Original Contribution
High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis

https://doi.org/10.1016/j.ajem.2006.07.014Get rights and content

Abstract

Objectives

The optimal timing of interventional endoscopy within the initial 24 hours remains controversial. We designed a retrospective study to compare the outcomes between emergency endoscopy (EE) and urgent endoscopy (UE) for high-risk patients with nonvariceal upper gastrointestinal hemorrhage presenting to the emergency department (ED).

Methods

The medical records of 189 patients with nonvariceal upper gastrointestinal hemorrhage who underwent endoscopy within 24 hours of admission to the ED were reviewed. Patients were divided into 2 groups: EE group (<8 hours) or UE group (8-24 hours). We compared the endoscopic findings, hemostatic procedures, rate of hemostasis, rebleeding, need for transfusion, length of hospitalization, and mortality between the 2 groups.

Results

There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group. Ulcers with active bleeding or exposed vessel were found more frequently in the EE group than in the UE group (19% vs 8%, P = .03; 34% vs 12%, P < .001). Fifty patients had blood retention in the stomach, especially in the EE group (40% vs 15%, P < .001). Forty-four (50%) patients in the EE group and 21 (21%) patients in the UE group received endoscopic interventions. Combination modalities of endoscopic hemostasis were more commonly used in the EE group than in the UE group (40% vs 15%, P < .001). Primary hemostasis was achieved at a rate of 95% in both groups. There was no statistical difference regarding the rate of recurrent bleeding, total amount of transfusion, length of hospital stay, and mortality rate in both groups.

Conclusions

Although more active lesions were detected and more therapeutic attempts were performed in the EE group, the outcome showed no difference in both groups. Emergency endoscopy performed less than 8 hours after arrival to the ED showed no definite benefit in comparison with UE performed within 8 to 24 hours.

Introduction

Upper gastrointestinal hemorrhage (UGIH) is commonly encountered in emergency medical practice. Despite considerable advances in endoscopic hemostatic modalities and pharmacologic treatment, UGIH still causes significant morbidity and mortality, as well as substantial financial costs. The annual incidence of hospital admissions for UGIH in the United States and Europe is 0.1%, with a mortality rate of 10% [1].

Esophagogastroduodenoscopy (EGD) plays a key role in both diagnosis and treatment of UGIH. It identifies the site of bleeding in more than 95% of cases of UGIH [2]. Currently, endoscopy within the initial 24 hours is the standard of therapy for the management of UGIH [3]. However, there is no general agreement on the definition of “early” regarding endoscopy in UGIH. It varies widely among studies, ranging from 2 to 24 hours after presentation to the emergency department (ED). Choudari and Palmer [4] reported no difference in endoscopic completeness, findings, injection intervention, and outcome for patients undergoing “early” (<6 hours), “intermediate” (>6-12 hours), and “ delayed” (>12-24 hours) endoscopy. Lin et al [5] found that “early” endoscopy (<12 hours) resulted in decreased demand of blood transfusion only for patients with bloody nasogastric aspirate. On the other hand, Yen et al [6] found that “early” endoscopy (<2 hours) resulted in more frequent and significant oxygen desaturation during the procedure.

A practical problem is that immediate interventional endoscopy is not readily available at anytime in most hospitals. Because the best timing and the benefit of endoscopy within the first 24 hours after admission are undetermined, we reviewed the medical records of high-risk patients with UGI bleeding who presented to the ED to understand the differences of endoscopic findings, hemostatic procedures, need for transfusion, and outcomes between emergency endoscopy (EE) (<8 hours) and urgent endoscopy (UE) (>8-24 hours).

Section snippets

Methods

From July 2004 to December 2004, 406 patients presenting to our ED underwent EGD for hematemesis and/or melena. High-risk patients were defined by age more than 60 years, severe comorbidity, active bleeding (witnessed hematemesis, red blood per nasogastric tube, hematochezia), hypotension or shock, red blood cell transfusion of more than 6 U, and severe coagulopathy [7]. A total of 189 patients who underwent EGD within 24 hours and met the previously mentioned criteria for the high-risk group

Statistical analysis

Analyses were based on the categorization of the 2 groups of EE and UE. Factors including demographic characteristics, clinical characteristics, endoscopic findings, therapeutic modalities, and outcomes between the 2 groups were compared. Categorical data were analyzed by Fisher exact test, and continuous data were compared by Mann-Whitney U test. All tests were 2-tailed, and a P value less than 0.05 was considered statistically significant. All analyses were performed by SPSS 11.0 version

Results

There were 88 patients (47%) in the EE group and 101 patients (53%) in the UE group enrolled for analysis. Demographic characteristics are shown in Table 1. Age, sex, comorbidity, and use of medication did not differ between both groups. Clinical characteristics, including bloody emesis, coffee ground emesis, melena, hematochezia, systolic blood pressure, heart rate, and hematocrit also showed no significant difference (Table 2).

The most frequently encountered endoscopic diagnoses were duodenal

Discussion

In the present study, we find that the outcomes including transfusion rate, length of hospitalization, and mortality rate were not different in both the EE and UE groups of high-risk UGIH patients, although more active lesions were detected and more therapeutic approaches were attempted in the EE group. For acute nonvariceal UGIH, EGD remains the most effective modality for diagnosing and treating most causes of UGIH [7]. Most of the earlier studies confirmed the advantage of early endoscopy,

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    In a retrospective study with 169 high-risk patients, no significant differences were observed in mortality and rebleeding between the two endoscopy groups (<6 vs. 6–12 h).18 In another retrospective study of 189 high-risk patients, Tai et al. found that performance of endoscopy within 8 h was not associated with lower mortality compared with endoscopy performed between 8 and 24 h.19 Another retrospective study by Kumar et al. showed no difference in mortality between the urgent (<12 h) and early (12–24 h) endoscopy groups. Yet, an increased risk of experiencing a composite outcome (mortality, inpatient rebleeding, need for angiographic embolization or surgery, endoscopic re-intervention) was found in the urgent endoscopy group.

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