Comparative outcomes in patients with ulcer‐ vs non‐ulcer‐related acute upper gastrointestinal bleeding in the United Kingdom: a nationwide cohort of 4474 patients

Abstract

Background: Outcomes after Nonvariceal upper gastrointestinal bleeding (NVUGIB)have historically focused on ulcer-related causes. Little is known regarding non-ulcer bleeding, the most common cause of NVUGIB. Aim:To compare outcomes between ulcer-and non-ulcer-related NVUGIB and explore whether these could be explained by differences in baseline characteristics, bleeding severity or processes of care.Methods: Analysis of 4474 patients with NVUGIB from 212 United Kingdom hospitals as part of a nationwide audit. Logistic regression models were used to adjust for baseline characteristics, bleeding severity and processes of care.Results: 1682 patients had ulcer-related and 2792 patients had non-ulcer-related bleeding. Those with ulcer-related bleeding were older (median age 73 vs 69, P < 0.001), less likely to have been taking a PPI (18% vs 32%, P < 0.001), more likely to have been taking aspirin (40% vs 27%, P < 0.001) and present with shock (43% vs 32%, P < 0.001). Furthermore, those with ulcer-related bleeding were more likely to receive blood transfusion (66% vs 39%, P < 0.001), PPI infusion (27% vs 5%, P < 0.001) and endoscopic therapy (37% vs 8%, P < 0.001). Overall, ulcer-related bleeding had higher odds of in-hospital mortality (OR: 1.54; 95% CI:1.21-1.96, P < 0.0001), rebleeding (OR: 2.08; 95% CI: 1.73-2.51, P < 0.0001) and need for surgical/radiologic intervention (OR: 2.64; 95% CI: 1.85-3.77, P < 0.0001).The associations disappeared after adjustment for bleeding severity, whereas adjustment for patient characteristics or process of care factors had no impact. Conclusion:Patients with ulcer-related NVUGIB bleeding have worse outcomes than those with non-ulcer-related NVUGIB bleeding, which is due to more severe bleeding.Michael Sai Lai Sey and Seid B. Mohammed share co-first authorship. Brennan C. Kahan and Vipul Jairath share co-last authorship.

Validation of a New Risk Score System for Non-variceal Upper Gastrointestinal Bleeding

“…Despite the development of endoscopic therapies and pharmacological management, NVUGIB is still associated with considerable rates of mortality and morbidity, and high medical expenses. [2][3][4][5] The International Consensus Recommendations on the management of patients with NVUGIB recommend "early risk stratification" using validated prognostic scales. 6 A number of scoring systems have been devised to predict the outcome of patients with AUGIB, including the Rockall (RS), 7 preendoscopic Rockall (pre-RS), 8 Glasgow-Blatchford (GBS), 9 AIMS65, 10,11 and ProgettoNazionaleEmorragiaDigestiva (PNED) 12 scores.…”

Editorial: ulcer‐related vs non‐ulcer‐nonvariceal upper gastrointestinal bleeding—which has worse outcomes?

“…Adjustment for interventions (transfusions, proton pump inhibitor treatment, endoscopic haemostatic therapy) had little impact on the results, probably because these interventions were very closely correlated with bleeding severity. Similarly, adjustment for patient characteristics (age, sex, individual comorbidities, previous use of medications, Rockall score) had minimal impact on the results; although several of these factors are established confounders and/or predictors of outcomes within each group of patients, they would not necessarily influence the relative odds of outcomes between those groups …”

“…Still, there is a need for additional studies, conducted with similar rigour as that by Sey and colleagues . This way, future systematic reviews and meta‐analyses will have the power to identify specific subgroups of non‐ulcer‐related NVUGIB with substantially high or markedly low odds of mortality and rebleeding, thereby justifying a different management approach for these subgroups.…”

“…This is why the recent paper in AP&T by Sey and colleagues is so interesting and important . It sheds some light on non‐ulcer‐related NVUGIB, the ‘dark side of the moon’.…”

“…It is a post hoc analysis of one of the most rigorously conducted prospective upper gastrointestinal bleeding studies, the 2007 UK National Audit . Among 4474 patients with NVUGIB, ulcer‐related bleeding was associated with higher in‐hospital mortality (OR: 1.54; 95% CI: 1.21‐1.96) and rebleeding rates (OR: 2.08; 95% CI: 1.73‐2.51) compared to non‐ulcer‐related NVUGIB; in‐hospital mortality rates were 8% vs 6% respectively …”