Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Feb 16, 2020; 12(2): 72-82
Published online Feb 16, 2020. doi: 10.4253/wjge.v12.i2.72
Endoscopic treatment modalities and outcomes in nonvariceal upper gastrointestinal bleeding
Benjamin Cherng Hann Yip, Hossain Sayeed Sajjad, Jie-Xun Wang, Constantinos P Anastassiades
Benjamin Cherng Hann Yip, Constantinos P Anastassiades, Department of General Medicine, Khoo Teck Puat Hospital, Singapore 768828, Singapore
Hossain Sayeed Sajjad, Department of Acute Medicine, Northampton General Hospital, Cliftonville, Northampton NN1 5BD, United Kingdom
Jie-Xun Wang, Clinical Research Unit, Khoo Teck Puat Hospital, Singapore 768828, Singapore
Author contributions: All the authors contributed equally in data extraction, data analysis and writing of the paper.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer-NHG Domain Specific Review Board.
Informed consent statement: A waiver of informed consent has been obtained from our institution ethics review board.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Benjamin Cherng Hann Yip, MBBS, MRCP, Doctor, Department of General Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828, Singapore. yip.benjamin.ch@ktph.com.sg
Received: June 18, 2019
Peer-review started: June 23, 2019
First decision: August 2, 2019
Revised: November 25, 2019
Accepted: December 14, 2019
Article in press: December 14, 2019
Published online: February 16, 2020
ARTICLE HIGHLIGHTS
Research background

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common condition that results in significant morbidity and mortality. Mortality rates have not improved over the years. There are currently several endoscopic modalities for the treatment of this condition.

Research motivation

However, the dosage or amount of treatment to be used for each modality is not well studied. Moreover, it is not known whether a combination of three or more modalities combined is associated with better outcomes.

Research objectives

Our study aims to investigate whether various clinical outcomes in NVUGIB are influenced by the volume of adrenaline injected, the number of hemoclips placed and the number of treatment modalities used.

Research methods

A retrospective cohort study conducted in a single large district general hospital. All patients admitted for NVUGIB and needing endoscopic treatment over a two-year period were analyzed. The various endoscopic treatment modalities were compared against several outcomes including rebleeding, repeat endoscopy rates, surgical intervention, transfusion requirements, length of hospital stay, death during the same admission and 30 d mortality.

Research results

Close to one third of our patients needed endoscopic therapy. < 10 mL adrenaline injected was associated with less re-bleeding (P < 0.0001), need for repeat endoscopy (P = 0.001) and decreased length of hospital stay (P = 0.026). > 2 treatment modalities used was associated with more re-bleeding (P = 0.009) and need for repeat endoscopy (P = 0.048). > 1 hemoclip placed was associated with decreased length of hospital stay (P = 0.044).

Research conclusions

Our study is the first to show that more hemoclips placed was associated with a decreased length of stay. Also, we report novel findings that a reduced volume of adrenaline injected and a reduced number of endoscopic treatment modalities used was associated with better outcomes. More hemoclips used being associated with a better outcome is intuitive. However, previous studies have shown that larger volumes of adrenaline used led to better outcomes. These studies were conducted with adrenaline as the only treatment modality. This is not in line with the current management guidelines of NVUGIB which states that adrenaline use needs to be combined with another modality. Most of our patients who received adrenaline also received at least another treatment modality, this may be one reason why the volume of adrenaline required to arrest the bleeding may be smaller in our study. There are no previous studies that have shown that > 2 treatment modalities led to poorer outcomes. These findings are counter-intuitive but may be due to certain variables not captured in this retrospective study causing poorer outcomes. A prospective study with a larger sample size is needed to compare the various dosages and amounts of treatment used to manage this common condition.

Research perspectives

In the endoscopic management of NVUGIB, more may not be merrier for all treatment modalities. A prospective trial is needed to confirm this.