|Year : 2022 | Volume
| Issue : 3 | Page : 548-551
An observational study about incidence of upper gastrointestinal bleeding, endoscopic profile of patients in tertiary care hospital
Sanujit A Pawde1, Abhay D Chougale2
1 Department of General Surgery, D. Y. Patil Education Society (Deemed to be University), Kolhapur, Maharashtra, India
2 Department of General Surgery D. Y. Patil Medical College, D. Y. Patil Education Society (Deemed to be University), Kolhapur, Maharashtra, India
|Date of Submission||14-May-2020|
|Date of Decision||08-Dec-2020|
|Date of Acceptance||10-Dec-2020|
|Date of Web Publication||2-Nov-2022|
Dr. Abhay D Chougale
Department of General Surgery, D Y Patil Medical College, D Y Patil Education Society (Deemed to be University), Kolhapur - 416 006, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Despite treatment advancement of upper gastrointestinal bleeding (UGIB), overall mortality has still remained constant and the reasons behind it are still unclear. Aim: The aim is to study the endoscopic profile of patients suffering from UGIB in a tertiary care hospital. Materials and Methods: Observational study conducted among consenting patients, undergoing Esophago gastro duodenoscopy in the department of general surgery at a tertiary care hospital, between November 2018 and April 2019. Cases included were (n = 86). Standard case history pro forma was used for data collection. Interventions were given in the form of pharmacotherapy, endoscopic band ligation, and sclerotherapy. Follow-up was done after 2 months. Data were analyzed using R software version 3.6.0. Chi-square test used to find the association between variables (P < 0.05). Results: Most patients were male (n = 78) with a mean age of 48.05 ± 14.96 years. Common complaints were of melena (n = 71). History of cases included in this study; history of alcoholic liver disease (n = 35), long-term use of nonsteroidal anti-inflammatory drugs (NSAIDS) (n = 26). The common causes for GI bleeding were esophageal varices (n = 52). Significant association was observed between diagnosis and alcoholic liver disease (P = 0.004), history of long-term NSAIDS (P = 0.002), respectively. All cases were given pharmacological intervention. Higher statistically significant association found between follow-up and sclerotherapy(P = 0.0004). Association was seen between the number of interventions and follow-up (P = 0.016). Adverse event in form of bleeding was seen in 1.2% of cases. Conclusion: The most common cause of UGIB was esophageal varices. Combination of interventions could provide solution to reduce mortality in cases of UGIB.
Keywords: Anti-inflammatory agents, duodenoscopy, gastrointestinal hemorrhage, male, melena
|How to cite this article:|
Pawde SA, Chougale AD. An observational study about incidence of upper gastrointestinal bleeding, endoscopic profile of patients in tertiary care hospital. J Datta Meghe Inst Med Sci Univ 2022;17:548-51
|How to cite this URL:|
Pawde SA, Chougale AD. An observational study about incidence of upper gastrointestinal bleeding, endoscopic profile of patients in tertiary care hospital. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Jan 28];17:548-51. Available from: http://www.journaldmims.com/text.asp?2022/17/3/548/360186
| Introduction|| |
The incidence of upper gastrointestinal bleeding (UGIB) is approximately 50 per 100 000 persons per year. The mortality of this condition ranges between 5% and 11%.
The common causes of bleeding are peptic ulcers, esophagitis, drug-induced mucosal damage, esophageal varices, varices of the gastric fundus, portal hypertensive gastropathy, etc., Clinical manifestations of UGIB are seen in form of melena and hematemesis.
Upper gastrointestinal (GI) endoscopy is crucial to the diagnosis and treatment of UGIB. It also offers the opportunity for interventions such as band ligation and sclerotherapy.
Despite advancement in endoscopy, the overall mortality has remained constant for the past four decades. Thus, the study was undertaken to find the incidence of upper GI bleed in patients, to find the etiologies of UGIB, to determine the complications of Oesophago-Gastro- Duodenoscopy (OGDscopy), and to assess post-therapeutic interventions in patients.
| Materials and Methods|| |
The prospective observational study was conducted among patients, undergoing OGD in the department of general surgery at a tertiary care hospital, between November 2018 and April 2019. Institutional ethical clearance (DYPMCK/111R/2018, July 5, 2018) was obtained before the study. Patients with a history of hematemesis, melena, dyspeptic symptoms, liver diseases, and willing to give informed consent, were included in the study. Patients who were friable, unfit for OGD, suffering from any neck pathology or esophageal stricture, and age <14 years, were excluded from the study.
Data collection was done with standard case history pro forma. Standard systemic investigations were performed (data not presented). Esophageal varices were classified according to Paquet. Duration of the procedure noted for each case. Postoperative complications were assessed. Pain scoring was achieved through the Wongbaker pain rating scale (0 – no pain; 5 – moderate pain; 10 – worst pain).
Local anesthesia (topical) was used along with sedation and the patient was kept in the left lateral position. Survey examination of the esophagus, stomach, and duodenum was done priorly. The procedure for OGD in the patients was described previously.
