Management of overt upper gastrointestinal bleeding in a low resource setting: a real world report from Nigeria

Upper gastrointestinal bleeding (UGIB) is a major affliction that has been known from antiquity and remains a common medical problem worldwide [1]. It is associated with significant morbidity, mortality, and health care resource utilization [2]. It is estimated that about 100–150 cases will occur per 100,000 adults per year in any given population [3],[4]. About 4–14% of the affected patients will die from the condition, while 10–30% of patients will have rebleeding [5]-[7]. In resource-poor settings where facilities and the required equipment and training that are necessary for the management of this condition are limited, mortality will undoubtedly be higher.

Endoscopy has significantly revolutionised the management of patients with UGIB. It is used for diagnosis, stratifying patients, and treating the disease [6]. Therapeutic procedures, such as rubber band ligation, haemoclip, injection sclerotherapy and an endoscopic coagulation technique such as a heater probe, bipolar and monopolar coagulation, and argon plasma coagulation have been used to treat various causes of UGIB [6]-[8]. These treatment modalities have been shown to reduce rebleeding, blood transfusion requirements, and the need for ulcer surgery for definitive haemostasis [8]. In addition, appropriate use of endoscopy treatments significantly reduces hospital length of stay and health care costs [9]-[11].

In Nigeria and many economically resource-poor countries, upper gastrointestinal (GI) endoscopy services are not readily available. Where they are available, they are seldom affordable for most patients. This has limited the use of endoscopy in diagnosing the possible causes of bleeding. Worse still, the paucity of trained manpower in therapeutic procedures and the high cost of therapeutic endoscopic accessories have further limited the use of therapeutic techniques in the treatment of UGIB in Nigeria. The few centres that introduced therapeutic techniques had to adapt several modalities to reduce costs and maintain supplies [12]. Since the introduction of upper GI endoscopy to our hospital about three decades ago, few therapeutic procedures were performed, as reported in the literature [13]. Since 2007, different modalities of therapeutic procedures have been offered to patients that had overt UGIB. This study outlines the aetiology of UGIB, clinical presentation, treatment and outcomes of patients treated with endoscopy for UGIB. We identify the possible challenges preventing the routine use of these life-saving techniques in Nigeria.

Upper gastrointestinal bleeding continues to be a significant cause of morbidity and mortality worldwide, which places a significant demand on healthcare facilities [2]-[4],[17]. In our experience, it is one of the leading causes of referral for upper GI endoscopy. We found that 12.6% of the endoscopy referrals were for UGIB. This is higher than previously reported from our centre, [18] but similar to findings reported by Malu et al. [19] in their series from Northern Nigeria. However, Olokooba et al. [20] reported a high rate in the middle belt of Nigeria. This disparity may be due to the fact that the latter was an initial report with a small sample size. Being an initial report, the referrals were likely those that would benefit from the upper GI endoscopy the most.

Upper GI endoscopy remains the most effective modality to localise the site and cause of bleeding in over 95% of patients, especially when the procedure is performed within 24 hours of bleeding [5],[21],[22]. In the present study, the site of bleeding was detected in 91.6% of patients, which was similar to findings previously reported [23],[24]. Not all patients had the endoscopy procedure done within 48 hours of the initial occurrence of bleeding. Mucosal lesions are well known to heal quickly and generally the time interval between the bleeding episode and the endoscopic procedure is known to influence the accuracy and likelihood of finding a cause endoscopically [25]. Therefore, the availability of emergency endoscopy within 24 hours is most desirable. In reality, however, emergency endoscopy is rarely available in most healthcare centres in developing countries due to the insufficiency of well-trained endoscopists, trained support staff, or equipment. In addition, difficulty in accessing tertiary health services due to the poor referral systems that characterise most developing countries also prevents early presentation and detection of the cause of bleeding.

Our finding that duodenal ulcers were the most common cause of upper gastrointestinal bleeding in our study is consistent with reports from most Western countries [26]-[28]. Most studies from the Western world report that almost half of their cases with UGIB are due to duodenal ulcers, which is higher than the finding in this study [26]-[30]. The possible reason may be because of the fact that the median age of our patients was almost a decade lower than the average age in most Western case series [28],[29]. It is worth noting that variceal bleeding was the most common cause of UGIB in Northern Nigeria and most parts of North Africa where there is a high prevalence of chronic liver disease due to hepatitis B infection and schistosomiasis [19],[22],[25],[31]-[33]. This implies that the most common cause of UGIB in any given environment may be influenced by the prevalence of hepatitis B virus and schistosomiasis. However, we found that oesophageal varices were the second-most common cause of UGIB in our cohort. All of the patients in our study had a history of liver disease from hepatitis B or C virus. None of the patients had screening or preventive therapy for cirrhosis. In fact the diagnosis of cirrhosis was heralded by the occurrence of variceal bleeding in some of these patients. This implies that public education must be undertaken to inform people of the early features of liver disease and the advantages of early diagnosis.

