Akut Üst Gastrointestinal Kanama İle Başvuran Hastaların Endoskopi Yapılma Zamanının Hastaların Mortalitesine Etkileri

Yıl 2023, , 959 - 965, 30.09.2023

Guner Yurtsever

https://doi.org/10.16899/jcm.1341380

Öz

Amaç: Endoskopi akut üst gastrointestinal kanamada (AUGIB) kanama kaynağını tespit etmek ve kanamayı durdurmak için önerilir. Endoskopinin AUGIB'de optimal zamanlaması tartışmalıdır. Çalışmamızda endoskopi zamanını ve etkileyen faktörleri araştırmayı amaçladık.
Yöntem: Çalışma retrospektif, tek merkezlidir. Hastalar taburculuk sonrası endoskopi, 0-12 saat endoskopi, 12-24 saat endoskopi ve 24 saat sonra endoskopi olmak üzere 4 gruba ayrıldı. Yaş, cinsiyet, vital bulgular, laboratuvar bulguları kaydedildi. Glasgow-Blatchford Skoru (GBS) ve Charlson komorbidite indeksi (CCI) hesaplandı. Elde edilen veriler bu dört grup arasında karşılaştırıldı. 30 gün boyunca tüm nedenlere bağlı ölümler kaydedildi.
Bulgular: Toplam 318 hasta dahil edildi. Endoskopi sürelerinin karşılaştırılmasında dört grup arasında istatistiksel olarak anlamlı bulunan parametreler Hb, BUN ve INR seviyeleri, GBS ve CCI’dır. CHAID analizi sonucunda endoskopi zamanını etkileyen en önemli değişkenin hastaların Hb değeri olduğu bulundu (χ2=66,528; düzeltilmiş p=0,000). Mortalite hastaların %10.69'unda meydana geldi. Endoskopinin zamanlaması mortaliteyi etkilemedi. Binary lojistik regresyon analizinde düşük sistolik KB (0,967 kat artış), yüksek CCI (86.402 kat artış) mortaliteyi etkilediği bulundu.
Sonuç: Endoskopinin zamanlamasını etkileyen faktörler kanama belirtileridir. Akut gastrointestinal kanama ile acil servise başvuran hastalarda hayati bulguların tam olarak izlenmesi, özellikle sistolik kan basıncının değerlendirilmesi ve ek komorbid durumların ayrıntılı olarak sorgulanması, mortaliteyi azaltmak için kritik öneme sahiptir.

Anahtar Kelimeler

endoskopi zamanlaması, acil durum, üst gastrointestinal kanama, akut gastrointestinal kanama

Teşekkür

Çalışmaya katkılarından dolayı Demokrasi Üniversitesi Acil Tıp AD Başkanı Doç Dr Rezan Karaali'ye teşekkür ederim.

Evaluation of endoscopy timing in patients with acute upper gastrointestinal bleeding in emergency department

Öz

Background: Endoscopy is recommended in acute upper gastrointestinal bleeding (AUGIB) to detect the bleeding source and stop the bleeding. The optimal timing of endoscopy in AUGIB is controversial. We aimed to investigate the time of endoscopy and the factors affecting it.
Materials and methods: Retrospective, single-center study. The patients were divided into four groups: endoscopy after discharge, 0-12 hours endoscopy, 12-24 hours endoscopy and 24 hours later. Age, sex, vital signs, laboratory findings were recorded. Glasgow-Blatchford Score (GBS) and Charlson comorbidity index (CCI) were calculated. The obtained data were compared between these four groups. All-cause mortality for 30 days was recorded.
Results: A total of 318 patients were included. In the comparison of endoscopy times, the parameters found to be statistically significant between the four groups are Hb, BUN, and INR levels, GBS and CCI. As a result of CHAID analysis, the most crucial variable affecting the timing of endoscopy was found to be the Hb value of the patients (χ2=66.528; adjusted p=0.000). Mortality occurred in 10.69% of the patients. The timing of endoscopy did not affect mortality. In binary logistic regression analysis, low systolic BP (0.967 times increase), high CCI (86,402 times increase) were found to affect mortality.
Conclusion: The factors affecting the timing of endoscopy are the signs of bleeding. A thorough follow-up of vital signs in patients presenting to the emergency department with acute gastrointestinal bleeding, particularly an evaluation of systolic blood pressure and detailed questioning of additional comorbid conditions, is critical to reduce mortality.

