Decreasing trend of upper gastrointestinal bleeding mortality risk over three decades

Trends for Admission, Mortality and Emergency Surgery in Upper Gastrointestinal Bleeding: A Study of Eight Years of Admissions in a Tertiary Care Hospital

Introduction

Most studies have shown a declining incidence of upper gastrointestinal bleeding (UGIB) in recent years. Data regarding mortality were controversial; in non-variceal bleeding, the increasing age of the population, increased use of anti-thrombotic and anticoagulant therapy in patients with cardiovascular diseases, and the use of non-steroidal anti-inflammatory drugs are counterbalanced by the progress in endoscopic therapy with stable mortality.

Material and Method

We performed a retrospective, cross-sectional study that included patients admitted with UGIB in Clinical Emergency Hospital Craiova during 2013-2020.

Results

3571 patients with UGIB were selected; a trend toward increased admission for UGIB from 2013 to 2019 was noted, with a significant decrease in 2020. Non-variceal bleeding remains the most frequent form, with a slight increase in variceal bleeding, of Mallory-Weiss syndrome and angiodysplasia, and a 3-fold decrease for unknown etiology bleeding (with no endoscopy performed) during the 2017-2020 period as compared to 2013-2016. There was a trend toward decreased mortality, with lower mortality in 2017-2020 (12.83%) compared to 2013-2016 (17.41%). The mortality for variceal bleeding and peptic ulcer bleeding has declined, but mortality for non-variceal bleeding has slightly increased during 2013-2020. Mortality has decreased in admissions during regular hours/after hours and weekdays/weekends, but the difference (off-hours and weekend effects) had increased. The percentage of endoscopies performed in the first 24 hours after admission and the rate of therapeutic endoscopy increased during 2017-2020; the median time between admission and endoscopy was 17.0 hours during 2017-2020 and 59.1 hours during 2013-2016. The proportion of patients who needed emergency surgery for uncontrolled bleeding has significantly declined since 2013-2015, with an average value of 1% in the last 5 years of the study.

Conclusion

Increased admissions for UGIB, with lower mortality, especially for peptic ulcer bleeding and variceal bleeding were noted; higher percentages of therapeutic endoscopies and endoscopies performed during the first 24 hours after admission were also recorded.

Ulcer Bleeding in the United States: Epidemiology, Treatment Success, and Resource Utilization

BACKGROUND AND GOALS

Peptic ulcer disease is the most frequent cause of upper gastrointestinal bleeding. We sought to establish the epidemiology and hemostasis success rate of the different treatment modalities in this setting.

METHODS

Retrospective cohort study using the National Inpatient Sample. Non-elective adult admissions with a principal diagnosis of ulcer bleeding were included. The primary outcome was endoscopic, radiologic and surgical hemostasis success rate. Secondary outcomes were patients' demographics, in-hospital mortality and resource utilization. On subgroup analysis, gastric and duodenal ulcers were studied separately. Confounders were adjusted for using multivariate regression analysis.

RESULTS

A total of 136,425 admissions (55% gastric and 45% duodenal ulcers) were included. The mean patient age was 67 years. The majority of patients were males, Caucasians, of lower income and high comorbidity burden. The endoscopic, radiological and surgical therapy and hemostasis success rates were 33.6, 1.4, 0.1, and 95.1%, 89.1 and 66.7%, respectively. The in-hospital mortality rate was 1.9% overall, but 2.4% after successful and 11.1% after failed endoscopic hemostasis, respectively. Duodenal ulcers were associated with lower adjusted odds of successful endoscopic hemostasis, but higher odds of early and multiple endoscopies, endoscopic therapy, overall and successful radiological therapy, in-hospital mortality, longer length of stay and higher total hospitalization charges and costs.

CONCLUSIONS

The ulcer bleeding endoscopic hemostasis success rate is 95.1%. Rescue therapy is associated with lower hemostasis success and more than a ten-fold increase in mortality rate. Duodenal ulcers are associated with worse treatment outcomes and higher resource utilization compared with gastric ulcers.

Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis

GOALS

We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB).

BACKGROUND

NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking.

STUDY

We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis.

RESULTS

Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1 d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P <0.001) or NC (1.4%, P <0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05).

CONCLUSIONS

NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.