Interventions were given in the form of pharmacotherapy, endoscopic band ligation (EBL), and sclerotherapy as described previously. Follow-up was done after 2 months.
Data analysis was performed using R Statistical Software (version 3.6.0; R Foundation for Statistical Computing, Vienna, Austria). Frequency and percentages were used for categorical variables and continuous variables. Chi-square test was used to find the association between different variables (P < 0.05).
| Results|| |
Cases were included after fulfilling inclusion and exclusion criteria (n = 86). Of the total participants, male predominance was observed (n = 78). The mean age of the study participants was 48.05 ± 14.96 years. Most cases were in the age group 41–60 years (n = 36) followed by 21–40 years (n = 29). Mean duration of symptoms was 10.6 ± 9.46 days [Table 1]. The incidence of upper GI bleed in hospital patients was 7.88%. The mean duration of the procedure was 12.71 ± 6.75 min. Sensitivity of the instrument was found to be 95.34%. Complaints among patients were of melena (n = 71), followed by hematemesis (n = 50), nausea (n = 37), and pain (n = 20). Patients were seen to have a history of alcoholic liver disease (n = 35), long-term use of nonsteroidal anti-inflammatory drugs (NSAIDS) (n = 26), and similar complaint in the past (n = 41). The most common etiology for GI bleeding was esophageal varices (n = 52) [Table 2]. Clinical findings among patients were pallor (n = 46), and icterus (n = 26). Deranged liver function test (LFT) was observed in some cases (n = 32). Diagnosis was significantly associated with hematemesis (P = 0.0004), melena (P = 0.0264), and pain (P = 0.049). Similar association was observed between diagnosis and pallor (P = 0.002). No association observed between diagnosis and nausea (P = 0.061), icterus (P = 0.178), respectively. Significant association was observed between diagnosis and alcoholic liver disease (P = 0.004), history of long-term NSAIDS (P = 0.002), and deranged LFT (P = 0.0009), respectively. No association was observed between the diagnosis and history of similar complaints in the past (P = 0.190). Complication in form of bleeding was seen in 1.2% of cases. Pharmacological intervention was used in all cases 100%, EBL and sclerotherapy was carried out in 50% & 24.2% cases. Only one type of intervention was used in 44% of cases, followed by two types of interventions in 37% cases. [Table 3].
Good regression was seen in most of the cases during follow-up (n = 77) [Figure 1]. Significant association was observed between follow-up and sclerotherapy (P = 0.014), the number of interventions (P = 0.016), respectively. Significantly higher association seen between follow-up and pharmacotherapy, EBL, respectively, (P = 0.0004).
| Discussion|| |
Upper GI bleeding is a prevalent medical emergency. Despite newer advances in diagnostic procedures and therapy, the mortality due to GI bleeding has not reduced much. Thus, the aim of the study was to find incidence, endoscopic diagnostic findings, and management of upper GI bleed.
Male predilection is observed with UGIB, as seen in previous studies., Majority of cases were of the age group 41–60 years. GI bleed is more common in the elderly population., Analgesic and anti-inflammatory medication requirement increase with age; hence, there is an increase consumption of NSAIDS. An increased alcohol consumption in this age group may also be a contributing factor. The incidence of UGIB in the hospital was seen to be 7.88%. No recent reports are there for comparison in the region.
Endoscopy for upper GI bleed has a sensitivity of 95.34%, as observed in the previous study. This further emphasizes it as the primary diagnostic method for the assessment of upper GI bleed.
Melena is considered as classical sign of UGIB and was the most common presenting symptom, followed by hematemesis. This is in concurrence with similar studies., A significant association was found between complaints and diagnosis. Patient complaints provide clues and help the localization of gastrointestinal bleed and chances of any accompanying illnesses.
History of alcoholic liver diseases and usage of NSAIDS are considered as risk factors for UGIB., Alcoholic liver diseases also point toward the prevalence of alcohol use in the region., NSAIDS not only have a tendency to cause bleeding ulcers but also increase the chances of bleeding from a preexisting ulcer. Patients are also not properly informed about side effects of NSAIDS and tend to overuse them.
The most common cause of UGIB was found to be esophageal varices. Alcohol consumption increases the likeliness of bleeding from varices. These findings contrast with Rathod et al., where acute erosive gastritis was seen to be the most common cause of UGIB. Variations will be seen with different populations as the predisposing factors are different.
Most patients had clinically visible pallor. UGIB causes acute blood loss, which leads to pallor.
Abnormal LFT indicates the presence of liver disease, which in turn may be a comorbid phenomenon associated with UGIB. Hence, deranged LFT was found to be significantly associated with diagnosis.
All the patients were given pharmacological intervention in line with previous study. Significantly higher association was observed between pharmacotherapy and follow-up. Administration of drugs helps to lower splanchnic blood flow, encourages hemostasis, and in turn, makes endoscopic treatment easier.
Patients were also given interventions in form of EBL and sclerotherapy similar to other studies. Significantly higher association was observed between follow-up and EBL. Obliteration of varices with ligation requires fewer endoscopic sessions. Significant association was also seen between follow-up and sclerotherapy. This could be ascribed to the occlusion of vascular structures.
