The Outcome of Suspected Upper Gastrointestinal Bleeding With 24-Hour Access to Upper Gastrointestinal Endoscopy: A Prospective Cohort Study

Background and Study Aim: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital.
Patients and Methods: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study.
Results: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % (P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death.
Conclusions: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.

References

• 1 Rockall T A, Logan R F, Devlin H B, Northfield T C. 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. 1995;  311 222-226
• 2 Chung S C, Leung J W, Steele R J. et al . Endoscopic injection of adrenaline for actively bleeding ulcers: a randomised trial.  Br Med J (Clin Res Ed). 1988;  296 1631-1633
• 3 Chung S C, Leong H T, Chan A C. et al . Epinephrine or epinephrine plus alcohol for injection of bleeding ulcers: a prospective randomized trial.  Gastrointest Endosc. 1996;  43 591-595
• 4 Kubba A K, Murphy W, Palmer K R. Endoscopic injection for bleeding peptic ulcer: a comparison of adrenaline alone with adrenaline plus human thrombin.  Gastroenterology. 1996;  111 623-628
• 5 Laine L. Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial.  Gastroenterology. 1990;  99 1303-1306
• 6 Lin H J, Tsai Y T, Lee S D. et al . A prospectively randomized trial of heat probe thermocoagulation versus pure alcohol injection in nonvariceal peptic ulcer hemorrhage.  Am J Gastroenterol. 1988;  83 283-286
• 7 Cook D J, Guyatt G H, Salena B J, Laine L A. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis.  Gastroenterology. 1992;  102 139-148
• 8 Rockall T A, Logan R F, Devlin H B, Northfield T C. Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Steering Committee of the National Audit of Acute Upper Gastrointestinal Haemorrhage.  Gut. 1997;  41 606-611
• 9 Masson J, Bramley P N, Herd K. et al . Upper gastrointestinal bleeding in an open-access dedicated unit.  J R Coll Physicians Lond. 1996;  30 436-442
• 10 Sanderson J D, Taylor R F, Pugh S, Vicary F R. Specialized gastrointestinal units for the management of upper gastrointestinal haemorrhage.  Postgrad Med J. 1990;  66 654-656
• 11 Everett S M, Hendrickse M, Chalmers D, Axon A TR. Upper gastrointestinal haemorrhage can be safely managed using a defined, risk based protocol.  Gut. 1996;  39 (Suppl 1) A4
• 12 Lau J Y, Sung J J, Lee K K. et al . Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.  N Engl J Med. 2000;  343 310-316
• 13 Rockall T A, Logan R F, Devlin H B, Northfield T C. Risk assessment after acute upper gastrointestinal haemorrhage.  Gut. 1996;  38 316-321
• 14 Desmet V J, Gerber M, Hoofnagle J H. et al . Classification of chronic hepatitis: diagnosis, grading and staging.  Hepatology. 1994;  19 1513-1520
• 15 Holman R A, Davis M, Gough K R. et al . Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital.  Gut. 1990;  31 504-508
• 16 van Leerdam M E, Vreeburg E M, Rauws E A. et al . Acute upper gastrointestinal bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper gastrointestinal bleeding between 1993/1994 and 2000.  Am J Gastroenterol. 2003;  98 1494-1499
• 17 Kapur K C, Green J T, Turner R G. et al . Auditing mortality from upper gastrointestinal haemorrhage: impact of a high dependency unit.  J R Coll Physicians Lond. 1998;  32 246-250
• 18 Clements D, Aslan S, Foster D. et al . Acute upper gastrointestinal haemorrhage in a district general hospital: audit of an agreed management policy.  J R Coll Physicians Lond. 1991;  25 27-30
• 19 Anderson J T, Johnston D A, Murray F E. A hospital policy for acute upper gastrointestinal haemorrhage.  Scott Med J. 1994;  39 166-168
• 20 Sanders D S, Perry M J, Jones S G. et al . Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation.  Eur J Gastroenterol Hepatol. 2004;  16 487-494
• 21 Fleischer D. Etiology and prevalence of severe persistent upper gastrointestinal bleeding.  Gastroenterology. 1983;  84 538-443