Breaking News
February 18, 2019 - New dental adhesive prevents tooth decay around orthodontic brackets
February 18, 2019 - New eHealth tool shows potential to improve quality of asthma care
February 18, 2019 - New Australian initiative helps emergency clinicians to improve patient care
February 17, 2019 - Apellis Pharmaceuticals’ APL-2 Receives Fast Track Designation from the FDA for the Treatment of Patients with Paroxysmal Nocturnal Hemoglobinuria
February 17, 2019 - Researchers identify faulty ‘brake’ that interferes with heart muscle’s ability to contract and relax
February 17, 2019 - Support from trusted adults can reduce risk of dying in suicidal teens, finds study
February 17, 2019 - Heart attack awareness improved since 2008
February 17, 2019 - Exercise gives a better brain boost to older men than women
February 17, 2019 - New research disproves previous assumptions of how looks influence personality
February 17, 2019 - Cannabis use as a teenager linked to depression later in life
February 17, 2019 - Sinks by Toilets in ICU Patient Rooms Harbor Harmful Bacteria
February 17, 2019 - Cancer cells’ plasticity makes them harder to stop
February 17, 2019 - Young cannabis users have increased risk of depression and suicidal behavior
February 17, 2019 - Tasmanian Devils Likely to Survive Cancer Scourge
February 17, 2019 - Neoadjuvant PD-1 blockade seems effective in glioblastoma
February 17, 2019 - Personal, social factors play role in enabling sustainable return to work after ill health
February 17, 2019 - Mouse studies show ‘inhibition’ theory of autism wrong
February 17, 2019 - Study shows how neuroactive steroids inhibit activity of pro-inflammatory proteins
February 17, 2019 - Use of liver grafts from older donors decreased despite better outcomes in recipients
February 17, 2019 - MUSC researchers discover new mechanism for a class of anti-cancer drugs
February 17, 2019 - HPV misconceptions are causing women to miss smear tests
February 17, 2019 - Sanofi and Regeneron Offer Praluent (alirocumab) at a New Reduced U.S. List Price
February 17, 2019 - Researchers say auditory testing can identify children for autism screening
February 17, 2019 - New method analyzes how single biological cells react to stressful situations
February 17, 2019 - WVU gynecologic oncologist investigates novel treatment for cervical and vaginal cancers
February 17, 2019 - ADHD diagnoses poorly documented
February 17, 2019 - Majority of gender minority youth do not identify with traditional sexual identity labels
February 17, 2019 - AbbVie, Teneobio enter into strategic transaction to develop potential treatment for multiple myeloma
February 17, 2019 - Lower Birth Weight May Up Risk for Psychiatric Disorders
February 17, 2019 - Scientists identify reversible molecular defect underlying rheumatoid arthritis
February 17, 2019 - Moffitt researchers shed light on how CAR T cells function mechanistically
February 16, 2019 - Female Anatomy May Play Big Role in Sperm’s Success
February 16, 2019 - BMI may mediate inverse link between fiber intake, knee OA
February 16, 2019 - Movement impairments in autism can be reversed through behavioral training
February 16, 2019 - Studies address racial disparities in postpartum period and cardiovascular health
February 16, 2019 - Scientists implicate hidden genes in the severity of autism symptoms
February 16, 2019 - Decreased deep sleep linked to early signs of Alzheimer’s disease
February 16, 2019 - Neuroscientists show how the brain responds to texture
February 16, 2019 - Gilead Announces Topline Data From Phase 3 STELLAR-4 Study of Selonsertib in Compensated Cirrhosis (F4) Due to Nonalcoholic Steatohepatitis (NASH)
February 16, 2019 - What Can I Do About Sweating? (for Teens)
February 16, 2019 - Companies navigate dementia conversations with older workers
February 16, 2019 - Newly developed stem cell technologies show promise for treating PD patients
February 16, 2019 - Collaborative material research could advance self-assembling nanomaterials
February 16, 2019 - Researchers take major step in creating technology that mimics the human brain
February 16, 2019 - Erasing memories associated with cocaine use reduces drug seeking behavior
February 16, 2019 - Artificial intelligence can accurately predict prognosis of ovarian cancer patients
February 16, 2019 - Racial disparities in cancer deaths on the decline for America
February 16, 2019 - FDA authorizes new interoperable insulin pump for children, adults with diabetes
February 16, 2019 - Coexisting Medical Conditions, Smoking Explain PTSD-CVD Link
February 16, 2019 - Skin Cancer Screening: MedlinePlus Lab Test Information
February 16, 2019 - ‘Happiness’ exercises can boost mood in those recovering from substance use disorder
February 16, 2019 - Cell manipulation could soon halt or reverse aging
February 16, 2019 - Pumped Breast Milk Falls Short of Breastfed Version
February 16, 2019 - Men’s porn habits could fuel partners’ eating disorders, study suggests
February 16, 2019 - Rapid progression of age-related diseases may result from formation of vicious cycles
February 16, 2019 - Immune checkpoint molecule protects against future development of cancer
February 16, 2019 - New method produces hydrogels that have properties similar to cells’ environment
February 16, 2019 - $4.1 million funding for heart research on Valentine’s Day
February 16, 2019 - General anesthesia in early infancy unlikely to have lasting effects on developing brains
February 16, 2019 - New breakthroughs for muscular dystrophy research
February 16, 2019 - First Opinion: Embryo editing for higher IQ is a fantasy. Embryo profiling for it is almost here
February 16, 2019 - Vapers develop cancer-related gene deregulation as cigarette smokers
February 16, 2019 - Bringing Antimicrobial Susceptibility Testing (AST) to the Community
February 16, 2019 - Decolonization protocol after hospital discharge can prevent dangerous infections
February 16, 2019 - Children with ASD more likely to face maltreatment, study finds
February 16, 2019 - Study finds genetic vulnerability to use of menthol cigarettes
February 16, 2019 - Promising drug developed to rejuvenate muscle cells
February 16, 2019 - H-RT should be the standard of care for men with low risk prostate cancer, study shows
February 16, 2019 - New technique using patients’ own modified cells could help treat Crohn’s disease
February 16, 2019 - Therapeutic endoscopy has an expanding role in the treatment of IBD
February 16, 2019 - Blood clot discovery could lead to development of better treatments for blood diseases
February 16, 2019 - Intervention can increase exclusive breastfeeding rates
February 16, 2019 - New project explores how gaming technologies can help cancer patients communicate better
February 16, 2019 - Catalyst Biosciences Presents Updated Data from Its Phase 2/3 Trial of Subcutaneous Marzeptacog Alfa (Activated) in Individuals with Hemophilia A or B with Inhibitors at the 12th Annual EAHAD Congress
February 16, 2019 - Rerouting nerves during amputation reduces phantom limb pain before it starts
February 16, 2019 - A Hormone Produced When We Exercise Might Help Fight Alzheimer’s
February 16, 2019 - Millions of British people breathe toxic air travelling to GPs
February 16, 2019 - Conformance of genetic characteristics found to be crucial for longer preservation of kidney graft
February 16, 2019 - Researchers use optogenetic tool to control, visualize receptor signals in neural cells
February 16, 2019 - New reversible antiplatelet therapy could reduce risk of blood clots, prevent cancer metastasis
Urgent Endoscopy Predicts Lower Death Rate in UGIB