The number of interventions observed to have significant association with follow-up. Combined intervention can be an effective approach for treating UGIB. Hence, in turn, could reduce mortality associated with it.
Limitations could be a small sample size; the sample is not a true representation of the population as it is a hospital-based study.
| Conclusion|| |
The most common cause of UGIB was esophageal varices. Combination of interventions could provide solution to reduce mortality in cases of UGIB. Further research is required to prove the effectiveness of combined interventions in reducing mortality among patients undergoing OGDscopy.
Mortality due to UGIB has been constant despite advances in technology. The underlying causes vary from individual to individual. Endoscopy is a time-proven technique. However, still mortality has been constant. Combined interventions could be an answer to it.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rollhauser C, Fleischer DE. Nonvariceal upper gastrointestinal bleeding. Endoscopy 2004;36:52-8.
Ell C, Hagenmüller F, Schmitt W, Riemann JF, Hahn EG, Hohenberger W. Multizentrische prospektive Untersuchung zum aktuellen Stand der Therapie der Ulcusblutung in Deutschland [Multicenter prospective study of the current status of treatment for bleeding ulcer in Germany]. Dtsch Med Wochenschr. 1995;120:3-9. German.
Biecker E, Heller J, Schmitz V, Lammert F, Sauerbruch T. Diagnosis and management of upper gastrointestinal bleeding. Dtsch Arztebl Int 2008;105:85-94.
Jain J, Rawool A, Banait S, Maliye C. Clinical and endoscopic profile of the patients with upper gastrointestinal bleeding in central rural India: A hospital-based cross-sectional study. J Mahatma Gandhi Inst Med Sci 2018;23:13-8. [Full text]
Siau K, Hodson J, Ingram R, Baxter A, Widlak MM, Sharratt C, et al
. Time to endoscopy for acute upper gastrointestinal bleeding: Results from a prospective multicentre trainee-led audit. United Eur Gastroenterol J 2019;7:199-209.
Paquet KJ. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices – A prospective controlled randomized trial. Endoscopy 1982;14:4-5.
Lewis SL, Bucher L, Heitkemper MM. Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems. Available from: https://books.Google.co.in/books
. [Last accessed on 2019 Sep 25].
Ahlawat R, Ross AB. Esophagogastroduodenoscopy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January, 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532268/
. [Last updated on 2019 Feb 03; Last accessed on 2019 Sep 25].
Chafoord C, Frenckner P. New surgical treatment of varicous veins of the oesophagus. Acta Oto-laryngologica 1939;27:422-9.
Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995;123:280-7.
Mahajan P, Chandail VS. Etiological and endoscopic profile of middle aged and elderly patients with upper gastrointestinal bleeding in a tertiary care hospital in North India: A retrospective analysis. J Midlife Health 2017;8:137-41.
Saowaros V, Udaya Chalem W, Wee-sakul B, Tienpaitoon V. Causes of upper GI bleeding in Thai patient: Review of 5000 upper GI endoscopy. J Med Assoc Thai 1994;77:561-5.
Rathod JB, Shah DK, Yagnik BD, Yagnik VD. Upper gastrointestinal bleeding: Audit of a single center experience in Western India. Clin Pract 2011;1:e132.
Singh SP, Panigrahi MK. Spectrum of upper gastrointestinal hemorrhage in coastal Odisha. Trop Gastroenterol 2013;34:14-7.
Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut 2008; 57:814-820.
Wilcox CM, Alexander LN, Straub RF, Clark WS. A prospective endoscopic evaluation of the causes of upper GI hemorrhage in alcoholics: A focus on alcoholic gastropathy. Am J Gastroenterol 1996;91:1343-7.
Deshmukh PR, Gupta SS, Bharambe MS, Maliye C, Kaur S, Garg BS. Prevalence of hypertension, its correlates and levels of awareness in rural Wardha, Central India. World Health Popul 2005;21:1-12. [doi: 10.12927/whp. 2005.17651].
Gokak VP, Hajare SD, Patil A, Tukade S, Bellari S. Clinical Profile of Patients Presenting with Upper Gastrointestinal Bleed in a Tertiary Care Hospital from South India. Int J Sci Res 2019;8:802-5.
Lakhwani MN, Ismail AR, Barras CD, Tan WJ. Upper gastrointestinal bleeding in Kuala Lumpur Hospital, Malaysia. Med J Malaysia 2000;55:498-505.
National Clinical Guideline Centre (UK). Acute Upper Gastrointestinal Bleeding: Management. London: Royal College of Physicians (UK); June, 2012. (NICE Clinical Guidelines, No. 141). Available from: https://www.ncbi.nlm.nih.gov/books/NBK247794/
. [Last accessed on 2019 Sep 29].
Lam KL, Wong JC, Lau JY. Pharmacological treatment in upper gastrointestinal bleeding. Curr Treat Options Gastroenterol 2015;13:369-76.
Albanese G, Kondo KL. Pharmacology of sclerotherapy. Semin Intervent Radiol 2010;27:391-9.
[Table 1], [Table 2], [Table 3]