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Cazacu SM, Turcu-Stiolica A, Florescu DN, Ungureanu BS, Iovanescu VF, Neagoe CD, Burtea DE, Genunche-Dumitrescu AV, Avramescu TE, Iordache S. The Reduction of After-Hours and Weekend Effects in Upper Gastro-intestinal Bleeding Mortality During the COVID-19 Pandemic Compared to the Pre-Pandemic Period. J Multidiscip Healthc 2023; 16:3151-3165. [PMID: 37908341 PMCID: PMC10615097 DOI: 10.2147/jmdh.s427449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023] Open
Abstract
Background In upper gastrointestinal bleeding (UGIB), admissions after normal working hours and during weekends may be associated with increased mortality. Aim To assess the evolution of the after-hours and weekend effects during the COVID-19 pandemic as a result of progressive improved management despite management challenges during the pandemic. Methods We performed an observational study of patients admitted for UGIB at a tertiary academic center between March 2020 and December 2021, compared to the corresponding timeframe before the pandemic. Admissions were assessed based on regular hours versus after-hours and weekdays versus weekends. We stratified patients based on demographic data, etiology, prognostic scores, the time between symptom onset and admission, as and between admission and endoscopy. The outcomes included mortality, rebleeding rate, the requirement for surgery and transfusion, and hospitalization days. Results 802 cases were recorded during the pandemic, and 1006 cases before the pandemic. The overall mortality rate was 12.33%. Patients admitted after hours and during weekends had a higher mortality rate compared to those admitted during regular hours and weekdays (15.18% versus 10.22%, and 15.25% versus 11.16%), especially in cases of non-variceal bleeding. However, the difference in mortality rates was reduced by 2/3 during the pandemic, despite the challenges posed by COVID-19 infection. This suggests that there was an equalization effect of care in UGIB, regardless of the admission time. The differences observed in mortality rates for after-hours and weekend admissions seem to be primarily related to a higher proportion of patients who did not undergo endoscopy, while the proportion of severe cases remained similar. Blood requirements, hospital days, and rebleeding rate were similar between the two groups. Conclusion Admissions during weekends and after-hours have been associated with increased mortality, particularly in cases of non-variceal bleeding. However, the impact of this association was significantly reduced during the pandemic.
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Affiliation(s)
- Sergiu Marian Cazacu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Adina Turcu-Stiolica
- Biostatistics Department, University of Medicine and Pharmacy Craiova, Dolj County, Romania
| | - Dan Nicolae Florescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Bogdan Silviu Ungureanu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Vlad Florin Iovanescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Carmen Daniela Neagoe
- Internal Medicine Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | - Daniela Elena Burtea
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
| | | | - Taina Elena Avramescu
- Individual Sports, and Medical Disciplines Departments, University of Craiova, Dolj County, Romania
| | - Sevastita Iordache
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Clinical Emergency Hospital Craiova, Dolj County, Romania
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Sun H, Zhou Y, Shu C, Huang T, Xiao J. Effects of gastrointestinal endoscopy at different time points on diagnosis and treatment of upper gastrointestinal bleeding in patients with liver cirrhosis. Wideochir Inne Tech Maloinwazyjne 2023; 18:467-474. [PMID: 37868275 PMCID: PMC10585461 DOI: 10.5114/wiitm.2023.130325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Liver cirrhosis is a common diffuse and persistent liver disease in the gastroenterology department. Aim To assess the effects of gastrointestinal endoscopy at different time points on the diagnosis and treatment of upper gastrointestinal bleeding (UGIB) in patients with liver cirrhosis. Material and methods The clinical data of 102 liver cirrhosis patients with UGIB admitted from July 2020 to May 2022 were retrospectively analysed. According to the timing of the first gastroscopy after hospitalization, the patients were divided into 4 groups: Group A (n = 25, gastroscopy performed within 12 h of the first bleeding), Group B (n = 29, gastroscopy performed within 12-48 h of the first bleeding), Group C (n = 25, elective gastroscopy performed > 48 h after the first bleeding), and Group D (n = 23, emergency gastroscopy was conducted due to active bleeding manifestations after failure of medication). Results The success rate of haemostasis in Group A was higher than in Groups B-D (p < 0.05). The early rebleeding rates of the 4 groups were similar (p > 0.05). After treatment, the levels of serum malondialdehyde and lipid hydrogen peroxide declined but the levels of glutathione peroxidase and superoxide dismutase rose in all groups compared to those immediately after hospitalization (p < 0.05), and these indicators were improved more significantly in Group A (p < 0.05). Conclusions Gastroscopy performed within 12 h of the first bleeding is more conducive to improving the haemostatic effect and thus shortening the length of hospital stay.
