In-hospital acute upper gastrointestinal bleeding: What is the scope of the problem?

Table 1 Demographics and baseline characteristics

	In-hospital GI bleed (n = 139)	GI bleed on presentation (n = 196)	P value
Baseline characteristics, n (%)
Sex
Male	82 (59)	116 (59.2)	0.93
Female	57 (41)	80 (40.8)
Age
< 60	28 (20.2)	62 (31.6)	0.05
60-79	71 (51.1)	85 (43.4)	> 0.05
> 80	39 (28.1)	49 (25)	> 0.05
Smoking	56 (40.3)	76 (38.8)	0.78
Alcohol use	23 (16.6)	58 (29.6)	0.01
Hospitalization within last 6 mo	62 (44.6)	78 (39.8)	0.35
Prior history of upper GI bleed	18 (13)	50 (25.5)	0.66
Prior history of lower GI bleed	3 (2.2)	6 (3.1)
Prior history of PUD	25 (18)	38 (19.4)	0.8
Medication use prior to bleeding
Proton pump inhibitors	51 (36.7)	64 (32.7)	0.44
H2-blockers	11 (7.9)	14 (7.1)	0.79
NSAIDs for > 5 d	11 (7.9)	9 (4.6)	0.21
Steroid	38 (27.3)	23 (11.7)	0.01
Antiplatelets or anticoagulants	112 (80.6)	65 (33.2)	0.01
Aspirin	67 (48.2)	65 (33.2)	0.01
Clopidogrel	36 (25.9)	26 (13.3)	0.01
Prasugrel	0	2 (1)	0.23
Cilostazol	1 (0.7)	0	0.23
Dipyridamole	1 (0.7)	0	0.23
Heparin	55 (39.6)	5 (2.6)	0.01
Low molecular weight heparin	25 (18)	5 (2.6)	0.01
Warfarin	29 (20.9)	22 (11.2)	0.02
Eptifibatide	2 (1.4)	0	0.92
Novel anticogulants	4 (2.9)	12 (6.1)	0.18
Apixaban	3 (2.2)	0	0.04
Rivaroxaban	1 (0.7)	9 (4.6)	0.04
Dabigatran	0	3 (1.5)	0.14

GI: Gastrointestinal; PUD: Peptic ulcer disease; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 2 Bleeding characteristics

	In-hospital GI bleed (n = 139)	GI bleed on presentation (n = 196)	P value
Bleeding type, n (%)
Melena	81 (58.3)	133 (67.9)	0.07
Hematemesis	57 (41)	74 (37.8)	0.55
Hematochezia	18 (13)	30 (15.3)	0.54
Nasogastric lavage finding
Bright red blood	5 (3.6)	6 (3.1)	0.79
Ground coffee	22 (15.8)	10 (5.1)	0.01
EGD indication
GI bleed	62 (44.6)	89 (45.4)	0.88
Anemia	48 (34.5)	68 (34.7)	0.98
Melena	39 (28.1)	49 (25)	0.53
Hematemesis	34 (24.5)	40 (20.4)	0.38
Hematochezia	6 (4.3)	6 (3.1)	0.54
Maroon stools	3 (2.2)	-	0.04
Fecal occult blood positive	5 (3.6)	8 (4.1)	0.82
Abdominal pain	6 (4.3)	4 (2)	0.23
Dysphagia	1 (0.7)	2 (1)	0.77
NSAIDs use	1 (0.7)	1 (0.5)	0.81
Vomiting	2 (1.4)	3 (1.5)	0.95
Diarrhea	-	1 (0.5)	0.4
Nausea	-	1 (0.5)	0.4
Weight loss	-	1 (0.5)	0.4
Other	8 (5.8)	22 (11.2)	0.08
Diagnosis
Chronic gastritis	82 (59)	131 (66.8)	0.14
Esophagitis	57 (41)	48 (24.5)	0.01
Other	39 (28.1)	50 (25.5)	0.6
Duodenitis	33 (23.7)	37 (18.9)	0.54
Gastric ulcer	28 (20.1)	53 (27)	0.15
Duodenal ulcer	17 (12.2)	40 (20.4)	0.05
Peptic ulcer	1 (0.7)	1 (0.5)	0.81
Acute gastritis	15 (10.8)	13 (6.6)	0.18
Angiodysplasia of stomach and duodenum	7 (5)	19 (9.7)	0.12
Ulcer of esophagus	7 (5)	8 (4.1)	0.68
Esophageal varices	6 (4.3)	25 (12.8)	0.01
Alcoholic gastritis	1 (0.7)	1 (0.5)	0.81
Gastritis and duoedenitis	2 (1.4)	3 (1.5)	0.95
Gastroduodenitis, unspecified	1 (0.7)	0	0.23
Malignant neoplasm of duodenum	1 (0.7)	0	0.23
Malignant neoplasm of esophagus	2 (1.4)	2 (1)	0.73
Malignant neoplasm of stomach	2 (1.4)	2 (1)	0.73

GI: Gastrointestinal; EGD: Esophagogastroduodenoscopy; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 3 Complications and outcomes