Anahtar Kelimeler

endoscopy timing, emergency, upper gastrointestinal bleeding, acute gastrointestinal bleeding

Kaynakça

• 1. Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917. doi: 10.14309/ajg.0000000000001245. Erratum in: Am J Gastroenterol. 2021 Nov 1;116(11):2309. PMID: 33929377.
• 2. Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy. 2021 Mar;53(3):300-332. doi: 10.1055/a-1369-5274. Epub 2021 Feb 10. PMID: 33567467.
• 3. Lim LG, Ho KY, Chan YH, et al. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy. 2011 Apr;43(4):300-6. doi: 10.1055/s-0030-1256110. Epub 2011 Feb 28. PMID: 21360421.
• 4. Laursen SB, Leontiadis GI, Stanley AJ, Møller MH, Hansen JM, Schaffalitzky de Muckadell OB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc. 2017 May;85(5):936-944.e3. doi: 10.1016/j.gie.2016.08.049. Epub 2016 Sep 10. PMID: 27623102.
• 5. Cho SH, Lee YS, Kim YJ, et al. Outcomes and Role of Urgent Endoscopy in High-Risk Patients With Acute Nonvariceal Gastrointestinal Bleeding. Clin Gastroenterol Hepatol. 2018 Mar;16(3):370-377. doi: 10.1016/j.cgh.2017.06.029. Epub 2017 Jun 19. PMID: 28634135.
• 6. Bjorkman DJ, Zaman A, Fennerty MB, Lieberman D, Disario JA, Guest-Warnick G. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study. Gastrointest Endosc. 2004 Jul;60(1):1-8. doi: 10.1016/s0016-5107(04)01287-8. PMID: 15229417.
• 7. Lau JYW, Yu Y, Tang RSY, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2020 Apr 2;382(14):1299-1308. doi: 10.1056/NEJMoa1912484. PMID: 32242355.
• 8. Lee JG, Turnipseed S, Romano PS, et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999 Dec;50(6):755-61. doi: 10.1016/s0016-5107(99)70154-9. PMID: 10570332.
• 9. Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2019 Oct-Dec;42-43:101618. doi: 10.1016/j.bpg.2019.05.005. Epub 2019 Jun 3. PMID: 31785731.
• 10. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000 Oct 14;356(9238):1318-21. doi: 10.1016/S0140-6736(00)02816-6. PMID: 11073021.
• 11. Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017 Jan 4;356:i6432. doi: 10.1136/bmj.i6432. PMID: 28053181; PMCID: PMC5217768.
• 12. Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019 Dec 3;171(11):805-822. doi: 10.7326/M19-1795. Epub 2019 Oct 22. PMID: 31634917; PMCID: PMC7233308.
• 13. Jensen DM, Kovacs TO, Jutabha R, et al. Randomized trial of medical or endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots. Gastroenterology. 2002 Aug;123(2):407-13. doi: 10.1053/gast.2002.34782. PMID: 12145792.
• 14. Bleau BL, Gostout CJ, Sherman KE, et al. Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy. Gastrointest Endosc. 2002 Jul;56(1):1-6. doi: 10.1067/mge.2002.125365. PMID: 12085028.
• 15. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010 Nov;138(5):1093-100. doi: 10.1378/chest.10-0134. Epub 2010 Mar 18. PMID: 20299623.
• 16. Bauersachs J, Soltani S. Herzinsuffizienzleitlinien 2021 der ESC [Guidelines of the ESC 2021 on heart failure]. Herz. 2022 Feb;47(1):12-18. German. doi: 10.1007/s00059-021-05084-5. Epub 2021 Nov 25. PMID: 34825250.
