Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding.

Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.

The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis.

BACKGROUND: Despite major advances in upper GI hemorrhage (UGIH) treatment, UGIH mortality has been reported as unchanged for the past 50 years. OBJECTIVE: To measure the UGIH in-hospital mortality rate and other important outcome trends from 1989 to 2009. DESIGN: A longitudinal study of UGIH hospitalizations by using the Nationwide Inpatient Sample. SETTING: Acute-care hospitals. PATIENTS: All patients admitted for UGIH. Patients who bled after admission were excluded. MAIN OUTCOME MEASUREMENTS: UGIH in-hospital mortality rate, incidence, in-hospital endoscopy and endoscopic therapy rates, length of hospital stay, and total in-hospital charges. RESULTS: The non-variceal UGIH mortality rate decreased from 4.5% in 1989 to 2.1% in 2009. The non-variceal UGIH incidence declined from 108 to 78 cases/100,000 persons in 1994 and 2009, respectively. In-hospital upper endoscopy and endoscopic therapy rates increased from 70% and 10% in 1989 to 85% and 27% in 2009, respectively. The early endoscopy rate increased from 36% in 1989 to 54% in 2009. The median length of hospital stay decreased from 4.5 days in 1989 to 2.8 days in 2009. Median total hospitalization charges increased from $9249 in 1989 to $20,370 in 2009. At the national level, the UGIH direct in-hospital economic burden increased from $3.3 billion in 1989 to $7.6 billion in 2009. Similar trends were found for variceal UGIH. LIMITATIONS: Retrospective data, administrative database. CONCLUSION: In-hospital mortality from UGIH has been decreasing over the past 2 decades, with a concomitant increase in rate of endoscopy and endoscopic therapy. However, despite decreasing length of stay, the total economic burden of UGIH is increasing.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

Impact of day of admission on mortality and other outcomes in upper GI hemorrhage: a nationwide analysis.

BACKGROUND: Studies have reached varying conclusions regarding the association between day of admission and outcomes in patients with upper GI hemorrhage (UGIH). OBJECTIVES: To evaluate whether important outcomes in UGIH, including in-hospital mortality, differ between patients admitted on weekends versus weekdays. DESIGN AND SETTING: Retrospective cohort study by using the 2009 Nationwide Inpatient Sample. PATIENTS: Patients were included if they were adults with a principal diagnosis of acute UGIH. Patients admitted between midnight Friday and midnight Sunday were classified as weekend admissions. MAIN OUTCOME MEASUREMENTS: In-hospital mortality, in-hospital endoscopy, endoscopic therapy, length of stay, and total hospitalization charges. RESULTS: The study included 199,008 patients with nonvariceal UGIH and 3251 patients with variceal UGIH. Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar adjusted in-hospital mortality rates (odds ratio [OR] 1.11; 95% confidence interval [CI], 0.93-1.30), endoscopic therapy rates (OR 0.98; 95% CI, 0.92-1.04), and length of stay (P = .09), but had lower early endoscopy rates (within 24 hours)(OR 0.64; 95% CI, 0.60-0.67), lower in-hospital endoscopy rates (OR 0.84; 95% CI, 0.78-0.91), and higher hospitalization charges (mean increase, $1558; P = .01). Patients with variceal UGIH admitted on weekends and weekdays did not differ in any of these outcomes. LIMITATIONS: Retrospective data, administrative database. CONCLUSIONS: Compared with patients admitted on weekdays, patients with nonvariceal UGIH admitted on weekends had similar mortality rates and lengths of stay, but lower endoscopy rates and higher hospitalization charges. Patients with variceal GI hemorrhage had similar outcomes regardless of day of admission.

A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding.

BACKGROUND: Although the early use of a risk stratification score in upper GI bleeding is recommended, existing risk scores are not widely used in clinical practice. OBJECTIVE: We sought to develop and validate an easily calculated bedside risk score, AIMS65, by using data routinely available at initial evaluation. DESIGN: Data from patients admitted from the emergency department with acute upper GI bleeding were extracted from a database containing information from 187 U.S. hospitals. Recursive partitioning was applied to derive a risk score for in-hospital mortality by using data from 2004 to 2005 in 29,222 patients. The score was validated by using data from 2006 to 2007 in 32,504 patients. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. MAIN OUTCOME MEASUREMENTS: Mortality, length of stay (LOS), and cost of admission. RESULTS: The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years. For those with no risk factors, the mortality rate was 0.3% compared with 31.8% in patients with all 5 (P < .001). The model had a high predictive accuracy (AUROC = 0.80; 95% CI, 0.78-0.81), which was confirmed in the validation cohort (AUROC = 0.77, 95% CI, 0.75-0.79). Longer LOS and increased costs were seen with higher scores (P < .001). LIMITATIONS: Database data used does not include outcomes such as rebleeding. CONCLUSIONS: AIMS65 is a simple, accurate risk score that predicts in-hospital mortality, LOS, and cost in patients with acute upper GI bleeding.