Rezumat

Mortalitatea i necesarul de tratament chirurgical n hemoragia digestiv superioar acut: un studiu pe o perioad de un an ntr-un centru teriar cu gard permanent de endoscopie. S-a schimbat ceva?"

Introducere: Dei n trecut o frecvent urgen chirurgical,hemoragia digestiv superioar constituie la ora actual ceamai frecvent urgen gastroenterologic.Scop: Evaluarea situaiei actuale privind mortalitatea i necesarul de tratament chirurgical n hemoragia digestivsuperioar.Material i metod: Studiu clinic retrospectiv nerandomizat desfurat la Institutul Regional de Gastroenterologie iHepatologie Profesor Dr. Octavian Fodor din Cluj Napoca.757 de pacieni cu hemoragie digestiv superioar au fostexaminai endoscopic n primele 24 de ore de la prezentare.Datele au fost colectate din foile de observaie i programulHospital Manager. Pentru analiza statistic, am efectuattestele: chi ptrat, Spearman, Kruskall-Wallis, Mann-Whitney,AUROC (area under receiver operating curve).Rezultate: A predominat etiologia non-variceal, etiologia principal fiind cea ulceroas. Mortalitatea intraspitaliceascglobal a fost de 10.43%, rata de resngerare de 12.02%, trata-

mentul chirurgical fiind efectuat n 7.66% din cazuri. 3.68%din cazurile de hemoragie nonvariceal au necesitat hemostazchirurgical de urgen. Necesarul de tratament chirurgical s-acorelat cu scorul Rockall complet (p=0.0425). Pentru ulcerulpeptic, necesarul chirurgical nu a fost influenat de momentulendoscopiei sau tipul de tratament efectuat (p=0.1452).Prezentarea n cursul weekendului (p=0.996) sau a nopii(p=0.5414) nu s-a corelat cu un necesar mai mare de inter-venie chirurgical.Concluzii: n ultimul deceniu, necesarul de tratament chirurgical de urgen n hemoragia superioar digestiv s-aredus cu 50% dar mortalitatea a rmas constant.

Cuvinte cheie: hemoragie digestiv superioar, hemostazendoscopic, tratament chirurgical, mortalitate

AbstractBackground: Acute upper gastrointestinal bleeding, previouslyoften a surgical problem, is now the most common gastro-enterological emergency.Aim: To evaluate the current situation in terms of mortalityand need of surgery.Subjects and methods: Retrospective non-randomised clinicalstudy performed between 1st January-31st December 2011, at"Professor Dr. Octavian Fodor Regional Institute of Gastro-enterology and Hepatology in Cluj Napoca. 757 patients withupper gastrointestinal bleeding were endoscopically examinedwithin 24 hours from presentation in the emergency unit. Datawere collected from admission charts and Hospital Manager

Mortality and Need of Surgical Treatment in Acute Upper GastrointestinalBleeding: A One Year Study in a Tertiary Center with a 24 Hours / Day-7Days / Week Endoscopy Call. Has Anything Changed?

A.M. Boianu1,2, D. Matei1, M. Tanu1, M. Acalovschi1

1"Professor Dr. Octavian Fodor Regional Institute of Gastroenterology and Hepatology, "Iuliu Haieganu University of Medicine and Pharmacy, Cluj Napoca, Romania2University of Medicine and Pharmacy Trgu Mure, Internal Medicine Departament, Trgu Mure, Romania

Chirurgia (2013) 108: 312-318No. 3, May - JuneCopyright Celsius

Corresponding author: Ana-Maria Boianu, MDNo.66/1 Gheorghe Marinescu StreetTrgu Mure, Mure County, RomaniaE-mail: anamariabotianu@yahoo.com

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programme. Statistical analysis was performed with GraphPad2004, using the following tests: chi square, Spearman, KruskallWallis, Mann-Whitney, area under receiver operating curve.Results: Non-variceal etiology was predominant, the maincause was bleeding being peptic ulcer. In hospital global mortality was of 10.43%, global rebleeding rate was 12.02%,surgery was performed in 7.66% of patients. Urgent haemosta-tic surgery was needed in 3.68% of patients with nonvaricealbleeding. The need for surgery correlated with the postendo-scopic Rockall score (p=0.0425). In peptic ulcer, the need forsurgery was not influenced by time to endoscopy or type oftreatment (p=0.1452). Weekend (p=0.996) or night(p=0.5414) admission were not correlated with a higher needfor surgery.Conclusions: Over the last decade, the need for urgent surgery in upper gastrointestinal bleeding has decreased byhalf, but mortality has remained unchanged.