Trends of Upper Gastrointestinal Bleeding Mortality in the United States Before and During the COVID-19 Era: Estimates From the Centers for Disease Control WONDER Database

Background

There have been reports of increased upper gastrointestinal bleeding (UGIB) in patients with coronavirus disease 2019 (COVID-19). Still, only a few studies have examined the mortality rate associated with UGIB in the United States before and during COVID-19. Hereby, we explored the trends of UGIB mortality in the United States before and during COVID-19. The study's objective was to investigate whether the COVID-19 pandemic significantly impacted UGIB mortality rates in the USA.

Methods

The decedents with UGIB were included. Age-standardized mortality rates were estimated with the indirect method using the 2000 US Census as the standard population. We utilized the deidentified data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database. Linear regression analysis was performed to determine 2021 projected mortality rates based on trends between 2012 and 2019 to quantify the association of the pandemic with UGIB-related deaths.

Results

The mortality rate increased from 3.3 per 100,000 to 4.3 per 100,000 among the population between 2012 and 2021. There was a significant increase in the overall mortality rate between each year and the following year from 2012 to 2019, ranging from 0.1 to 0.2 per 100,000, while the rise in the overall mortality rate between each year and 2021 ranges from 0.4 to 0.9 per 100,000.

Conclusions

Our results showed that the mortality rate increased among the population between 2012and 2021, suggesting a possible influence of COVID-19 infection on the incidence and mortality of UGIB.

The impact of red blood cell transfusion practices on inpatient mortality in variceal and non-variceal gastrointestinal bleeding patients: a 20-year US nationwide retrospective analysis

BACKGROUND

Previous studies in upper gastrointestinal (GI) bleeding have reported inconsistent outcomes about packed red blood cell (PRBC) transfusion practices.

AIM

To assess whether PRBC transfusion is more likely to be dangerous in variceal bleeding than in non-variceal bleeding due to concern of over-transfusion leading to elevated portal pressure.

METHODS

We used the Nationwide Inpatient Sample (1999-2018). We identified patients with upper GI bleeding using an algorithmic approach, categorising bleeding from non-variceal or variceal sources. Our primary outcome was all-cause inpatient mortality. To control for the severity of bleeding, we performed propensity matching of baseline features, including age, gender, the presence of shock, the need for ICU care and co-morbidities. We also examined PRBC transfusion, inpatient mortality and hospitalisation rates for both populations.

RESULTS

We included 10,228,524 upper GI bleeding discharges; 755,135 patients had variceal bleeding. After propensity matching, PRBC transfusion in variceal bleeders was associated with a 22% increase in inpatient mortality, whereas non-variceal bleeders had a 9% increase in inpatient mortality. Compared to non-variceal bleeders receiving blood transfusion, variceal bleeders had nearly four-fold higher odds of inpatient mortality (propensity-matched OR: 3.8; 95% CI: 3.7-3.8; p < 0.001). Notably, PRBC transfusion rates in both groups have declined since 2011, although it has remained higher in variceal bleeders. Mortality for upper GI bleeding has been declining since 1999.

CONCLUSIONS

Although decreased over the last decade, PRBC transfusion rates remain high for variceal bleeders. In addition, PRBC transfusion appears to be more detrimental in variceal bleeders than in non-variceal bleeders.

Nature and treatment outcomes of bleeding post-bulbar duodenal ulcers

BACKGROUND

Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs).

METHODS

Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses.

RESULTS

Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in-hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs.

CONCLUSION

This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location.

Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases

OBJECTS

Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB.

METHODS

Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents.

RESULTS

Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti-thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non-users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%).

CONCLUSIONS

Although the usage of anti-thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti-thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti-thrombotic agents.

