S0596 Is Early Inpatient Endoscopy Necessary for Anticoagulant-Associated Gastrointestinal Bleeding?

Abstract

INTRODUCTION: Patients on systemic anticoagulation are at increased risk for gastrointestinal bleeding (GIB). In those that present with GIB, resuscitation and support remain the standard of care. Guidelines also recommend endoscopy within 24 hours for diagnostic and therapeutic purposes. Unfortunately, lack of resources and/or gastroenterologists in small, community centers limit the ability to perform timely endoscopy. Conservative management is used in this setting with delayed or outpatient endoscopy, specifically in those who respond to medical therapy. There is minimal data on the outcomes of patients managed in this fashion. We look to compare presentation and outcomes of patients on anticoagulation who present with non-variceal upper GIB in a small community hospital. METHODS: We conducted a retrospective review of 115 patients with non-variceal upper GIB who underwent medical therapy (MT) alone vs inpatient endoscopy with MT. Outcomes included red blood cell (RBC) transfusions, re-admission for GIB, and 30-day all-cause mortality. Sub-group analysis was also performed based on endoscopy timeline and anticoagulant type. RESULTS: The MT group was comprised of 54 patients while 61 patients underwent inpatient esophagogastroduodenoscopy (EGD). There were no difference in age, gender, baseline laboratory values, or co-morbidities between both groups. Patient in the MT group required less RBC transfusions compared to EGD group (1.4 vs 2.5 average units, P = 0.004). There was no significant difference in the re-admission for GIB and overall mortality. There were 3 deaths, one in the endoscopy group (<24 hours) and 2 in the MT group (P = 0.60). Most patients were on warfarin (n = 47) and there were no differences in re-admission for GIB or mortality based on anticoagulant type. CONCLUSION: We aimed to evaluate outcomes in patients on chronic anticoagulation with non-variceal UGIB at a small, community medical center where urgent endoscopy cannot always be performed. In this retrospective study, we found that patients receiving MT only required significantly fewer blood transfusions than those undergoing endoscopy with no difference in recurrent GIB or mortality. Our study suggests that in a small, community center, conservative management could be employed safely if urgent endoscopy is not available. Nevertheless, a randomized, large study is needed to substantiate this claim.Table 1.: Demographic data comparing endoscopy group with Medical Therapy only groupFigure 1.: Average number of packed red blood cell transfusions was greater with endoscopy.Table 2