Subscribe to RSS
DOI: 10.1055/s-0032-1325412
Behandlungsergebnisse der akuten oberen nicht varikösen gastrointestinalen Blutung in Relation zum Zeitpunkt der Endoskopie: Resultate einer landesweiten Studie
Outcomes Following Acute Nonvariceal Upper Gastrointestinal Bleeding in Relation to Time to Endoscopy: Results from a Nationwide StudyPublication History
Publication Date:
12 October 2012 (online)
![](https://www.thieme-connect.de/media/endoheute/201203/lookinside/thumbnails/10.1055-s-0032-1325412-1.jpg)
Zusammenfassung
Hintergrund und Studienziele: Der Nutzen der therapeutischen Endoskopie bei der nicht varikösen oberen gastrointestinalen Blutung (NVOGIB) ist unbestritten. Der optimale Zeitpunkt hingegen ist unklar. Ziel der vorliegenden Studie war die Untersuchung des Zusammenhangs zwischen Endoskopiezeitpunkt und klinischem Behandlungsergebnis bei Patienten mit NVOGIB.
Patienten und Methoden: Dieser Studie liegen prospektive Erhebungen in 212 britischen Krankenhäusern zugrunde. Mit einem Regressionsmodell wurde der Zusammenhang zwischen dem Zeitpunkt der Endoskopie (time to endoscopy) und der Mortalität einer Rezidivblutung, der Operationsnotwendigkeit und der Dauer der stationären Behandlung untersucht.
Ergebnisse: Bei 4478 Patienten war eine frühzeitige Endoskopie (< 12 Stunden) nicht mit einer geringeren Mortalität oder Operationshäufigkeit assoziiert im Vergleich zu einer späteren Endoskopie (> 12 Stunden) (Odds Ratio [OR] für die Mortalität 0,98, 95 %-Konfidenzintervall [CI] 0,88 – 1,09 für eine Endoskopie > 24 Stunden vs. < 12 Stunden, p = 0,70). Für Patienten, die eine therapeutische Endoskopie erhielten, ergab sich bei späterer Endoskopie ein Trend zu häufigerer Rezidivblutung (OR 1,13, 95 % CI 0,97 – 1,32 für Endoskopie > 24 Stunden vs. < 12 Stunden). Ein umgekehrter Trend wurde bei Patienten ohne endoskopische Behandlung beobachtet (OR 0,83, 95 % CI 0,73 – 0,95 für Endoskopie > 24 Stunden vs. < 12 Stunden, p = 0,003). Eine spätere Endoskopie (> 24 Stunden) war mit einer risikoadjustierten Erhöhung der stationären Behandlungsdauer assoziiert (1,7 Tage länger, 95 % CI 1,39 – 1,99 vs. < 12 Stunden; p < 0,001).
Schlussfolgerungen: Eine frühere Endoskopie war nicht mit einer Reduktion der Mortalität oder der Operationsnotwendigkeit assoziiert. Die Assoziation mit einer erhöhten Effizienz der Behandlung und einer potenziell verbesserten Blutungskontrolle bei Hochrisikopatienten unterstützt einen früheren Endoskopiezeitpunkt in der Routine-Praxis, wenn keine spezifischen Kontraindikationen existieren. Diese Resultate können für Diskussionen über die Organisation des Notfallendoskopiediensts hilfreich sein.
Abstract
Background and study aims: Despite the established efficacy of therapeutic endoscopy, the optimum timeframe for performing endoscopy in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) remains unclear. The aim of the current audit study was to examine the relationship between time to endoscopy and clinical outcomes in patients presenting with NVUGIB.
Patients and methods: This study was a prospective national audit performed in 212 UK hospitals. Regression models examined the relationship between time to endoscopy and mortality, rebleeding, need for surgery, and length of hospital stay.
Results: In 4478 patients, earlier endoscopy ( < 12 hours) was not associated with a lower mortality or need for surgery compared with later ( > 24 hours) endoscopy (odds ratio [OR] for mortality 0.98, 95 % confidence interval [CI] 0.88 – 1.09 for endoscopy > 24 hours vs. < 12 hours; p = 0.70). In patients receiving therapeutic endoscopy, there was a nonsignificant trend towards an increase in rebleeding associated with later endoscopy (OR 1.13, 95 %CI 0.97 – 1.32 for endoscopy > 24 hours vs. < 12 hours), with the converse seen in patients not requiring therapeutic endoscopy (OR 0.83, 95 %CI 0.73 – 0.95 for endoscopy > 24 hours vs. < 12 hours; interaction p = 0.003). Later endoscopy ( > 24 hours) was associated with an increase in risk-adjusted length of hospital stay (1.7 days longer, 95 %CI 1.39 – 1.99 vs. < 12 hours; p < 0.001).
