Relevance of surgery in patients with non-variceal upper gastrointestinal bleeding
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Upper GI bleeding remains one of the most common emergencies with a substantial overall mortality rate of up to 30%. In severe ill patients, death does not occur due to failure of hemostasis, either medical or surgical, but mainly from comorbidities, treatment complications, and decreased tolerated blood loss. Management strategies have changed dramatically over the last two decades and include primarily endoscopic intervention in combination with acid-suppressive therapy and decrease in surgical intervention. Herein, we present one of the largest patient-based analysis assessing clinical parameters and outcome in patients undergoing endoscopy with an upper GI bleeding. Data were further analyzed to identify potential new risk factors and to investigate the role of surgery.
Patients and methods
In this retrospective study, we aimed to analyze outcome of patients with an UGIB and data were analyzed to identify potential new risk factors and the role of surgery. Data collection included demographic data, laboratory results, endoscopy reports, and details of management including blood administration, and surgery was carried out. Patient events were grouped and defined as “overall” events and “operated,” “non-operated,” and “operated and death” as well as “non-operated and death” where appropriate. Blatchford, clinical as well as complete Rockall-score analysis, risk stratification, and disease-related mortality rate were calculated for each group for comparison.
Overall, 253 patients were eligible for analysis: endoscopy was carried out in 96% of all patients, 17% needed surgical intervention after endoscopic failure of bleeding control due to persistent bleeding, and the remaining 4% of patients were subjected directly to surgery. The median length of stay to discharge was 26 days. Overall mortality was 22%; out of them, almost 5% were operated and died. Anticoagulation was associated with a high in-hospital mortality risk (23%) and was increased once patients were taken to surgery (43%). Patients taking steroids presented with a risk of death of 26%, once taken to surgery the risk increased to 80%. Patients with liver cirrhosis had a risk of death of 42%; we observed a better outcome for these patients once taken to theater. Clinically, once scored with Blatchford score, statistical correlation was found for initial need for blood transfusion and surgical intervention. Clinical as well as complete Rockall score revealed a correlation between need for blood transfusion as well as surgical intervention in addition with a decreased outcome with increasing Rockall scores. Risk factor analysis including comorbidity, drug administration, and anticoagulation therapy introduced the combination of tumor and non-steroidal antirheumatic medication as independent risk factors for increased disease-related mortality.
UGIB remains challenging and endoscopy is the first choice of intervention. Care must be taken once a patient is taking antirheumatic non-steroidal pain medication and suffers from cancer. In patients with presence of liver cirrhosis, an earlier surgical intervention may be considered, in particular for patients with recurrent bleeding. Embolization is not widely available and carries the risk of necrosis of the affected organ and should be restricted to a subgroup of patients not primarily eligible for surgery once endoscopy has failed. Taken together, an interdisciplinary approach including gastroenterologists as well as surgeons should be used once the patient is admitted to the hospital to define the best treatment option.
KeywordsUpper GI bleeding Outcome Surgery Scoring systems
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
This article does not contain any studies with human participants or animals performed by any of the authors.
- 2.Lewis JD, Bilker WB, Brensinger C, Farrar JT, Strom BL (2002) Hospitalization and mortality rates from peptic ulcer disease and GI bleeding in the 1990s: relationship to sales of nonsteroidal anti-inflammatory drugs and acid suppression medications. Am J Gastroenterol 97(10):2540–2549CrossRefPubMedGoogle Scholar
- 4.Rockall TA, Logan RF, Devlin HB, Northfield TC (1995a) Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering committee and members of the National Audit of acute upper gastrointestinal haemorrhage. BMJ 311(6999):222–226CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Stromdahl M, Helgeson J and Kalaitzakis E (2016) "Emergency readmission following acute upper gastrointestinal bleeding." Eur J Gastroenterol HepatolGoogle Scholar
- 15.Sung JJ, Chan FK, Chen M, Ching JY, Ho KY, Kachintorn U, Kim N, Lau JY, Menon J, Rani AA, Reddy N, Sollano J, Sugano K, Tsoi KK, Wu CY, Yeomans N, Vakil N, Goh KL (2011) Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding. Gut 60(9):1170–1177CrossRefPubMedGoogle Scholar
- 18.Aquarius M, Smeets FG, Konijn HW, Stassen PM, Keulen ET, Van Deursen CT, Masclee AA, Keulemans YC (2015) Prospective multicenter validation of the Glasgow Blatchford bleeding score in the management of patients with upper gastrointestinal hemorrhage presenting at an emergency department. Eur J Gastroenterol Hepatol 27(9):1011–1016CrossRefPubMedGoogle Scholar
- 19.Yang, H. M., S. W. Jeon, J. T. Jung, D. W. Lee, C. Y. Ha, K. S. Park, S. H. Lee, C. H. Yang, J. H. Park and Y. S. Park (2015). "Comparison of scoring systems for nonvariceal upper gastrointestinal bleeding: a multicenter prospective cohort study." J Gastroenterol Hepatol.Google Scholar
- 24.Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P (2010) Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev 7:CD005415Google Scholar
- 27.Teles Sampaio E, Maia L, Salgueiro P, Marcos-Pinto R, Dinis-Ribeiro M and Pedroto I (2016) "Antiplatelet agents and/or anticoagulants are not associated with worse outcome following nonvariceal upper gastrointestinal bleeding." Rev Esp Enferm Dig 108Google Scholar
- 29.Kuo MT, Yang SC, Lu LS, Hsu CN, Kuo YH, Kuo CH, Liang CM, Kuo CM, Wu CK, Tai WC, Chuah SK (2015) Predicting risk factors for rebleeding, infections, mortality following peptic ulcer bleeding in patients with cirrhosis and the impact of antibiotics prophylaxis at different clinical stages of the disease. BMC Gastroenterol 15:61CrossRefPubMedPubMedCentralGoogle Scholar