Furthermore, in our study, gastritis accounted for the third-most common cause of UGIB. It should be noted that Ajayi et al. reported that gastritis was the most common cause of UGIB in their case study from southwest Nigeria [34]. Most of our patients were either farmers, artisans or traders. This group of patients is known to work long hours and they often abuse over-the-counter analgesics including nonsteroidal anti-inflammatory drugs (NSAIDs). Hence, gastritis and peptic ulcer-related causes were a common cause of UGIB in our series. This proposition is supported by the fact that almost 40% of our patients gave a history of recent or chronic use of NSAIDs. This finding was similar to a previous report from Nigeria [20]. However, the percentage is low compared to another study from Africa [22]. Data from Spain indicated that more than 50,000 gastrointestinal bleeding events and more than 1,000 deaths yearly were attributable to aspirin or other NSAID use [35],[36]. This national statistic translates to an NSAID-associated mortality of 5.6% or 15.3 deaths per 100,000 users [36]. Mortality from NSAIDs has, however, been reduced significantly because of a decrease in the prevalence of Helicobacter pylori infection as a result of frequent use of over-the-counter antibiotics. Additionally, increased use of proton pump inhibitors, widespread efforts to use lower doses of NSAIDs, increased use of safer NSAIDs, and improved treatment of acute ulcer bleeding have also contributed to lower mortality rates [37]-[40]. However, in Nigeria where there is a high prevalence of H. pylori [41] and indiscriminate use and purchase of NSAIDs across the counter, the morbidity and mortality of NSAID use may actually be on the rise. Regulations to discourage the prescription and dispensing of drugs by unqualified personnel are of paramount important in reducing this negative trend.

A previous report demonstrated that approximately 80% of patients with UGIB will experience an end of bleeding especially after treatment with medical therapy [30]. In this index study, however, only about two-thirds of the patients needed no other form of therapy than medical therapy. This may be because most of the cases of UGIB in our cohort were severe. This assertion was substantiated by the fact that over a third of the patients presented with haemorrhagic shock. Similarly, over 80% of our patients had a Rockall score of either medium or high risk. It may also be that only severe cases were referred to the tertiary health facility for treatment, while the mild cases were treated at the peripheral centre. In addition, health care expenses are largely out-of-pocket, so this may screen out mild cases.

This study also identify that endoscopic therapy was very effective for patients who could afford it. It also significantly reduced hospital stays and the number of patients that needed surgical haemostasis. Despite fewer endoscopic options due to availability, the effectiveness of endoscopic therapy in ulcer bleeding was comparable to a previous report [42]. This study reinforces the need to improve the availability and accessibility of endoscopic therapy for patients with UGIB. This can be achieved through collaboration with world bodies such as the World Gastroenterology Organization. Involvement of non-governmental organisations in sponsoring training programs and treatment of patients with UGIB are also needed.

This study also confirmed a previous report that variceal eradication using endoscopic rubber band ligation may be more effective than injection sclerotherapy [43]. Most patients with variceal bleeding needed more than one session for eradication because of a higher grade of varices encountered in the study. Patients should be properly counselled on the need for repeated procedures with variceal eradication at the commencement of therapy to improve compliance.

Rebleeding rates in this study were very low following endoscopic therapy and were expectedly higher in patients who did not have endoscopic haemostasis. This difference was most pronounced in patients with variceal bleeding. Rebleeding is associated with increased mortality; therefore, timely identification and aggressive management of patients at high risk for continued bleeding or rebleeding have become a major focus of UGIB therapy [43].

The mortality in this study was comparable to what was reported in previous studies [26],[44],[45]. Most of the mortality in this study was from variceal bleeding, especially in patients who did not have endoscopic therapy. The preventable deaths of patients with cirrhosis could be avoided if treatment is made free of charge for this group of patients.

One of the challenges encountered in management of patients with UGIB in developing countries is availability of safe blood for transfusion. Blood banks are always undersupplied, meaning that patients may have to provide donors when blood is needed. Only patients with good support are able to receive enough blood during resuscitation. In fact, most of the cases of mortality arise because of a lack of donor blood. While patients with higher Rockall scores needed more blood, survival is determined by the ability to stop bleeding endoscopically or surgically.

Despite the relevance of this study to a low resource setting, we noted some inherent defects in the study. Treatments were guided by availability and affordability rather than guidelines. This reflects the current situation of most resource-poor settings. Similarly, the H. pylori status of the patients was determined only by histopathology of biopsy specimens rather than medical records, which were not available for analysis. This limited the interpretation of the results of H. pylori status may also influence rebleeding rates.

In conclusion, this study clearly showed that UGIB is a common problem among Nigerians. Endoscopic therapy in a resource-poor setting like Nigeria is feasible, significantly reduces morbidity and mortality and is a cost-effective treatment. Efforts should be made to improve the accessibility of therapeutic procedures for patients with UGIB in Nigeria and other low resource settings.