• 17. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373-83. doi: 10.1016/0021-9681(87)90171-8. PMID: 3558716.
• 18. Sung JJ, Chiu PW, Chan FKL, et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut. 2018 Oct;67(10):1757-1768. doi: 10.1136/gutjnl-2018-316276. Epub 2018 Apr 24. Erratum in: Gut. 2019 Feb;68(2):380. PMID: 29691276; PMCID: PMC6145289.
• 19. Acute upper gastrointestinal bleeding in over 16s: management. London: National Institute for Health and Care Excellence (NICE); 2016 Aug. (NICE Clinical Guidelines, No. 141.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK554919/
• 19. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2015 Oct;47(10):a1-46. doi: 10.1055/s-0034-1393172. Epub 2015 Sep 29. PMID: 26417980.
• 20. Wong JC, Lau JY, Tang RS, Au KW, Chan FK, Sung JJ. Urgent versus early endoscopy for upper gastrointestinal bleeding with Glasgow-Blatchford score ≥ 12. Gastroenterology. 2015;148(4):S-154.
• 21. Sasaki Y, Abe T, Kawamura N, et al. Prediction of the need for emergency endoscopic treatment for upper gastrointestinal bleeding and new score model: a retrospective study. BMC Gastroenterol. 2022 Jul 11;22(1):337. doi: 10.1186/s12876-022-02413-8. PMID: 35820868; PMCID: PMC9277905.
• 22. Lin HJ, Wang K, Perng CL, et al Early or delayed endoscopy for patients with peptic ulcer bleeding. A prospective randomized study. J Clin Gastroenterol. 1996 Jun;22(4):267-71. doi: 10.1097/00004836-199606000-00005. PMID: 8771420.
• 23. Guo CLT, Wong SH, Lau LHS, et al. Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study. Gut. 2022 Aug;71(8):1544-1550. doi: 10.1136/gutjnl-2020-323054. Epub 2021 Sep 21. PMID: 34548338; PMCID: PMC9279843.
• 24. Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal GE. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999 Feb;49(2):145-52. doi: 10.1016/s0016-5107(99)70478-5. PMID: 9925690.
• 25. Schacher GM, Lesbros-Pantoflickova D, Ortner MA, Wasserfallen JB, Blum AL, Dorta G. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study. Endoscopy. 2005 Apr;37(4):324-8. doi: 10.1055/s-2004-826237. PMID: 15824941.
• 26. Hooper N, Armstrong TJ. Hemorrhagic Shock. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470382/
• 27. Siddique SM, Mehta SJ. Bundled Payments for Hospitalized Patients With Gastrointestinal Disease: Current Opportunities and Challenges for Gastroenterology Practices. Clin Gastroenterol Hepatol. 2021 Feb;19(2):215-218. doi: 10.1016/j.cgh.2020.09.022. Epub 2020 Sep 14. PMID: 32941996; PMCID: PMC8087107.
• 28. Siebenhüner K, Blaser J, Nowak A, et al. Comorbidities Associated with Worse Outcomes Among Inpatients Admitted for Acute Gastrointestinal Bleeding. Dig Dis Sci. 2022 Aug;67(8):3938-3947. doi: 10.1007/s10620-021-07197-7. Epub 2021 Aug 7. PMID: 34365536; PMCID: PMC8349143.
• 29. Crooks CJ, West J, Card TR. Comorbidities affect risk of nonvariceal upper gastrointestinal bleeding. Gastroenterology. 2013 Jun;144(7):1384-93, 1393.e1-2; quiz e18-9. doi: 10.1053/j.gastro.2013.02.040. Epub 2013 Mar 5. PMID: 23470619; PMCID: PMC3776918.