Endotherapy for Nonvariceal Upper Gastrointestinal Hemorrhage

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is a common GI emergency with significant morbidity and mortality. Triaging cases on the basis of patient-related factors, restrictive blood transfusion strategy, and hemodynamic stabilization are key initial steps for the management of patients with NVUGIH. Endoscopy remains a vital step for both diagnosis and definitive management. Multiple studies and guidelines have now defined the optimum timing for performing the endoscopy after hospitalization, to better the outcome. Conventional methods for achieving endoscopic hemostasis, such as injection therapy, contact, and noncontact thermal therapy, and mechanical therapy, such as through-the-scope clips, have reported to have 76 to 90% efficacy for primary hemostasis. Newer modalities to enhance hemostasis rates have come in vogue. Many of these modalities, such as cap-mounted clips, coagulation forceps, and hemostatic powders have proved to be efficacious in multiple studies. Thus, the newer modalities are recommended not only for management of persistent bleed and recurrent bleed after failed initial hemostasis, using conventional modalities but also now being advocated for primary hemostasis. Failure of endotherapy would warrant radiological or surgical intervention. Some newer tools to optimize endotherapy, such as endoscopic Doppler probes, for determining flow in visible or underlying vessels in ulcer bleed are now being evaluated. This review is focused on the technical aspects and efficacy of various endoscopic modalities, both conventional and new. A synopsis of the various studies describing and comparing the modalities have been outlined. Postendoscopic management including Helicobacter pylori therapy and starting of anticoagulants and antiplatelets have also been outlined.

Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

Thirty-Year Incidence and Mortality Trends in Upper and Lower Gastrointestinal Bleeding in Finland

IMPORTANCE

Epidemiological data on lower gastrointestinal bleeding (GIB) in the general population are sparse.

OBJECTIVE

To describe the incidence, recurrence, mortality, and case fatality rates of major upper GIB and lower GIB in the general population of Finland between 1987 and 2016.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study used data from the 1987 to the 2012 cycles of the National FINRISK Study, a health examination survey that was conducted every 5 years in Finland. Survey participants were adults aged 25 to 74 years who were recruited from a population register by random sampling; those with a history of hospitalization for GIB were excluded. Participants were followed up from survey enrollment to onset of GIB that led to hospitalization, death from any cause, or study end (December 31, 2016). Follow-up was performed through linkage with national electronic health registers. Data were analyzed from February 1, 2019, to January 31, 2020.

MAIN OUTCOMES AND MEASURES

Incidence, recurrence, mortality, and case fatality rates for all, upper, lower, and unspecified GIB. Outcome measures were stratified by sex and age group.

RESULTS

Among the 39 054 participants included in the study, 494 (1.3%) experienced upper GIB (321 men [65.0%]; mean [SD] age, 52.8 [12.1] years) and 645 (1.7%) had lower GIB (371 men [57.5%]; mean [SD] age, 54.0 [11.7] years). The age-standardized incidence rate was 0.94 per 1000 person-years (95% CI, 0.85-1.04) for upper GIB and 1.26 per 1000 person-years (95% CI, 1.15-1.38) for lower GIB; the incidence was higher in men than in women. Between 1987 and 2016 the incidence rate of upper GIB remained mostly stable, ranging from 0.40 to 0.66 per 1000 person-years, whereas constant increases occurred in the incidence of lower GIB until the rate stabilized. The proportion of recurrent GIB events showed an increasing trend from 1987 to 2016. The upper GIB-specific mortality was higher (0.07 per 1000 person-years; 95% CI, 0.04-0.09) than the lower GIB-specific mortality (0.01 per 1000 person-years; 95% CI, 0.001-0.03). Case fatality was high for those with upper GIB (7.0%; 95% CI, 4.7-10.1) compared with those with lower GIB (0.4%; 95% CI, 0.1-1.3). Case fatality remained stable over the years but was higher in men (between 5% and 10%) than women (<2%) with GIB.

CONCLUSIONS AND RELEVANCE

This study found that the overall incidence rate of upper GIB was lower than the incidence of lower GIB, but the recurrence, mortality, and 28-day case fatality were higher in participants with upper GIB. These data can serve as a reference when putting into context the rates of drug-associated GIB and can inform efforts to improve GIB care and outcome and to prevent rebleeding or death for patients with major GIB.

Prevalence, short term outcome and factors associated with survival in patients suffering from upper gastrointestinal bleeding in a resource limited-setting, the case of Mulago hospital in Kampala, Uganda

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a common cause of admission and death in the gastroenterology service. The prevalence, risk factors and the case fatality rate of UGIB may differ by settings.

OBJECTIVES

Our objective was to determine the prevalence of symptoms and the case fatality rate of UGIB among patients at the gastroenterology service of Mulago Hospital in Kampala, Uganda and to describe the clinical and laboratory risk factors associated with the survival of these patients.

METHODS

In a cross-sectional study performed between September 2013 and April 2014, patients were screened for UGIB symptoms. Data was collected on socio-demographic characteristics, clinical presentation and patient's outcome within one week of admission. Bivariate, multivariate, and survival analysis were performed to identify variables that were significantly associated with mortality.

