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Many studies of upper gastrointestinal bleeding (UGIB) are centered in tertiary hospitals with centers of excellence. Now, in the setting of 53 public hospitals in France, investigators describe treatment, outcomes during hospitalization, and prognostic indicators in 3203 prospectively enrolled patients admitted for UGIB during 1 year.
Results are as follows.
Endoscopy was performed in 96% of patients and indicated peptic ulcer bleeding in 37% of patients, bleeding varices or portal hypertensive gastropathy in 25%, and erosive esophagitis in 13%.
Endoscopic hemostasis was performed in 66% of patients with ulcers and in 63% with varices.
Most patients (88%) were treated with a proton-pump inhibitor.
The overall rebleeding rate was 10%, and the hospital mortality rate was 8.3% (5.6% for ulcers, 10.5% for varices or portal hypertension).
In multivariate analysis, risk for rebleeding was associated with the need for transfusion (odds ratio, 19.1; 95% confidence interval, 10.1–35.9), hemoglobin <10 g/dL at admission (OR, 1.7; 95% CI, 1.1–3.3), increasing Rockall score (OR, 1.4 per 1-point increase; 95% CI, 1.0–1.9), systolic blood pressure <100 mg Hg at admission (OR, 1.9; 95% CI, 1.4–2.5), and signs of recent bleeding (OR, 2.4; 95% CI, 1.7–3.5).
Mortality risk was associated with increasing Rockall score (OR, 2.8 per 1-point increase; 95% CI, 2.0–4.0), comorbidities (OR, 3.6; 95% CI, 2.0–6.3 for each additional morbidity), and systolic blood pressure <100 mm Hg at admission (OR, 2.1; 95% CI, 1.8–2.8).
In 29% of deaths, the cause was directly related to UGIB. The other most frequent causes of death were hepatic failure (18%), sepsis (13%), and cardiorespiratory failure (11%).
The authors point out that portal hypertension accounted for nearly 1 in 4 cases of UGIB; that the mortality rate was lower than in previous studies (which they suggest might result from improved endoscopic and pharmacologic therapy); and that these results confirm prior findings that comorbidities and transfusions are associated with worse outcomes.
Nahon S et al. Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: Results of a French prospective multicenter study. Endoscopy 2012 Nov; 44:998. (http://dx.doi.org/10.1055/s-0032-1310006)
Comment
This study provides a snapshot of the standard of care for upper gastrointestinal bleeding and its outcomes in France. The results are similar to studies in the U.K. and a study in Canada limited to nonvariceal bleeding. Of note, the increased risk for UGIB associated with the increasing Rockall score likely reflects the underlying risk factors of hypotension, comorbidity, and stigmata of recent bleeding that constitute the score. Access to aggressive treatment was available to all patients in this study; similar studies should be conducted in countries without universal access to optimal therapy.