Urgent Endoscopy Predicts Lower Death Rate in UGIB

image_pdfDownload PDFimage_print

Action Points

  • Urgent endoscopy within 6 hours of hospital presentation was an independent predictor of reduced mortality, but not rehemorrhaging, in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB).
  • Mortality was associated with malignancy, cirrhosis, urgent endoscopy, failed primary endoscopic treatment, and rebleeding.

Urgent endoscopy within 6 hours of hospital presentation was an independent predictor of reduced mortality, but not rehemorrhaging, in high-risk patients with acute nonvariceal upper gastrointestinal bleeding (UGIB), according to Korean researchers.

In 961 consecutive high-risk emergency department (ED) patients (81% men, mean age 57) with Glasgow-Blatchford scores (GBS) of >7 (mean 12.1), the mortality rate was 1.6% with urgent endoscopy versus 3.8% with elective endoscopy, reported Yoon-Seon Lee, MD, PhD, of Ulsan College of Medicine in Seoul, and colleagues.

The two timing groups also differed in the number of transfused packed red blood cells (urgent 2.6-2.5 versus elective 2.3-2.1 packs), need for intervention (69.5% versus 53.5%), and embolization (2.8% versus 0.5%), they wrote in Clinical Gastroenterology and Hepatology.

Study Details

The authors noted that endoscopy timing in high-risk patients is controversial. While the 2010 International Consensus Recommendations call for the procedure endoscopy within 24 hours of presentation, accumulating evidence has suggested that endoscopy within 12 hours may provide better outcomes. Data are sparse and conflicting on the benefit of much earlier endoscopy within 6 hours of hospital admission.

