Upper GI bleeding – Has mortality changed with advancements in therapy?

Abstract

Upper gastrointestinal bleeding (UGIB) is one of the most common GI medical emergencies, which all GI units deal with everyday. UGIB is broadly categorized into variceal and non variceal bleeding .This distinction becomes crucial as the management strategies are different for variceal and nonvariceal bleeding .There has been tremendous advancement in pharmacological and endoscopic interventions in management of upper GI bleeding over the past decade. However, it still carries considerable morbidity, mortality and health economic burden. Peptic ulcer bleeding is the predominant cause of nonvariceal bleeding in the US and Europe. Recent data indicate a decline in the incidence of peptic ulcer disease and peptic ulcer bleeding in both the United States and Europe, which can be attributed to a decrease in H. pylori infection. Numerous studies from US, Europe and some Asian countries have reported peptic ulcer bleeding mortality 5-12%. Furthermore, these peptic ulcer bleeding linked deaths are not a direct result of bleeding ulcers. Instead, death occurs due to multi organ failure and other associated co morbidities. These studies have also shown that endoscopic interventions and pharmacological treatments have reduced rebleeding rates, rates of surgical interventions, days of hospitalization and number of blood units transfused. However, none of these therapeutic approaches have reduced the overall mortality associated with the bleed event. Hence, there is a need to relook at factors associated with mortality and revise management strategies accordingly. Foremost, reasons for failure to reduce mortality rates despite major advances in endoscopic hemostatic modalities needs to be explored . A number of factors have been proposed as possible causes of persistently high mortality associated with peptic ulcer bleeding .Age and the presence of associated comorbidities are the most important factors for high mortality in a bleeding event. Sung et al reported an overall mortality of 6.2% in patients with peptic ulcer bleeding in a large cohort of 9,375 patients. 80% of these deaths were not related to ulcer bleed as opposed to 20% of mortality directly relatedto peptic ulcer bleed. Among those who died of non-bleeding related causes, multi-organ failure (24%), pulmonary causes (23.5%) and terminal malignancies were the most common causes, while bleeding related deaths occurred when immediate control of bleed could not be achieved or failure of endoscopic therapy within 48 hrs. The mean age of patients who died of bleeding related causes was higher than those who died of non-bleeding related causes. (75.4 years Vs 71.7 years, p=0.01). The survivors were younger with less severe comorbid diseases than non survivors. (61years vs 72.5years).This data clearly indicate that pharmacological or endoscopic intervention will have little impact on overall mortality. Hence, the efforts should be focused on identifying non GI factors associated with poor outcomes and reduce the risk of multi organ failure, especially in elderly population. How relevant is the above-mentioned scenario in the Indian context? Can we extrapolate the Western experience in India? What are the most common causes of UGI bleeding in India? What is overall prevalence of peptic ulcer bleeding? Do these patients have access to a high