RESULTS

Out of 1085 patients screened, we identified the prevalence of UGIB symptoms in 220 patients (20.3%). Among these, 150 met the inclusion criteria for our study. The majority were males (70.7%) and 40 years of age or less (60%). The most prevalent clinical diagnosis were gastritis (39.3%), esophageal varices (17.3%) and peptic ulcer disease (PUD) (16%). Among patients who underwent endoscopy, esophageal varices (42.2%), PUD (26.3%) and gastritis (15.8%) were the leading causes of bleeding. The overall case fatality rate was 16.7% (25/150). Uremia remained associated with mortality after controlling for confounders.Survival was significantly reduced for males as well as for patients with uremia and malignancy.

CONCLUSION

the prevalence of symptoms and the case fatality rate of UGIB among patients admitted to the gastroenterology ward in Mulago hospital were higher than in developed countries and similar to other resource-limited setting. The majority of patients were young men and presented with both hematemesis and melena. The most common causes of UGIB were esophageal varices, gastritis and PUD. Survival analysis indicate that male gender, uremia, and malignancy are associated with reduced survival.

Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding (NVUGIB) is bleeding that develops in the oesophagus, stomach or proximal duodenum. Peptic ulcers, caused by Helicobacter pylori infection or use of NSAIDs and low-dose aspirin (LDA), are the most common cause. Although the incidence and mortality associated with NVUGIB have been decreasing owing to considerable advances in the prevention and management of NVUGIB over the past 20 years, it remains a common clinical problem with an annual incidence of ∼67 per 100,000 individuals in the United States in 2012. NVUGIB is a medical emergency, and mortality is in the range ∼1-5%. After resuscitation and initial assessment, early (within 24 hours) diagnostic and therapeutic endoscopy together with intragastric pH control with proton pump inhibitors (PPIs) form the basis of treatment. With a growing ageing population treated with antiplatelet and/or anticoagulant medications, the clinical management of NVUGIB is complex as the risk between gastrointestinal bleeding events and adverse cardiovascular events needs to be balanced. The best clinical approach includes identification of risk factors and prevention of bleeding; available strategies include continuous treatment with PPIs or H. pylori eradication in those at increased risk of developing NVUGIB. Treatment with PPIs and/or use of cyclooxygenase-2-selective NSAIDs should be implemented in those patients at risk of NVUGIB who need NSAIDs and/or LDA.

Gastrointestinal Bleeding During the Index Hospitalization for Mechanical Circulatory Support Devices Implantation, a Nationwide Perspective

BACKGROUND

Gastrointestinal bleeding (GIB) is a common adverse event after mechanical circulatory support device implantation. However, the majority of the reported data were obtained from small single-center studies. Our aim was to study the prevalence and predictors of GIB during the index hospitalization of mechanical circulatory support devices implantation using a nationwide database.

METHODS

Nationwide inpatient sample (2009-2011) was used to perform a retrospective cross-sectional study. Adult patients with discharge diagnosis codes of congestive heart failure and procedure codes of left-ventricular assist device (LVAD) or intra-aortic balloon pump (IABP) implantation or orthotopic heart transplant (OHT, reference group) were identified. Our outcome was GIB during the index hospitalization when the device was implanted. Predictors that achieved statistical significance on the univariate analysis were included in a multivariable logistic-regression analysis.

RESULTS

A total of 87,462 patients were included, 87 % of the patients received an IABP, 6 % received LVAD, and 5 % underwent OHT. Prevalence of GIB was 8, 5, and 3 % among those who had LVAD, IABP implantation, and OHT recipients, respectively (p < 0.001). Patients who underwent LVAD implantation had twofold increase in the prevalence of GIB (OR 2.1, 1.7-2.5, p < 0.001) when using IABP or OHT groups as a reference. This increase in the prevalence was not demonstrated among IABP recipients on a multivariate level.

CONCLUSION

Prevalence of GIB was higher among LVAD compared to OHT and IABP recipients and could occur as early as the index admission of the device implantation.

A simple scoring system to assess the need for an endoscopic intervention in suspected upper gastrointestinal bleeding: A prospective cohort study

BACKGROUND

Assessment of the emergent endoscopy for upper gastrointestinal bleeding (UGIB) patients has important clinical implications. There is no validated criterion to triage.