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Affiliation(s)
- He Sun
- Department of Gastroenterology, Hubei Aerospace Hospital, Xiaogan, Hubei Province, China
| | - You Zhou
- Department of Gastroenterology, Hubei Aerospace Hospital, Xiaogan, Hubei Province, China
| | - Cheng Shu
- Department of Emergency Medicine, Hubei Aerospace Hospital, Xiaogan, Hubei Province, China
| | - Tizheng Huang
- Department of Gastroenterology, Hubei Aerospace Hospital, Xiaogan, Hubei Province, China
| | - Jun Xiao
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei Province, China
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Guo CLT, Wong SH, Lau LHS, Lui RNS, Mak JWY, Tang RSY, Yip TCF, Wu WKK, Wong GLH, Chan FKL, Lau JYW, Sung JJY. Timing of endoscopy for acute upper gastrointestinal bleeding: a territory-wide cohort study. Gut 2022; 71:1544-1550. [PMID: 34548338 PMCID: PMC9279843 DOI: 10.1136/gutjnl-2020-323054] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/08/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE While it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess whether endoscopy timing postadmission would affect outcomes. DESIGN We conducted a retrospective, territory-wide, cohort study with healthcare data from all public hospitals in Hong Kong. Adult patients (age ≥18) that presented with AUGIB between 2013 and 2019 and received therapeutic endoscopy within 48 hours (n=6474) were recruited. Patients were classified based on endoscopic timing postadmission: urgent (t≤6), early (6<t≤24) and late (24<t≤48). Baseline characteristics were balanced with inverse probability of treatment weighting. 30-day all-cause mortality, repeated therapeutic endoscopy rate, intensive care unit (ICU) admission rate and other endpoints were compared. RESULTS Results showed that urgent timing (n=1008) had worse outcomes compared with early endoscopy (n=3865), with higher 30-day all-cause mortality (p<0.001), repeat endoscopy rates (p<0.001) and ICU admission rates (p<0.001). Late endoscopy (n=1601) was associated with worse outcomes, with higher 30-day mortality (p=0.003), in-hospital mortality (p=0.022) and 30-day transfusion rates (p=0.018). CONCLUSION Compared with urgent and late endoscopy among patients who have received therapeutic endoscopies, early endoscopy was associated with superior outcomes especially among patients with non-variceal bleeding. This supports the notion that non-variceal AUGIB patients should receive endoscopy within 24 hours, but also emphasises the importance of prior resuscitation and pharmacotherapy.
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Affiliation(s)
- Cosmos L T Guo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Louis H S Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rashid N S Lui
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joyce W Y Mak
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Raymond S Y Tang
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Terry C F Yip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K K Wu
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Grace L H Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Medical Data Analytics Centre, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Francis K L Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - James Y W Lau
- Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong,Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Joseph J Y Sung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong .,Institute of Digestive Disease, State Key Laboratory of Digestive Disease, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Tarar ZI, Zafar MU, Farooq U, Ghous G, Shoukat HMH, Kuwajima V. Does Performing Endoscopy Sooner Have an Impact on Outcomes in Patients With Acute Nonvariceal Upper Gastrointestinal Hemorrhage? A Systematic Review. Cureus 2021; 13:e16092. [PMID: 34367748 PMCID: PMC8330500 DOI: 10.7759/cureus.16092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Endoscopy is the cornerstone for the diagnosis and treatment of nonvariceal upper gastrointestinal bleeding. Regarding the management of nonvariceal bleeding, the administration of crystalloid solution and proton pump inhibitors before endoscopy is well established, but the optimal timing of endoscopy has been a matter of debate and a subject of many investigational studies. The need for urgent endoscopy arises to provide prompt redress to acute bleeding, decrease the length of stay, and lower mortality from ongoing bleeding. Objective This study aimed to determine if endoscopy performed within 24 hours of presentation improves outcomes in terms of mortality, hospital length of stay, and rebleeding in individuals presenting with nonvariceal upper gastrointestinal bleed with any risk. Methodology We performed a systematic review of two large databases (PubMed and Google Scholar) to incorporate all studies published after 2000. We included studies with nonvariceal upper gastrointestinal bleeding and excluded those reporting variceal gastrointestinal hemorrhage. Results We reviewed eight studies that qualified after meeting our inclusion and exclusion criteria. We divided these studies into three separate groups based on the timing of endoscopy. Only two studies found a difference in mortality that was statistically significant in patients who underwent endoscopy within 24 hours of presentation. One study showed lower mortality in a patient who underwent urgent endoscopy, but it did not reach statistical significance. Other studies did not show any statistical difference in mortality, hospital length of stay, and rebleeding rates. The studies showed conflicting evidence on the amount of blood transfusion, though urgent endoscopy was found to be difficult in few studies due to blood obscuring the lesion. Conclusions While data suggest that there is a potential benefit in performing endoscopy sooner, there is no concrete evidence to point to a particular time range. Before performing endoscopy, the American Society for Gastrointestinal Endoscopy (2012) recommends adequate resuscitation with crystalloid solutions, blood transfusions, and antisecretory and prokinetic agent therapy. More investigational studies are needed to formulate a time-sensitive flow sheet to approach endoscopy in patients with nonvariceal upper gastrointestinal bleeding. A strict criterion is also needed to delineate patients into low-risk and high-risk groups. Doing so would provide a systematic approach to help with mortality, rebleeding, and healthcare resource utilization.
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Affiliation(s)
| | | | - Umer Farooq
- Internal Medicine, Loyola Medicine, MacNeal Hospital, Berwyn, USA
| | - Ghulam Ghous
- Hematology/Oncology, University of Missouri, Columbia, USA
| | | | - Vanessa Kuwajima
- Gastroenterology and Hepatology, University of Missouri, Columbia, USA
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