Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding

Jeong-Ju Yoo, Young Chang, Eun Ju Cho, Ji Eun Moon, Sang Gyune Kim, Young Seok Kim, Yun Bin Lee, Jeong-Hoon Lee, Su Jong Yu, Yoon Jun Kim, Jung-Hwan Yoon, Jeong-Ju Yoo, Young Chang, Eun Ju Cho, Ji Eun Moon, Sang Gyune Kim, Young Seok Kim, Yun Bin Lee, Jeong-Hoon Lee, Su Jong Yu, Yoon Jun Kim, Jung-Hwan Yoon

Abstract

Aim: To examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.

Methods: This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.

Results: A total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).

Conclusion: In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.

Keywords: Cirrhosis; Endoscopy; Gastroesophageal varices; Timing; Upper gastrointestinal bleeding.

Conflict of interest statement

Conflict-of-interest statement: All authors have no conflict of interest with respect to the subjects described in this article.

Figures

Figure 1
Figure 1
Comparison of 6-wk survival in the urgent and the non-urgent endoscopy groups. Kaplan-Meier survival plot stratified by timing of endoscopy of all patients. The dotted line indicates urgent endoscopy and the solid line indicates non-urgent endoscopy. The black line is the unadjusted cumulative survival graph before inverse probability weighting (IPW), and the gray line is the adjusted after the IPW correction.
Figure 2
Figure 2
Comparison of 6-wk transplant-free survival in the urgent and the non-urgent endoscopy groups. Kaplan-Meier survival plot stratified by timing of endoscopy of all patients. The dotted line indicates urgent endoscopy and the solid line indicates non-urgent endoscopy. The black line is the unadjusted cumulative graph before inverse probability weighting (IPW), and the gray line is the adjusted after the IPW correction.
Figure 3
Figure 3
Comparison of 6-wk re-bleeding rate in the urgent and the non-urgent endoscopy groups. Kaplan-Meier survival plot stratified by timing of endoscopy of all patients. The dotted line indicates urgent endoscopy and the solid line indicates non-urgent endoscopy. The black line is the unadjusted cumulative graph before inverse probability weighting (IPW), and the gray line is the adjusted after the IPW correction.

References

    1. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey WD; Practice Guidelines Committee of American Association for Study of Liver Diseases; Practice Parameters Committee of American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086–2102.
    1. Villanueva C, Piqueras M, Aracil C, Gómez C, López-Balaguer JM, Gonzalez B, Gallego A, Torras X, Soriano G, Sáinz S, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol. 2006;45:560–567.
    1. Abraldes JG, Villanueva C, Bañares R, Aracil C, Catalina MV, Garci A-Pagán JC, Bosch J; Spanish Cooperative Group for Portal Hypertension and Variceal Bleeding. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol. 2008;48:229–236.
    1. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65:310–335.
    1. de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63:743–752.
    1. Seo YS. Prevention and management of gastroesophageal varices. Clin Mol Hepatol. 2018;24:20–42.
    1. Cheung J, Wong W, Zandieh I, Leung Y, Lee SS, Ramji A, Yoshida EM. Acute management and secondary prophylaxis of esophageal variceal bleeding: a western Canadian survey. Can J Gastroenterol. 2006;20:531–534.
    1. Cheung J, Soo I, Bastiampillai R, Zhu Q, Ma M. Urgent vs. non-urgent endoscopy in stable acute variceal bleeding. Am J Gastroenterol. 2009;104:1125–1129.
    1. Hsu YC, Chung CS, Tseng CH, Lin TL, Liou JM, Wu MS, Hu FC, Wang HP. Delayed endoscopy as a risk factor for in-hospital mortality in cirrhotic patients with acute variceal hemorrhage. J Gastroenterol Hepatol. 2009;24:1294–1299.
    1. Lee JG, Turnipseed S, Romano PS, Vigil H, Azari R, Melnikoff N, Hsu R, Kirk D, Sokolove P, Leung JW. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999;50:755–761.
    1. Schacher GM, Lesbros-Pantoflickova D, Ortner MA, Wasserfallen JB, Blum AL, Dorta G. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A “fortuitously controlled” study. Endoscopy. 2005;37:324–328.
    1. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38:316–321.
    1. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356:1318–1321.
    1. Kumar NL, Cohen AJ, Nayor J, Claggett BL, Saltzman JR. Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding. Gastrointest Endosc. 2017;85:945–952.e1.
    1. Hart A. Mann-Whitney test is not just a test of medians: differences in spread can be important. BMJ. 2001;323:391–393.
    1. Thabut D, Bernard-Chabert B. Management of acute bleeding from portal hypertension. Best Pract Res Clin Gastroenterol. 2007;21:19–29.
    1. Escorsell A, Ruiz del Arbol L, Planas R, Albillos A, Bañares R, Calès P, Pateron D, Bernard B, Vinel JP, Bosch J. Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology. 2000;32:471–476.
    1. Escorsell A, Bordas JM, del Arbol LR, Jaramillo JL, Planas R, Bañares R, Albillos A, Bosch J. Randomized controlled trial of sclerotherapy versus somatostatin infusion in the prevention of early rebleeding following acute variceal hemorrhage in patients with cirrhosis. Variceal Bleeding Study Group. J Hepatol. 1998;29:779–788.
    1. D'Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev. 2010:CD002233.
    1. Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Therap Adv Gastroenterol. 2014;7:206–216.
    1. Dai C, Liu WX, Jiang M, Sun MJ. Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis. World J Gastroenterol. 2015;21:2534–2541.
    1. Augustin S, González A, Genescà J. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010;2:261–274.
    1. Sung JJ, Chung SC, Yung MY, Lai CW, Lau JY, Lee YT, Leung VK, Li MK, Li AK. Prospective randomised study of effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation. Lancet. 1995;346:1666–1669.
    1. Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 2017;85:936–944.e3.
    1. Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29:1655–1661.
    1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69:406–460.
    1. Sarin SK, Kumar A, Angus PW, Baijal SS, Chawla YK, Dhiman RK, Janaka de Silva H, Hamid S, Hirota S, Hou MC, et al. Primary prophylaxis of gastroesophageal variceal bleeding: consensus recommendations of the Asian Pacific Association for the Study of the Liver. Hepatol Int. 2008;2:429–439.
    1. Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal GE. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999;49:145–152.
    1. 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.
    1. Lim LG, Ho KY, Chan YH, Teoh PL, Khor CJ, Lim LL, Rajnakova A, Ong TZ, Yeoh KG. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy. 2011;43:300–306.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren