Variation in outcome after acute upper gastrointestinal haemorrhage

doi:10.1016/S0140-6736(95)92227-X

The Lancet

Volume 346, Issue 8971, 5 August 1995, Pages 346-350

https://doi.org/10.1016/S0140-6736(95)92227-X Get rights and content

Abstract

Summary

Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multicentre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation.

We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14·3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places.

Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.

References (25)

Rfa Logan et al.
Death in acute upper gastrointestinal bleeding can endoscopy reduce mortality?
Lancet
(1976)
Ar Berry et al.
Upper gastrointestinal haemorrhage in Oxford
J R Coll Surg Edinb
(1984)
PS. Hunt
Mortality in patients with haematemesis and melaena: a prospective study
BMJ
(1979)
Rae Holman et al.
Value of centralised approach in the management of haematemesis and melaena: experience in a district general hospital
Gut
(1990)
Tk Daneshmend et al.
Omeprazole versus placebo for acute upper gastrointestinal bleeding: randomised double blind controlled trial
BMJ
(1992)
FA. Jones
Haematemesis and melaena with special reference to bleeding peptic ulcer
BMJ
(1947)
Sj Johnston et al.
Epidemiology and course of gastrointestinal haemorrhage in North-east Scotland
BMJ
(1973)
Bd Katschinski et al.
Audit of mortality in upper gastrointestinal bleeding
Postgrad Med J
(1989)
Jf Mayberry et al.
Mortality in acute upper gastrointestinal haemorrhage: a six year survey from the University Hospital in Wales
Postgrad Med J
(1981)
Kfr Schiller et al.
Haematemesis and melaena, with special reference to factors influencing the outcome
BMJ
(1970)

Ta Rockall et al.

Incidence and mortality from acute upper gastrointestinal bleeding in the UK

Gut

(1974)

M. Emberton et al.

Caught in the act

Br J Healthcare Computing Information Management

(1993)

Cited by (129)

Management of massive gastrointestinal haemorrhage
2022, Surgery (United Kingdom)
Gastrointestinal haemorrhage (GI bleeding) is a common medical emergency, with one patient presenting every 6 minutes in the UK, or 85,000 cases per annum. It is associated with a significant mortality rate that has remained relatively static at 10% for more than two decades. Haemorrhage is commonly categorized as upper or lower gastrointestinal in origin, but for organization of care, both groups should be regarded as one clinical entity. Rapid assessment, resuscitation and correction of coagulopathy should be undertaken, and investigation or definitive management urgently arranged. For upper GI haemorrhage, endoscopy remains the cornerstone of investigation and treatment. In lower GI haemorrhage, a more nuanced algorithm utilizing CT angiography and endoscopic evaluation is recommended. Clinicians may utilize a range of treatment modalities including endoscopic and interventional techniques to diagnose and control the source of haemorrhage, which should be tailored to the site of bleeding and pathology. Where control is not achieved the clinician should consider either repeat intervention, use of alternative haemostatic techniques or a different modality to achieve haemostasis. Surgery is rarely used as a treatment and should only be undertaken where all other measures to control haemorrhage have failed.
Acute Gastrointestinal Bleeding – Locating the Source and Correcting the Disorder
2021, Physician Assistant Clinics
AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review
2020, Gastroenterology
Citation Excerpt :
Patients with NVUGIB may have variable presentations ranging from harmless, minor, self-limited bleeding that can be managed with an outpatient workup, to hypovolemic shock requiring transfer to the intensive care unit. The treating provider should be familiar with various scoring systems that have been developed to help triage patients with NVUGIB.7–10 These scoring systems are based on clinical parameters and endoscopic findings that predict mortality and rebleeding risk in patients with NVUGIB (Table 1).
The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available evidence and best practice advice statements regarding the use of endoscopic therapies in treating patients with non-variceal upper gastrointestinal bleeding.
This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. This review is framed around the 10 best practice advice points agreed upon by the authors, which reflect landmark and recent published articles in this field. This expert review also reflects the experiences of the authors who are gastroenterologists with extensive experience in managing and teaching others to treat patients with non-variceal upper gastrointestinal bleeding (NVUGIB).
Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB.
Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding.
Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips.
Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base.
Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective.
Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy.
Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement.
Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding.
In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery.
Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.
Acute non-variceal upper gastrointestinal bleeding
2013, Core Topics in General and Emergency Surgery, Fifth Edition
The role of endoscopy in the management of acute non-variceal upper GI bleeding
2012, Gastrointestinal Endoscopy
Citation Excerpt :
In 3 studies comparing clinical prediction rule scores in the same study population, the Blatchford score performed better than the Clinical Rockall score for predicting patients at high risk for clinical intervention.12-14 The Blatchford score15 and the Clinical Rockall score16 have been examined in several studies and may determine the need for urgent endoscopy. The Blatchford score uses data on blood urea and hemoglobin levels, systolic blood pressure, pulse, presentation with melena, presentation with syncope, history of hepatic disease, and history of heart failure (Table 2).15
Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding
2012, American Journal of Emergency Medicine
Citation Excerpt :
The goals of these tools are to identify patients most likely to suffer an adverse outcome and, therefore, more likely to benefit from early, aggressive management as well as to identify those most likely to have a benign course so that early hospital discharge or even outpatient management can be considered. The Rockall score is a scoring system that was developed to predict mortality in patients with acute UGIH [5-8]. The score consists of a clinical component composed of preendoscopy variables as well as an endoscopic component (Table 1).
Acute upper gastrointestinal hemorrhage (UGIH) is a common reason for hospitalization with substantial associated morbidity, mortality, and cost. Differentiation of high- and low-risk patients using established risk scoring systems has been advocated.
The aim of this study was to determine whether these scoring systems are more accurate than an emergency physician's clinical decision making in predicting the need for endoscopic intervention in acute UGIH.
Patients presenting to a tertiary care medical center with acute UGIH from 2003 to 2006 were identified from the hospital database, and their clinical data were abstracted. One hundred ninety-five patients met the inclusion criteria and were included in the analysis. The clinical Rockall score and Blatchford score (BS) were calculated and compared with the clinical triage decision (intensive care unit vs non–intensive care unit admission) in predicting the need for endoscopic therapy.
Clinical Rockall score greater than 0 and BS greater than 0 were sensitive predictors of the need for endoscopic therapy (95% and 100%) but were poorly specific (9% and 4%), with overall accuracies of 41% and 39%. At higher score cutoffs, clinical Rockall score greater than 2 and BS greater than 5 remained sensitive (84% and 87%) and were more specific (29% and 33%), with overall accuracies of 48% and 52%. Clinical triage decision, as a surrogate for predicting the need for endoscopic therapy, was moderately sensitive (67%) and specific (75%), with an overall accuracy (73%) that exceeded both risk scores.
The clinical use of risk scoring systems in acute UGIH may not be as good as clinical decision making by emergency physicians.

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Variation in outcome after acute upper gastrointestinal haemorrhage

Abstract

Lancet

Upper gastrointestinal haemorrhage in Oxford

J R Coll Surg Edinb

Mortality in patients with haematemesis and melaena: a prospective study

BMJ

Value of centralised approach in the management of haematemesis and melaena: experience in a district general hospital

Gut

Omeprazole versus placebo for acute upper gastrointestinal bleeding: randomised double blind controlled trial

BMJ

Haematemesis and melaena with special reference to bleeding peptic ulcer

BMJ

Epidemiology and course of gastrointestinal haemorrhage in North-east Scotland

BMJ

Audit of mortality in upper gastrointestinal bleeding

Postgrad Med J

Mortality in acute upper gastrointestinal haemorrhage: a six year survey from the University Hospital in Wales

Postgrad Med J

Haematemesis and melaena, with special reference to factors influencing the outcome

BMJ

Incidence and mortality from acute upper gastrointestinal bleeding in the UK

Gut

Caught in the act

Br J Healthcare Computing Information Management