Outcomes of acute upper gastrointestinal bleeding in relation to timing of endoscopy and the experience of endoscopist: a tertiary center experience

Abstract

Introduction: Patients with gastrointestinal bleeding admitted out of hours or at the weekends may have an excess mortality rate. The literature reports around this are conflicting. Aims and methods: We aimed to analyze the outcomes of emergency endoscopies performed out of hours and over the weekends in our center. We retrospectively analyzed data from April 2008 to June 2012. Results: A total of 507 ‘high risk’ emergency gastroscopies were carried out over the study period for various indications. Patients who died within 30 days of the index procedure [22 % (114 /510)] had a significantly higher Rockall score (7.6 vs. 6.0, P < 0.0001), a higher American Society of Anesthesiologists (ASA) status (3.5 vs. 2.7, P < 0.001), and a lower systolic blood pressure (BP) at the time of the examination (94.8 vs 103, P = 0.025). These patients were significantly older (77.7 vs. 67.5 years, P = 0.006), and required more blood transfusion (5.9 versus 3.8 units). Emergency out-of-hours endoscopy was not associated with an increased risk of death [relative risk (RR) 1.09, 95 % confidence interval (CI) 1.12 – 1.95]. Whether the examination was carried out by a senior specialist registrar (senior trainee) or a consultant made no difference to the survival of the patient (RR 0.98, CI 0.77 – 1.32). Conclusion: Higher pre-endoscopy Rockall score and ASA status contributed significantly to the 30-day mortality following upper gastrointestinal bleeding, whereas lower BP tended towards significance. Outcomes did not vary with the time of the endoscopy nor was there any difference between a consultant and a senior specialist registrar led service.

The effect of off-hours hospital admission on mortality and clinical outcomes for patients with upper gastrointestinal hemorrhage: A systematic review and meta-analysis of 20 cohorts

“…Five studies were carried out in Asia (Hong Kong, South Korea, Taiwan, and Saudi Arabia), 8 , 10–13 six in North America (USA), 4 , 6, 14–17 and nine in Europe (Italy, the Netherlands, Serbia, and the United Kingdom) 2 , 3, 5, 7, 18–22 . Six studies reported patients with UGIH caused by peptic ulcer, 8 , 10, 12, 19, 20, 22 one study included patients with bleeding gastroduodenal angiodysplasia, 17 three demonstrated the sources of bleeding were from the esophagus varix, 11 , 13, 15 and 10 studies included patients with both variceal and nonvariceal UGIH 2 , 3, 5–7 , 14, 16, 18, 21, 22 . Most recruited studies defined the “off‐hours” as weekends only,4–7, 11, 13–17 , 21 while four studies defined it as weekends and public holidays; 3 , 8, 12, 18 one study defined it as weekends and nighttime, 20 and one study defined it as nighttime only 19 .…”

“…Mortality was in-hospital in all studies in North America, whereas 30-day mortality was reported in some studies in Asia 8,12 and Europe. 2,3,7,[19][20][21][22] Thirty-day mortality includes all-cause deaths occurring only within 30 days of hospitalization and after being discharged from the hospital. For in-hospital mortality, all mortality will be counted, so long as the patient stays in the hospital.…”

“…2,3,5,7,[18][19][20][21][22] Six studies reported patients with UGIH caused by peptic ulcer, 8,10,12,19,20,22 one study included patients with bleeding gastroduodenal angiodysplasia, 17 three demonstrated the sources of bleeding were from the esophagus varix, 11,13,15 and 10 studies included patients with both variceal and nonvariceal UGIH. 2,3,[5][6][7]14,16,18,21,22 Most recruited studies defined the ''off-hours'' as weekends only, [4][5][6][7]11,[13][14][15][16][17]21 while four studies defined it as weekends and public holidays; 3,8,12,18 one study defined it as weekends and nighttime, 20 and one study defined it as nighttime only. 19 Three studies reported results by comparison to weekend admissions as well as nighttime admissions.…”

“…2,10,22 In order to avoid repeated calculation, we combined only weekend admissions for the current analysis. All studies were designed as cohorts; 17 were retrospective [3][4][5][6][7][8][10][11][12][13][14][15][16][17][18]21,22 and three were prospective. 2,19,20 We contacted the authors of one of the included studies and obtained additional information for our analysis.…”

“…Of these, 10 studies reported in-hospital mortality, [4][5][6]10,11,13,[15][16][17][18] nine reported 30-day mortality, 2,3,7,8,12,[19][20][21][22] and one reported both. 14 The result of meta-analysis showed that patients who were admitted during off-hours had (Table 2).…”