Rebleeding After Endoscopy for Bleeding Peptic Ulcer
Rebleeding After Endoscopy for Bleeding Peptic Ulcer
Background Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.
Aim To identify predictors of rebleeding after endoscopic therapy.
Methods Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.
Results Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57–4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14–2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31–2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98–4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38–10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69–4.86).
Conclusions Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.
Peptic ulcer bleeding (PUB) is a major cause of acute nonvariceal gastrointestinal bleeding. It is a common reason for emergency hospital admission and a major cause of mortality, morbidity and health care expenditure.
In recent years, improvements in the treatment of PUB have reduced the risk of rebleeding and death. Most severe bleeding is associated with high-risk endoscopic stigmata. In these patients, the combination of aggressive volume repletion and rapid correction of hypotension, endoscopic therapy and intravenous proton-pump inhibitors (PPI) improve outcomes.
Recurrent haemorrhage is one of the most significant predictive factors for mortality. The risk of rebleeding in patients with clean ulcers is insignificant and recurrence occurs mainly after endoscopic therapy of ulcers showing high-risk stigmata. Identifying patients at very high risk for rebleeding within this population may allow targeting additional haemostatic measures in a cost-effective way. For example, routine use of second-look endoscopy in all endoscopically treated patients is not cost-effective but becomes so when performed in those at very high risk. At the other end of the scale, identifying patients with the lowest risk of rebleeding after therapy may also be useful: A previous study by our group showed that highly selected patients could be safely discharged after endoscopic therapy. Even if not discharged immediately, patients at low risk of rebleeding after therapeutic endoscopy are likely to benefit from an early switch to oral PPI and discharge instead of maintaining the costly and uncomfortable hospitalisation for a 72-h PPI perfusion that is currently recommended in all patients after endoscopic therapy.
The scores currently available were not designed to predict rebleeding after endoscopic therapy, and may not work well in this setting: Most have been developed in cohorts that included different causes of haemorrhage and patients not receiving endoscopic treatment. In addition, many were designed on the basis of a single study and their reproducibility has never been satisfactory. Finally, most scores were designed to predict mortality or a combination of mortality and rebleeding instead of only rebleeding. Predictors of ulcer rebleeding differ from those for mortality: they are related more to the severity of haemorrhage and the ulcer characteristics, whereas predictors for mortality are mainly comorbidity and rebleeding.
In consequence, it is important from a clinical point of view to develop a specific score for predicting rebleeding after endoscopic therapy. The first step in developing an accurate score is to identify the most important predictive variables. To ensure general applicability, we aimed to determine which variables have been found to be prognostic in a range of populations, instead of deriving them from a single study. For this reason, the present study performed a systematic review and a meta-analysis to identify the most consistent predictors of recurrent haemorrhage in patients after endoscopic therapy.
In addition, little attention has been paid to the heterogeneity in the definition of the different prognostic variables. A secondary aim of the study was to address this issue and to evaluate whether the definition or the cut-off value used could influence a variable's prognostic value. Therefore we set out to determine how these variables are described in the different studies and to establish whether a reliable cut-off value for predicting rebleeding can be established.
Abstract and Introduction
Abstract
Background Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.
Aim To identify predictors of rebleeding after endoscopic therapy.
Methods Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.
Results Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57–4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14–2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31–2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98–4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38–10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69–4.86).
Conclusions Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.
Introduction
Peptic ulcer bleeding (PUB) is a major cause of acute nonvariceal gastrointestinal bleeding. It is a common reason for emergency hospital admission and a major cause of mortality, morbidity and health care expenditure.
In recent years, improvements in the treatment of PUB have reduced the risk of rebleeding and death. Most severe bleeding is associated with high-risk endoscopic stigmata. In these patients, the combination of aggressive volume repletion and rapid correction of hypotension, endoscopic therapy and intravenous proton-pump inhibitors (PPI) improve outcomes.
Recurrent haemorrhage is one of the most significant predictive factors for mortality. The risk of rebleeding in patients with clean ulcers is insignificant and recurrence occurs mainly after endoscopic therapy of ulcers showing high-risk stigmata. Identifying patients at very high risk for rebleeding within this population may allow targeting additional haemostatic measures in a cost-effective way. For example, routine use of second-look endoscopy in all endoscopically treated patients is not cost-effective but becomes so when performed in those at very high risk. At the other end of the scale, identifying patients with the lowest risk of rebleeding after therapy may also be useful: A previous study by our group showed that highly selected patients could be safely discharged after endoscopic therapy. Even if not discharged immediately, patients at low risk of rebleeding after therapeutic endoscopy are likely to benefit from an early switch to oral PPI and discharge instead of maintaining the costly and uncomfortable hospitalisation for a 72-h PPI perfusion that is currently recommended in all patients after endoscopic therapy.
The scores currently available were not designed to predict rebleeding after endoscopic therapy, and may not work well in this setting: Most have been developed in cohorts that included different causes of haemorrhage and patients not receiving endoscopic treatment. In addition, many were designed on the basis of a single study and their reproducibility has never been satisfactory. Finally, most scores were designed to predict mortality or a combination of mortality and rebleeding instead of only rebleeding. Predictors of ulcer rebleeding differ from those for mortality: they are related more to the severity of haemorrhage and the ulcer characteristics, whereas predictors for mortality are mainly comorbidity and rebleeding.
In consequence, it is important from a clinical point of view to develop a specific score for predicting rebleeding after endoscopic therapy. The first step in developing an accurate score is to identify the most important predictive variables. To ensure general applicability, we aimed to determine which variables have been found to be prognostic in a range of populations, instead of deriving them from a single study. For this reason, the present study performed a systematic review and a meta-analysis to identify the most consistent predictors of recurrent haemorrhage in patients after endoscopic therapy.
In addition, little attention has been paid to the heterogeneity in the definition of the different prognostic variables. A secondary aim of the study was to address this issue and to evaluate whether the definition or the cut-off value used could influence a variable's prognostic value. Therefore we set out to determine how these variables are described in the different studies and to establish whether a reliable cut-off value for predicting rebleeding can be established.
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