gms | German Medical Science

Background: Upper GI bleeding remains one of the most common emergencies with a substantial overall mortality rate of up to 30%. In severe ill patients death does not occur due to failure of hemostasis, either medical or surgical, but mainly from co-morbidities, treatment complications and decreased tolerated blood loss. Management strategies have changed dramatically over the last two decades and include primarily endoscopic intervention in combination with acid suppressive therapy and decrease in surgical intervention. Herein we present one of the largest patient-based analysis assessing clinical parameters and outcome in patients undergoing endoscopy with an upper GI bleeding investigating the role of surgery in particular.

Materials and methods: Prospective data collection including demographic data, laboratory results, endoscopy reports and details of management including blood administration, and surgery was carried out. Patient events were grouped and defined as „overall“ events, „operated“, „non-operated“ and „operated and death“ as well as „non-operated and death“ where approriate. Blatchford, clinical as well as complete Rockall-score analysis, risc stratification and disease-related mortality rate were calculated for each group for comparison.

Results: Overall 283 patients were eligible for analysis, endoscopy was carried out in 96% of all patients, 17% needed surgical intervention after endoscopic failure of bleeding control; ten patients were subjected directly to surgery due to technical failure of endoscopic intervention. The median length of stay to discharge was 26 days. Overall mortality was 22%, out of them almost 5% were operated. Patients with either gastric or duodenal ulcera needed surgical intervention in almost 25% and 20%, respectively. Also, endoscopic complications with need for surgical intervention was necessary in almost 25% promoting increased high in-hospital mortality. Anticoagulation was associated with a high in hospital mortality of 43%. Interestingly, disease-related survival analysis demarked a better in hospital outcome for patients undergoing surgery compared to endoscopy alone. Clinically, statistical correlation was found for initial systemic hemoglobin count, blood transfusion, need for surgical intervention, length of admission, and risk of death once scored with Blatchford, clinical, as well as complete Rockall score. Risk factor analysis including co-morbidity, drug administration as well as anticoagulation therapy introduced the combination of tumor and non-steroidal antirheumatic medication as independent risk factors for increased disease-related mortality.

Conclusion: Our data here promote earlier surgical intervention for patients with an upper GI bleeding event, in particular for patients with recurrent bleeding as well as endoscopic complications. Taken together, an interdisciplinary approach including gastroenterologists as well as surgeons should be used once the patient is admitted to the hospital to define best treatment option.