Published online Feb 16, 2020. doi: 10.4253/wjge.v12.i2.72
Peer-review started: June 23, 2019
First decision: August 2, 2019
Revised: November 25, 2019
Accepted: December 14, 2019
Article in press: December 14, 2019
Published online: February 16, 2020
Processing time: 204 Days and 13.2 Hours
Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common condition that results in significant morbidity and mortality. Mortality rates have not improved over the years. There are currently several endoscopic modalities for the treatment of this condition.
However, the dosage or amount of treatment to be used for each modality is not well studied. Moreover, it is not known whether a combination of three or more modalities combined is associated with better outcomes.
Our study aims to investigate whether various clinical outcomes in NVUGIB are influenced by the volume of adrenaline injected, the number of hemoclips placed and the number of treatment modalities used.
A retrospective cohort study conducted in a single large district general hospital. All patients admitted for NVUGIB and needing endoscopic treatment over a two-year period were analyzed. The various endoscopic treatment modalities were compared against several outcomes including rebleeding, repeat endoscopy rates, surgical intervention, transfusion requirements, length of hospital stay, death during the same admission and 30 d mortality.
Close to one third of our patients needed endoscopic therapy. < 10 mL adrenaline injected was associated with less re-bleeding (P < 0.0001), need for repeat endoscopy (P = 0.001) and decreased length of hospital stay (P = 0.026). > 2 treatment modalities used was associated with more re-bleeding (P = 0.009) and need for repeat endoscopy (P = 0.048). > 1 hemoclip placed was associated with decreased length of hospital stay (P = 0.044).
Our study is the first to show that more hemoclips placed was associated with a decreased length of stay. Also, we report novel findings that a reduced volume of adrenaline injected and a reduced number of endoscopic treatment modalities used was associated with better outcomes. More hemoclips used being associated with a better outcome is intuitive. However, previous studies have shown that larger volumes of adrenaline used led to better outcomes. These studies were conducted with adrenaline as the only treatment modality. This is not in line with the current management guidelines of NVUGIB which states that adrenaline use needs to be combined with another modality. Most of our patients who received adrenaline also received at least another treatment modality, this may be one reason why the volume of adrenaline required to arrest the bleeding may be smaller in our study. There are no previous studies that have shown that > 2 treatment modalities led to poorer outcomes. These findings are counter-intuitive but may be due to certain variables not captured in this retrospective study causing poorer outcomes. A prospective study with a larger sample size is needed to compare the various dosages and amounts of treatment used to manage this common condition.
In the endoscopic management of NVUGIB, more may not be merrier for all treatment modalities. A prospective trial is needed to confirm this.