Abstract
BackgroundUpper gastrointestinal bleeding (UGIB) is a common cause of hospital admissions worldwide. Aetiologies vary by sociodemographics and geography. Retrospective studies of endoscopies in much of Africa have documented oesophageal varices as a leading cause of UGIB. Prospective studies describing outcomes and associations with clinical factors are lacking.MethodsWe conducted a prospective cohort study at a referral hospital in Mwanza, Tanzania where schistosomiasis is endemic. Adults admitted with haematemesis underwent laboratory workup, schistosomiasis antigen testing and elective endoscopy, and were followed for two months for death or re-bleeding. We assessed predictors of endoscopic findings using logistic regression models, and determined prediction rules that maximised sensitivity and positive predictive value (PPV).ResultsOf 124 enrolled patients, 13 died within two months (10%); active schistosomiasis prevalence was 48%. 64/91(70%) patients had oesophageal varices. We found strong associations between varices and numerous demographic or clinical findings, permitting construction of simple, high-fidelity prediction rules for oesophageal varices applicable even in rural settings. Portal vein diameter ≥ 13 mm or water sourced from the lake yielded sensitivity, specificity, PPV and NPV > 90% for oesophageal varices; presence of splenomegaly or water sourced from the lake maintained sensitivity and PPV > 90%.ConclusionsOur results guide identification of patients, via ultrasound and clinical examination, likely to have varices for whom referral for endoscopy may be life-saving. Furthermore, they support empiric anti-schistosome treatment for patients with UGIB in schistosome-endemic regions. These interventions have potential to reduce UGIB-related morbidity and mortality in Africa.
Highlights
Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admissions worldwide
We found that nearly 60% of patients presenting with haematemesis due to variceal bleeding and 30% presenting with haematemesis due to other causes had evidence of active schistosomiasis
Scaling up efforts to control schistosomiasis could lead to significant reductions in morbidity and mortality among the ~54 million people living in sub-Saharan Africa who have S. mansoni infection and are at risk for periportal fibrosis, oesophageal varices, and death [22]
Summary
Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admissions worldwide. Retrospective studies of endoscopies in much of Africa have documented oesophageal varices as a leading cause of UGIB. At our hospital in Tanzania, a diagnosis of schistosomiasis or cirrhosis, which was associated with UGIB in more than 2/3 of patients, was recently documented to be the fourth leading cause of both admissions and deaths in the medicine wards [5]. UGIB can be categorised as oesophageal variceal and non-variceal bleeding. Underlying aetiologies of UGIB vary markedly with geographic region and socioeconomic status [6]. If the underlying cause of the varices can be determined and is treatable (including infectious aetiologies such as schistosomiasis), pathology leading to oesophageal varices may be diminished
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