	In-hospital GI bleed (n = 139)	GI bleed on presentation (n = 196)	P value
Transfusion, n (%)	30 (21.6)	61 (31.1)	0.05
Patients requiring PRBC	106 (76.3)	132 (67.3)	0.08
Patients requiring FFP	32 (23)	25 (12.8)	0.01
Number of PRBC median [Interquartile range] (Units)	3 [2-5]	2 [2-4]	< 0.05
Number of FFP (Units)	3 [2-5.5]	2 [2-5]	0.54
Rockall score at endoscopy	5 [4-6]	5 [3-6]	0.45
Glasgow- Blatchford score	12 [9-14]	13 [9-14.5]	0.22
Child-Pugh score in cirrhotics	8 [7-12]	8 [6-9]	0.22
Platelets at bleeding (mean +/-SD)	230.3 +/-9.9	261.5 +/-8.7	0.02
Creatinine at bleeding	1.8 +/-0.1	1.7 +/-0.1	0.77
ASA sore	3.7 +/-0.05	3.4 +/-0.05	0.01
Days till bleeding in inpatients	7.2 +/-7.9
Day of admission
Mon-Fri	99 (71.2)	144 (73.5)	> 0.05
Sat-Sun	38 (27.3)	52 (26.5)
Time of EGD
Before 5 pm	119 (86.9)	166 (84.7)	> 0.05
After 5 pm	18 (13.1)	30 (15.3)
ICU admission	57 (41)	88 (44.9)	0.51
Intubation	22 (15.8)	18 (9.2)	0.06
Vasopressors use	17 (12.2)	8 (4.1)	0.01
Complications
Re-bleeding	3 (2.2)	6 (3.1)	0.62
Aspiration	0	0
Perforation	0	0
Obstruction	1 (0.7)	0	0.23
Other	4 (2.9)	11 (5.6)	0.23
Intervention after EGD			0.02
Interventional radiology guided	4 (2.9)	5 (2.6)	0.87
Surgical	19 (13.7)	52 (26.5)	0.01
Mean duration of bleed (hours)	41	58	< 0.05
Bleed to EGD time (h)	40.9 +/-4.2	57.9 +/-5.7	0.02
LOS post endoscopy (d)	7 [4-11]	4 [2-8]	< 0.05
Length of hospitalization (d)	13 [9-22]	6 [4-11]	< 0.05
Mortality	25 (20)	6 (3.1)	0.01
Cause of mortality
Cardiovascular	15 (10.8)	4 (2)	0.01
GI bleed	4 (2.9)	1 (0.5)	0.08
Malignancy	0	0
Multiorgan failure	6 (4.3)	1 (0.5)	0.02
Sepsis	7 (5)	1 (0.5)	0.01
Thromboembolic	0	1 (0.5)	0.4
Other	11 (7.9)	3 (1.5)	0.01

GI: Gastrointestinal; PRBCs: Packed red blood cells; FFP: Fresh frozen plasma; EGD: Esophagogastroduodenoscopy; ASA: American society of anesthesiologists; LOS: Length of stay; ICU: Intensive care unit; SD: Standard deviation.

Table 4 Comparison of current findings with previous studies

	Jairath et al[30], 2014	Marmo et al[35], 2014	Müller et al[31], 2009	Klebl et al[32], 2005	Our study
Medications at time of bleeding	Ips > Ops were taking antiplatelet agents	Ips > Ops were taking steroids and heparin	Ips > Ops were taking aspirin, steroids and heparin	Ips > Ops were taking proton pump inhibitors	Ips > Ops were taking heparin, antiplatelets and steroids
		Ips = Ops taking antiplatelets and anticoagulant
PRBC transfusion requirements	Ips = Ops	Ips > Ops	Ips = Ops	Ips > Ops	Ips = Ops
Hemodynamic instability	Ips > Ops	Ips > Ops	Ips = Ops	Ips = Ops regarding systolic blood pressure	Ips > Ops manifested by higher pressure support requirement
				Ips had lower diastolic blood pressure
Rockall score	Ips > Ops	-	-	Ips = Ops	Ips = Ops
Time to endoscopy	Ips = Ops	Ips = Ops	Ips waited longer for upper endoscopy	Ips = Ops in terms of time to endoscopy	Ips waited less for upper endoscopy
Diagnosis	Ips > Ops had more PUD	Ips > Ops had active bleeding lesions	Ips = Ops had ulcers and erosions predominatly	Ips = Ops had predominantly PUD	Ips = Ops had predominantly acid related conditions
	Ops > Ips had variceal bleed
		Ips > Ops had more gastric and duodenal ulcers
ICU admissions	-	Ips > Ops	Ips > Ops	Ips = Ops	Ips = Ops
Alternative treatments	Ips > Ops required more surgical and/or radiolgical interventions	Ips = Ops in terms of surgery requirement	Ips = Ops in terms of surgery requirement	Ips = Ops in terms of surgery requirement	Ops > Ips required surgical interventions
Re-bleeding	Ips > Ops	Ips > Ops (slight)	Ips = Ops	Ips = Ops	Ips = Ops
LOS	Ips > Ops (x2)	Ips > Ops	Ips > Ops	-	Ips > Ops
Mortality	Ips > Ops	Ips > Ops	Ips > Ops	Ips > Ops	Ips > Ops
Death secondary to GI bleeding	-	Ips > Ops	-	Ips > Ops	Ips = Ops

Ips: Inpatients; Ops: Outpatients; ICU: Intensive care unit; PRBC: Packed red blood cell; LOS: Length of stay; PUD: Peptic ulcer disease.