Gastrointestinal bleeding

Ramsoekh D, Leerdam van ME, Rauws EA, et al. Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol 2005; 3: 859 - 864

This epidemiologic survey focused on two university hospitals and 12 regional hospitals around Amsterdam, in which 14 % of patients admitted with hematemesis, melena, or hematochezia, or who developed peptic ulcer bleeding as inpatients, died. Mortality rate was nearly double the mortality rate of 5 - 8 % reported by specialized units that emphasize prompt resuscitation, early endoscopic diagnosis, and treatment followed by dedicated multidisciplinary postoperative care [1] [2]. Also, the 19 % recurrent bleeding rate and 7 % need for surgery rate are higher than rates reported elsewhere, and no doubt contributed to the overall mortality.

Some aspects of this interesting paper deserve to be underlined. First, the surprisingly high mortality rate is in line with the outcome of acute upper gastrointestinal bleeding in other European epidemiologic surveys [3]. This raises the issue of selection bias, which is often present in clinical trials, where patients with severe or life-threatening comorbidity, or who are older, or have coagulation disorders for example, are usually excluded. This results in a selected population that cannot be compared with the population of epidemiologic surveys that include all patients. Second, patients with severe acute upper gastrointestinal bleeding should be offered optimal management in specialized units. Management might have been suboptimal in regional hospitals, where early assessment and expert endoscopic intervention might not always be available. Most patients in this study who were given endoscopic treatment received epinephrine injection therapy alone, rather than combining this with a second hemostatic method, either thermal or mechanical, as recommended for patients with high-risk stigmata [4]. Last but not least, mortality was significantly higher in patients already admitted for other illness, 28 % vs. 5.3 % for newly admitted patients (P < 0.01), respectively. Severe or life-threatening comorbidity was present in 76 % of the patients who died. Therefore, the high mortality rate reported in this survey was mainly attributed to the high mortality rate among inpatients with severe comorbidity. The majority of deaths in these high-risk patients could not have been prevented, but they resulted from the comorbidity, independently of any effective endoscopic intervention.

References

• 1 Barkun A, Sabbah S, Enns R. et al . Endoscopic haemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.  Am J Gastroenterol. 2004;  99 1238-1246
• 2 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 standardization.  Eur J Gastroenterol Hepatol. 2004;  16 487-494
• 3 Vreeburg E M, Snel P, de Bruijne J W. et al . Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome.  Am J Gastroenterol. 1997;  92 236-243
• 4 Barkun A, Bardou M, Marshall J K. et al . Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.  Ann Intern Med. 2003;  139 843-857
• 5 Cipolletta L, Bianco M A, Rotondano G. et al . Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial.  Gastrointest Endosc. 2002;  55 1-5
• 6 Spiegel B M, Vakil N B, Ofman J J. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review.  Arch Intern Med. 2001;  161 1393-1404
• 7 Barkun A, Bardou M, Marshall J K. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding.  Ann Intern Med. 2003;  139 843-857
• 8 Bjorkman D J, Zaman A, Fennerty M B. et al . Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study.  Gastrointest Endosc. 2004;  60 1-8
• 9 Sung J JY, Chan F KL, Lau J YW. et al . The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots. A randomized comparison.  Ann Intern Med. 2003;  139 237-243
• 10 Khuroo M S, Yattoo G N, Javid G. et al . A comparison of omeprazole and placebo for bleeding peptic ulcer.  N Engl J Med. 1997;  336 1054-1058
• 11 Calvet X, Vergara M, Brullet E. et al . Addition of a second endoscopic treatment following epinephrine injection improves outcome in high risk bleeding ulcers.  Gastroenterology. 2004;  126 441-450
• 12 Bianco M A, Rotondano G, Marmo R. et al . Combined epinephrine and bipolar coagulation vs. bipolar coagulation alone for bleeding peptic ulcer: a randomized, controlled trial.  Gastrointest Endosc. 2004;  60 910-915
• 13 Marmo R, Rotondano G, Piscopo R. et al . Dual therapy vs. monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials.  Am J Gastroenterol. 2006;  101 (in press)
• 14 Rockall T A, Logan R FA, Devlin H B. et al . Risk assessment after acute upper gastrointestinal haemorrhage.  Gut. 1996;  38 316-321
• 15 Vreeburg E M, Twerwee C B, Snel P. et al . Validation of the Rockall risk scoring system in upper gastrointestinal bleeding.  Gut. 1999;  44 331-335
• 16 Sanders D S, Carter M J, Goodchap R J. et al . Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers.  Am J Gastroenterol. 2002;  97 630-635
• 17 Cipolletta L, Bianco M A, Rotondano G. et al . Outcome of outpatient management for low-risk patients with non-variceal upper gastrointestinal bleeding.  Gastrointest Endosc. 2002;  54 1-6
• 18 Bardou M, Toubouti Y, Benhaberou-Brun D. et al . Meta-analysis: proton-pump inhibition in high-risk patients with acute peptic ulcer bleeding.  Aliment Pharmacol Ther. 2005;  21 677-686