algorithm using retrospective data and then examined this algorithm in a prospective cohort.…”

Section: Timing Of Endoscopic Evaluationmentioning

confidence: 99%

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Trawick

Yachimski²

2012

WJG

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Upper gastrointestinal tract hemorrhage (UGIH) remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease (PU�) has revolutionized the treatment of UGIH. �espite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor (PPI) therapy has become standard empiric treatment for UGIH given that PU� is the leading cause of non-variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. However, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patients with evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today's medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper endoscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low-risk lesions or admission for further monitoring and treatment in higher-risk lesions. Concomitant pharmacotherapy with non-steroidal anti-inflammatory drugs (NSAI�s) and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severity, and potential treatment of UGIH. Long-term PPI use in patients taking chronic NSAI�s or clopidogrel is discussed thoroughly in this review.

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Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study

Cited by 180 publications

References 28 publications

Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding

Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding

Management of Patients With Ulcer Bleeding

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

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