Key words: upper digestive bleeding, endoscopic hemostasis,surgery, mortality

IntroductionIntroduction

Formerly a mainly surgical problem, acute upper gastrointestinalbleeding has become the most common gastroenterological life-threatening emergency. Management strategies have changeddramatically over the last 20 years due to the introduction ofacid suppressive therapy as well as endoscopic haemostasis, witha decrease in surgical need, but relatively unchanged mortalityrates of 6-13% in most studies. Mortality can reach higher values in variceal bleeding (1-4). The majority of deaths do notresult from failure of haemostasis, either medical or surgical, butmainly from comorbidities, poorly tolerated blood loss andresultant complications (3,4). Management strategies are clearlydefined by national and international guidelines (5-12), buttreatment varies according to local experience and medicalresources, especially the availability of permanent endoscopicdiagnosis and haemostasis. Currently, international guidelines(5-11) support the use of upper endoscopy within 24 hours forpatients presenting with upper gastrointestinal bleeding. Theguideline of The Romanian Society of Gastroenterology andHepatology and The Romanian Society of Endoscopy reducestiming recommendations to 16 hours from presentation (12). Inhigh risk patients presenting with haematemesis/haematocheziaor hemodynamic instability, endoscopy is recommended as soonas possible. Despite a rich international literature-on risk factorsand outcome in acute upper gastrointestinal bleeding, in ourcountry there are relatively few recent data on outcome, including the need for surgery.

The aim of the present study was to obtain actual dataon acute upper gastrointestinal bleeding regarding etiologyand outcome, as well as to study the factors correlated withmortality, rebleeding and need of surgical treatment in a tertiary specialized center, with a permanent endoscopy call(24 hours/day, 7 days/week).

Materials and MethodsMaterials and Methods

This is a retrospective non-randomised clinical study performed on the patients evaluated between 1st of January -31st of December 2011. The study took place at the 3rd MedicalClinic, "Professor Octavian Fodor Regional Institute ofGastro-enterology and Hepatology in Cluj Napoca. Patientswere considered for the study if they had evidence of overt gastro-intestinal bleeding on admission or a recent history ofhematemesis/ground vomiting, melena, haematochezia or acombination of any of the above. All patients were endos-copically examined within 24 hours from presentation to theemergency unit. In hospital bleedings were also included inour study. Data collected from admission charts and HospitalManager programme included: age and sex, etiology, previously validated prognostic scores (pre- and post-endoscopic Rockall score, Glasgow-Blatchford score), endo-scopic data (Forrest classification for non-variceal bleeding, thepresence of ongoing/stopped bleeding), use of antiplatelet/anti-coagulant medication, time to endoscopy from admission tothe emergency unit, time of emergency unit presentation(night/day, weekend/weekday), treatment. Outcome wasanalysed in terms of in hospital death and need of surgical therapy. Statistical analysis was performed with GraphPad2004, using the following tests: chi square, Spearman, Mann-Whitney, area under receiver operating curve.

ResultsResults

During the mentioned period, 757 endoscopies were performed for the diagnosis of acute upper gastrointestinalbleeding. Patient characteristics are given in Table 1 and 2.

Non-variceal etiology was dominant; the main cause ofupper gastrointestinal bleeding was gastric and duodenal ulcer.The second most frequent cause was variceal etiology, mainlyesophageal and rarely gastric location. The following cause wasneoplasia of the upper gastrointestinal tract, especially ulcerated lesions with oozing or adherent clot, and gastric

Table 1. Clinical characteristics of the patients with upperdigestive bleeding

Age : 62.1113.37 yearsGender: 413 (54.42%) males: 345 (45.57%) females

High risk patients according to prognostic scores

Postendoscopic Rockall score: 461 patients.Glasgow-Blatchford score: 432 patients.

Medication and alcohol use

Anticoagulation: n=53 (7%)NSAID : n=130 (17.17%)Aspirin: n=65 (8.58%)Clopidogrel : n=7 (0.92%)Alcohol: n=288 (38.04%)

Mode of presentation

Hematemesis: n=380 (50.19%)Melena: n=750 (99.07%)Hematochesia: n=35 (4.62%)

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cancer, eso-cardiotuberositary and esophageal location. Otherfrequent causes included erosive disease (gastritis or duodeni-tis) and Mallory-Weiss tear. We noticed a very small number ofcases in which the source of the bleeding was not localised,stress ulcer, as well as postprocedural bleeding. Bleeding complications of procedures such as gastric polypectomy, endoscopic sphincterotomy with stone extraction or endos-copic biliary prosthesis for cholangiocarcinoma, were presentmainly in patients with coagulation impairment (elevatedI.N.R., haemophilia).

A significant proportion of the patients included in our

study were high risk patients according either to a Glasgow-Blatchford score >=12 points (57.06% of patients) or a postendoscopic Rockall score >=6 points (60.89% ofpatients). Only 4 patients had a Glasgow-Blatchford score of0 with a possible indication of outpatient management.Despite high risk scores in over 50% of the patients, mostbleedings were not active at the time of endoscopy but highrisk bleeding stigmata were dominant, especially visible vessels without active bleeding