“Considering the poor outcomes of high-risk patients, it is critical to predict the clinical course of these patients in the ED, and provide timely and appropriate treatment,” they stated.

All patients underwent endoscopy at a tertiary-care center for acute nonvariceal UGIB during 2005-2014. “Urgent” referred to endoscopy performed earlier than 6 hours after presentation and “elective” to that done within 6-48 hours.

Overall, 571 (59.4%) underwent urgent endoscopic investigation, and these patients were somewhat older than their elective counterparts at a mean of approximately 58 versus 55, and were also unstable hemodynamically. Comorbidities were comparable in the two groups.

In the study’s two primary endpoints, the overall 28-day mortality rate was 2.5% (24 patients) and the rebleeding rate was 10.4% (100 patients).

Stratifying by urgent or elective endoscopy, the investigators found slight intergroup differences in rebleeding rate (11.4% versus 9.0%), ICU admission (4.4% versus 4.7%), vasopressor use (1.9% versus 0.8%), and length of stay (6.7 versus 6.4 days).

Surgery was performed in six patients with urgent endoscopy, but no statistically significant difference in surgery rate was evident between groups (1.1% versus 0%).

Among the diagnoses on endoscopy, gastric and duodenal ulcers were identified in 67.8% of patients, followed by Mallory-Weiss tear in 9.3%, Dieulafoy lesion in 4.6%, and vascular ectasia in 2.3%. Of the 100 patients who rebled within 28 days, 8% died.

Increased mortality was associated with malignancy (odds ratio 3.58, 95% CI 1.33-9.62) and cirrhosis (OR 4.67, 95% CI 1.85-11.76). Urgent endoscopy reduced the OR of death to 0.36 (95% CI 0.14-0.95).

In terms of malignancy and cirrhosis diagnosed at endoscopy, 26.8% of the cohort had cancer and 15% cirrhosis. GI cancer such as liver and stomach was by far the most common malignancy in patients (79.3%), followed distantly by lung cancer (1.5%).

Other independent predictors of mortality were 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).

The authors stressed that patient selection for urgent endoscopy is an important issue, since many hospitals are unable to provide this procedure 24/7. And while many studies have defined high-risk patients as those having a GBS of >12, they said their findings support a GBS cut-off of >7 for urgent endoscopy.

‘Limited Number of Mortality Outcomes’

In an accompanying editorial, Ian Gralnek, MD, MHS, of the Rappaport Faculty of Medicine at Technion-Israel Institute of Technology in Haifa, said the results are not likely generalizable because the sample came from a single tertiary-care center with an unusual capacity to routinely offer round-the-clock urgent endoscopy .

Furthermore, the findings’ implications for mortality need careful interpretation because of the small number of deaths in the large cohort. “This limited number of mortality outcomes is problematic because this can lead the multivariable regression model to be overfit,'” Gralnek wrote. “Overfitting a regression model describes random error or ‘noise’ and not a true underlying association between events.” It occurs when a regression model is too complex, meaning that too many variables are put into the model relative to the number of outcomes.

Nevertheless, the results offer some suggestion of the optimal timing of early endoscopy. “These data may support the role of very early upper GI endoscopy in patients with acute upper GI hemorrhage and high-risk clinical features,” Gralnek wrote, defining “very early” endoscopy as performed once the patient is hemodynamically resuscitated and within 12 hours of presentation.

“We are awaiting high-quality data that support the performance of endoscopy sooner than this, ” he stated. Of the two studies evaluating immediate endoscopy in this patient population, neither showed improvement in mortality, rebleeding, surgery, blood transfusions, or for repeat endoscopy, Gralnek noted, although a 1999 randomized trial showed that endoscopy within 2 hours of ED admission reduced length of hospital stay by a day.

In line with current guidelines, Gralnek recommended that very early endoscopy within 12 hours of patient presentation may improve outcomes, “but probably only in select acute UGI hemorrhage patients with high-risk clinical features. The onus is therefore on gastroenterologists and endoscopists to be vigilant and recognize the patients with high-risk features, and when present, take the necessary steps to perform very early endoscopy.”

Study limitations included its retrospective observational nature, its single-center tertiary-care population with unusual access to urgent endoscopy, and the potential for information gaps in existing records. Furthermore, a large proportion of patients had malignancy or cirrhosis, making it difficult to isolate the effect of urgent endoscopy on outcomes.

Lee and co-authors, as well as Gralnek, disclosed no relevant relationships with industry.

  • Reviewed by
    Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

1969-12-31T19:00:00-0500

last updated

Tagged with:

About author

Related Articles