Conclusions: Earlier endoscopy was not associated with a reduction in mortality or need for surgery. However, it was associated with an increased efficiency of care and potentially improved control of hemorrhage in higher risk patients, supporting the routine use of early endoscopy unless specific contraindications exist. These results may help inform the debate about emergency endoscopy service provision.
-
Literatur
- 1 van Leerdam ME, Vreeburg EM, Rauws EA et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am J Gastroenterol 2003; 98: 1494-1499
- 2 Lassen A, Hallas J, Schaffalitzky de Muckadell OB. Complicated and uncomplicated peptic ulcers in a Danish county 1993–2002: a population-based cohort study. Am J Gastroenterol 2006; 101: 945-953
- 3 Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993–2003. Clin Gastroenterol Hepatol 2006; 4: 1459-1466
- 4 Sacks HS, Chalmers TC, Blum AL et al. Endoscopic hemostasis. An effective therapy for bleeding peptic ulcers. JAMA 1990; 264: 494-499
- 5 Cook DJ, Guyatt GH, Salena BJ et al. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology 1992; 102: 139-148
- 6 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-113
- 7 Lim LG, Ho KY, Chan YH et al. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy 2011; 43: 300-306
- 8 Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med 2001; 161: 1393-1404
- 9 Cooper GS, Chak A, Way LE et al. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc 1999; 49: 145-152
- 10 Cooper GS, Kou TD, Wong RC. Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis. Gastrointest Endosc 2009; 70: 229-235
- 11 Yen D, Hu SC, Chen LS et al. Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department. Am J Emerg Med 1997; 15: 644-647
- 12 Choudari CP PK. Timing of endoscopy for severe peptic ulcer hemorrhage: out of hours emergency endoscopy is unnecessary. Gastroenterology 1993; 104: A55
- 13 UK Comparative Audit of Upper Gastrointestinal Bleeding and the Use of Blood. British Society of Gastroenterology. Available from: www.bsg.org.uk/pdf_word_docs/blood_audit_report_07.pdf Accessed: 15 January 2012
- 14 Hearnshaw SA, Logan RF, Lowe D et al. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut 2010; 59: 1022-1029
- 15 Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using Stata. College Station, Texas: Stata Press; 2008
- 16 Royston P, Altman DG, Sauerbrei W. Dichotomizing continuous predictors in multiple regression: a bad idea. Stat Med 2006; 25: 127-141
- 17 Royston P, Sauerbrei W. Multivariable model-building. A pragmatic approach to regression analysis based on fractional polynomials for modelling continuous variables. Chichester, UK: Wiley-Blackwell; 2008. ISBN: 978-0-470-02842-1
- 18 Royston P. Multiple imputation of missing values: further update of ice, with an emphasis on interval censor monitoring. Stata Journal 2007; 7: 445-464
- 19 Cipolletta L, Bianco MA, Rotondano G et al. Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 2002; 55: 1-5
- 20 Spiegel BM. Endoscopy for acute upper GI tract hemorrhage: sooner is better. Gastrointest Endosc 2009; 70: 236-239
- 21 Hay JA, Maldonado L, Weingarten SR et al. Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage. JAMA 1997; 278: 2151-2156
- 22 Lee JG, Turnipseed S, Romano PS et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50: 755-761
- 23 Rockall TA, Logan RF, Devlin HB et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996; 347: 1138-1140
- 24 Hill DB, Stokes BD, Gilinsky NH. Arterial oxygen saturation during emergency esophagogastroduodenoscopy. The effects of nasal oxygen. J Clin Gastroenterol 1994; 18: 284-286
- 25 Lin HJ, Wang K, Perng CL et al. Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study. J Clin Gastroenterol 1996; 22: 267-271
- 26 Bjorkman DJ, Zaman A, Fennerty MB et al. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointest Endosc 2004; 60: 1-8
- 27 Hearnshaw SA, Logan RF, Palmer KR et al. Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding. Aliment Pharmacol Ther 2010; 32: 215-224
- 28 Jairath V, Hearnshaw S, Brunskill SJ et al. Red cell transfusion for the management of upper gastrointestinal haemorrhage. Cochrane Database Syst Rev 2010; 9: CD006613
- 29 Jairath VKB, Kahan BC, Logan RFA et al. Red cell transfusion practice in patients presenting with acute upper gastrointestinal bleeding. A survey of 815 UK clinicians. Transfusion 2011; 51: 1940-1948
- 30 Palmer K. Non-variceal upper gastrointestinal haemorrhage: guidelines. British Society of Gastroenterology Endoscopy Committee. Gut 2002; 51 (Suppl. 04) iv1-iv6
- 31 Management of acute upper and lower gastrointestinal bleeding. A national clinical guideline. Scottish Intercollegiate Guidlelines Network. Available from: www.sign.ac.uk/pdf/sign105.pdf Accessed: 15 January 2012