AIMS

To develop a simple score predicting an endoscopic intervention.

METHODS

A prospective cohort study was conducted at a tertiary care centre. Primary outcome was the high-risk stigmata which were well-established endoscopic findings to determine the need for an endoscopic intervention. We created a simple score by multivariable logistic regression and compared with the Glasgow Blatchford Score (GBS). External validation was performed in a second cohort.

RESULTS

284 of consecutive 568 patients with suspected UGIB had the high-risk stigmata. Three variables were selected: "no daily use of proton pump inhibitors during one week before examination (+1 point)", "shock index (heart rate/systolic blood pressure)≥1 (+1 point)" and "urea/creatinine≥140 (blood urea nitrogen/creatinine≥30) (+1 point)". The accumulating score (range 0-3) achieved an area under the receiver-operating characteristic curve (AUC) of 0.74 (95% confidence interval [CI], 0.70-0.78), which was superior to the GBS (AUC, 0.63; 95% CI, 0.59-0.68; p<0.001). Validation in an external cohort demonstrated superiority to the GBS (AUC, 0.78 vs. 0.59; p<0.001).

CONCLUSIONS

The simple score has greater accuracy than the GBS for assessing the need for an endoscopic intervention in cases of suspected UGIB. Further external validation should be performed to verify generalizability.

Epidemiology and Risk Factors for Upper Gastrointestinal Bleeding

Although the incidence of nonvariceal upper gastrointestinal bleeding (UGIB) has been decreasing worldwide, nonvariceal UGIB continues to be a significant problem. Even with the advent of advanced endoscopic procedures and potent medications to suppress acid production, UGIB carries significant morbidity and mortality. Some of the most common risk factors for nonvariceal UGIB include Helicobacter pylori infection, nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, selective serotonin reuptake inhibitors, and other antiplatelet and anticoagulant medications. In patients with cardiovascular disease and kidney disease, UGIB tends to be more severe and has greater morbidity. Many of the newer NSAIDs have been removed from the market.

The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis

BACKGROUND

Despite major advances in upper GI hemorrhage (UGIH) treatment, UGIH mortality has been reported as unchanged for the past 50 years.

OBJECTIVE

To measure the UGIH in-hospital mortality rate and other important outcome trends from 1989 to 2009.

DESIGN

A longitudinal study of UGIH hospitalizations by using the Nationwide Inpatient Sample.

SETTING

Acute-care hospitals.

PATIENTS

All patients admitted for UGIH. Patients who bled after admission were excluded.

MAIN OUTCOME MEASUREMENTS

UGIH in-hospital mortality rate, incidence, in-hospital endoscopy and endoscopic therapy rates, length of hospital stay, and total in-hospital charges.

RESULTS

The non-variceal UGIH mortality rate decreased from 4.5% in 1989 to 2.1% in 2009. The non-variceal UGIH incidence declined from 108 to 78 cases/100,000 persons in 1994 and 2009, respectively. In-hospital upper endoscopy and endoscopic therapy rates increased from 70% and 10% in 1989 to 85% and 27% in 2009, respectively. The early endoscopy rate increased from 36% in 1989 to 54% in 2009. The median length of hospital stay decreased from 4.5 days in 1989 to 2.8 days in 2009. Median total hospitalization charges increased from $9249 in 1989 to $20,370 in 2009. At the national level, the UGIH direct in-hospital economic burden increased from $3.3 billion in 1989 to $7.6 billion in 2009. Similar trends were found for variceal UGIH.

LIMITATIONS

Retrospective data, administrative database.

CONCLUSION

In-hospital mortality from UGIH has been decreasing over the past 2 decades, with a concomitant increase in rate of endoscopy and endoscopic therapy. However, despite decreasing length of stay, the total economic burden of UGIH is increasing.

Role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension

A transjugular intrahepatic portosystemic shunt (TIPS) is an expandable metal stent inserted via the jugular vein that creates a shunt from the portal vein to the systemic circulation via an artificial communication through the liver. It is used to treat complications of portal hypertension. In addition to rescue treatment in variceal bleeding, TIPS can play an important role in prevention of rebleeding. TIPS can improve symptoms if medical treatment of ascites or hepatic hydrothrorax has failed, but may not improve survival. Selected cases of Budd-Chiari syndrome improve with TIPS. This article discusses the indications, evidence, and complications of TIPS.