Comparison of Efficacy of Open Access Endoscopy for Evaluation of Upper GI Bleeding with Non Open Access Endoscopy in a Developing Country and the Implications on the NHS of Sri Lanka

Abstract

Purpose: As open access endoscopy had been shown to improve the diagnostic yield of upper gastrointestinal bleeding (UGIB), where the said facility is a rarity in a developing country like Sri Lanka where we have compared the findings of endoscopic outcome of UGIB, in two cohorts of age and sex matched adult patient populations, seeking treatment in a secondary referral center (non open access/non fee levying) and a tertiary referral center (open access/fee levying) in Western Province of Sri Lanka, both belonging to NHS to evaluate the impact on formulating health policies, on a background of free NHS health facilities except for the tertiary referral center aforementioned. Methods: Case notes of 1200 and 1500 oral gastroduodenoscopies (OGD)s performed by the principal author's unit for various reasons from 8.3.1997 to 8.3.2001 at the District General Hospital, Panadura (secondary referral center) and at Sri Jayewardenepura General Hospital (tertiary referral center) from 13.3.2002 to 13.2.2004 were retrospectively analyzed and those who had UGIB were selected. Results: Secondary referral canter group had 300 bleeds (25%) with a male: female sex ratio of 210:90 (˜2:1), majority being in the 51-70 age group. Endoscopy showed presence of esophagitis, severe antral gastritis with duodenitis, peptic ulcer disease, varices, pangastritis, erosions and malignancies in 49%, 18%, 11%, 8%, 6%, 2% and 0.6% of the instances respectively. Tertiary referral center group had 343 bleeds (24%) with a male: female sex ratio of 229:114 (2:1), similarly majority being in the 51-70 age group. Similar endoscopic pathologies were seen in 28%, 48%, 28%, 32%, 15%, 17% and 5% of the cases in respective groups, while NSAID incrimination was seen in 12% and 5% respectively. Vast majority revealed multiple endoscopic pathologies. Only about 50% of the varices had the evidence of bleeding. Conclusion: The etiological variations of the UGIB are most likely be due to a “cohort effect” and open access endoscopy minimized the negatives and improved the diagnostic yield at a considerable cost to the patient, which would be a massive financial burden in a non fee levying NHS like Sri Lanka, if such units are to be established countrywide. Furthermore the cost difference between the management of endoscopy negative upper GI bleeding in the non open access system and open access system should be ascertained, to justify the presence of former facility in the NHS of a developing country.