Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit

Abstract

Objectives To examine the use of endoscopy in the UK for acute upper gastrointestinal bleeding (AUGIB) and compare with published standards. To assess the organisation of endoscopy services for AUGIB in the UK. To examine the relationship between outcomes and out of hours (OOH) service provision. Design Multi-centre cross sectional clinical audit. Setting All UK hospitals accepting admissions with AUGIB. Patients All adults ($16 yrs) presenting with AUGIB between 1st May and 30th June 2007. Data Collection A custom designed web-based reporting tool was used to collect data on patient characteristics, comorbidity and haemodynamic status at presentation to calculate the Rockall score, use and timing of endoscopy, treatment including endoscopic, rebleeding and in-hospital mortality. A mailed questionnaire was used to collect data on facilities and service organisation. Results Data on 6750 patients (median age 68 years) were analysed from 208 hospitals. 74% underwent inpatient endoscopy; of these 50% took place within 24 h of presentation, 82% during normal working hours and 3% between midnight and 8 am. Of patients deemed highrisk (pre-endoscopy Rockall score $5) only 55% were endoscoped within 24 h and 14% waited $72 h for endoscopy. Lesions with a high risk of rebleeding were present in 28% of patients of whom 74% received endoscopic therapy. Further bleeding was evident in 13% and mortality in those endoscoped was 7.4% (95% CI 6.7% to 8.1%). In 52% of hospitals a consultant led out of hours (OOH) endoscopy rota existed; in these hospitals 20% of first endoscopies were performed OOH compared with 13% in those with no OOH rota and endoscopic therapy was more likely to be administered (25% vs 21% in hospitals with no OOH rota). The risk adjusted mortality ratio was higher (1.21, p¼0.10, (95%CI 0.96 to 1.51)) in hospitals without such rotas. Conclusions This audit has found continuing delays in performing endoscopy after AUGIB and underutilisation of standard endoscopic therapy particularly for variceal bleeding. In hospitals with a formal OOH endoscopy rota patients received earlier endoscopy, were more likely to receive endoscopic therapy and may have a lower mortality.Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency and is associated with a significant mortality. Its incidence has been estimated to range from approximately 50e150 cases per 100 000 population and it accounts for over 4000 deaths a year in the UK.1e7 Timely endoscopy plays a central role in the modern management of AUGIB with the value of endoscopic therapy for bleeding from peptic ulcers and oesophageal varices being well established. The British Society of Gastroenterology and the National Blood Service together sponsored a prospective audit of the management of patients presenting with AUGIB to UK hospitals during a 2-month period in the summer of 2007. A previous audit carried out in 1993, also sponsored by the BSG and involving only four regions of England had found delays in undertaking endoscopy and underu...

Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding

“…Current evidence sug- gests that early administration of PPIs is the standard treatment of patients with NVUGB (20)(21)(22)(23)(24). The rebleeding rate observed in our patients (3.4%) was similar to that observed in the Italian PNED study (3.2%) and in other recent publications (17,18), but it was significantly lower than that reported in the Canadian RUGBE study (14.1%) (3,5,8). The divergence of our results from the ones of the Canadian study may be explained because a higher proportion of our patients received combined endoscopic therapy (adrenaline injection plus BICAP) than in the Canadian study; combined therapy has been shown to be superior to pharmacologic treatment for reduction of rebleeding in controlled trials (25)(26)(27).…”

“…In our study the occurrence of clinical manifestations of bleeding, the frequency of non-ulcerative lesions, the severity of gastrointestinal bleeding and the frequency of endoscopic high-risk stigmata for rebleeding were similar to those reported in the literature (11,(17)(18)(19). Nevertheless, the use of PPIs was not found as a protector risk factor of death in contrast to that observed in other studies.…”

Service provision for liver disease in the UK: a national questionnaire-based survey

“…[12][13][14] Only half of DGHs offer an acute gastrointestinal bleed service, which reflects the findings of other surveys. 15,16 A recent study showed that no change in mortality is achieved with an emergency gastrointestinal bleed service. 15 Most hospitals use banding and sclerotherapy and administer terlipressin.…”

“…15,16 A recent study showed that no change in mortality is achieved with an emergency gastrointestinal bleed service. 15 Most hospitals use banding and sclerotherapy and administer terlipressin. The use of antibiotic prophylaxis has been shown to reduce mortality in variceal bleeding.…”

Diagnosis and treatment of Helicobacter pylori for peptic ulcer bleeding in clinical practice - factors associated with non-diagnosis and non-treatment, and diagnostic yield in various settings

“…Upper gastrointestinal bleeding is an important cause of mortality worldwide (1)(2)(3)(4). Peptic ulcer disease is the most common cause of upper gastrointestinal bleeding (4)(5), and a significant proportion of peptic ulcers are caused by Helicobacter pylori (H. pylori) (6).…”