Published online Sep 26, 2019. doi: 10.12998/wjcc.v7.i18.2687
Peer-review started: June 25, 2019
First decision: July 20, 2019
Revised: August 16, 2019
Accepted: August 27, 2019
Article in press: August 26, 2019
Published online: September 26, 2019
Nonvariceal upper digestive bleeding (NVUDB) is a severe condition, associated with significant morbidity, mortality and health care resource use. Despite the progress in the treatment of NVUDB by using potent proton pump inhibitors and modern endoscopic devices, its mortality remains high. In recent years, considerable effort has been made to the identification of predictive factors for unfavorable outcome, defined by rebleeding, need of surgery and death.
The identification of prognostic factors of poor outcome and implementation of risk stratification systems helps to improve clinical management of the patients with NVUDB by optimal allocation of health care resources. This stratification allows an early discharge or outpatient management in low-risk patients, whereas high-risk patients benefit from an intensive therapeutic approach, needing endoscopic hemostasis and hospitalization.
The main objective of our study is to describe the particularities of patients with NVUDB, including demographic characteristics, clinical and endoscopic findings, treatment used, as well as to identify predictive factors of rebleeding and in-hospital mortality in patients with NVUDB admitted in an emergency hospital from western Romania.
Our retrospective study included patients with NVUDB admitted in the Gastroenterology Department of Emergency County Hospital Timisoara, Romania, during 2008-2016. On this batch we analyzed the demographic data, medication history, clinical and biological parameters, endoscopic findings, type of endoscopic hemostasis used, the Rockall score of the patients, length of hospitalization and associated comorbidities. Also, we assessed the rate of unfavorable outcome in patients with NVUDB (rebleeding, surgery, death). Furthermore, we evaluated the potential risk factors associated with rebleeding and death in patients with NVUDB.
We assessed a batch of 1581 patients with NVUDB, 523 (33%) females and 1058 (67%) males, median age of 66 years. Peptic ulcer represented the most common etiology of NVUDB. The rate of rebleeding was 7.72%, surgery was performed in 3.22% of patients; the in-hospital mortality rate was 8.09%, whereas bleeding-episode-related mortality was 2.97%. Parameters significantly associated with an increased risk of rebleeding (using logistic regression) were Rockall score (OR: 1.41), need for therapy [simple (OR: 3.18) or combined (OR: 1.75)], number of blood units transfused (OR: 1.46), and sepsis (OR: 2.95). Logistic regression demonstrated that parameters significantly associated with death were Rockall score (OR: 1.73) and the following comorbidities: respiratory diseases (OR: 3.29), liver cirrhosis (OR: 2.91), sepsis (OR: 8.03) and acute pancreatitis (OR: 6.58). We performed a predictive model for rebleeding associated with an accuracy of 92.35%, and a predictive model for death, with an accuracy of 92.35%. Because the predictive models have a low sensitivity and a very high specificity, they provide a better discriminative capacity for identifying patients with NVUDB with favorable outcomes (no evolution towards rebleeding or death).
Our study revealed that the risk factors for rebleeding were the Rockall score, need for endoscopic therapy, number of blood units transfused, and presence of sepsis. Our results showed that patients who died during hospitalization were significantly older, had a higher Rockall score, and a more severe anemia. The existence of severe comorbididies such as respiratory conditions, cirrhosis, sepsis, and acute pancreatitis were also risk factors for death in patients with NVUDB.
In the near future we expect to be able to implement better strategies of risk stratification of NVUDB patients in our daily practice, using the clinical and endoscopic findings demonstrated as predictive parameters of poor outcome in our specific pool of patients. The continuous use of the risk stratification algorithms for the patients with NVUDB will lead to an improved management of these patients, a better quality of care and cost-efficiency of health resource use, and finally to a better prognosis of the patients diagnosed with this severe condition. The therapeutic approach of patients with NVUDB should involve a multidisciplinary team for the initial assessment of patients and for hemodynamic stabilization. The involvement of an experienced endoscopist and availability of modern endoscopic devices and techniques are essential for the proper management, prevention of rebleeding, reduction of hospitalization length, and minimization of morbidity and mortality. A strategy for improving the outcome of the patients should focus on managing coexisting diseases. Multidisciplinary teams for the management of NVUDB patients should include experienced nurses, gastroenterologists, surgeons, and other clinicians who can deal with comorbidities.