Early Esophagogastroduodenoscopy Research Articles

Nonvariceal upper gastrointestinal bleeding in COVID-19 patients: insights from the National Inpatient Sample

Background This retrospective study, conducted using the U.S. National Inpatient Sample (NIS), examines the outcomes and management of nonvariceal upper gastrointestinal bleeding (NVUGIB) in COVID-19 patients and identifies predictive factors to enhance patient prognosis. Methods We analyzed the 2020 U.S. NIS data involving adult patients (≥18 years) admitted with NVUGIB and categorized them based on the presence of COVID-19. Primary and secondary outcomes, NVUGIB-related procedures, and predictive factors were evaluated. Results Of 184,885 adult patients admitted with NVUGIB, 1.6% (2990) had COVID-19. Patients with NVUGIB and COVID-19 showed higher inpatient mortality, acute kidney injury, need for intensive care, and resource utilization metrics. Notably, there was a lower rate of early esophagogastroduodenoscopy (EGD). Multivariate logistic regression revealed conditions like peptic ulcer disease, mechanical ventilation, and alcohol abuse as significant positive predictors for NVUGIB in COVID-19 patients, whereas female gender and smoking were negative predictors. Conclusion Our findings suggest that COVID-19 significantly increases the risk of mortality and complications in NVUGIB patients. The observed decrease in early EGD interventions, potentially contributing to higher mortality rates, calls for a review of treatment strategies. Further multicenter, prospective studies are needed to validate these results and improve patient care strategies.

Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis.

We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking. We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis. Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P<0.001) or NC (1.4%, P<0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05). NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.

Effect of Patient Age on Timing of Inpatient Esophagogastroduodenoscopy and Outcomes for Non-variceal Upper GI Bleeds.

Background Esophagogastroduodenoscopy (EGD) is typically performed within 24 hours of presentation for patients admitted to a hospital for patients presenting with a non-variceal upper gastrointestinal bleed (UGIB). To date, no studies have been performed to identify the impact of patient age on the timing of inpatient EGD and patient outcomes in non-variceal UGIB. Our aim was to assess the differences in the timing of EGD, blood transfusion requirements, development of hemorrhagic shock, development of acute renal failure, mortality, length of stay, and total hospital charges for patients aged 18-59 and those aged 60 and older. Methods Admissions for non-variceal UGIB were identified from the National (Nationwide) Inpatient Sample (NIS) database from 2016 and 2017. Patients who initially presented with hemorrhagic shock were excluded. Patients were divided into two age groups, those aged 18-59 and those aged 60 or older. We classified EGDs as early and delayed. Since the NIS database identifies days as midnight to midnight, we categorized early EGDs as those performed on day 0 and day 1. Delayed EGD were categorized as those performed on days 2 and 3. Multivariate logistic regression was performed on propensity-matched data to compare EGD timing, blood transfusion requirements, development of post-hospitalization hemorrhagic shock, development of acute renal failure, and mortality. The following patient and hospital variables were used in regression models: race, sex, insurance status, income quartile, mortality risk score, illness severity score, admission month, admission day, type of admission, region, bed size, and hospital teaching status. Finally, weighted two-sample T-tests were used to compare the length of stay and total hospitalization cost. Results A total of 12,449 weighted cases of inpatient non-variceal UGIB were included in this study. Patients aged 60 and older were more likely to die during the hospitalization (OR= 1.661, 95%CI:1.108-2.490, p= 0.014), require blood transfusion (OR= 1.257, 95%CI: 1.131-1.396, p<0.001), and develop acute renal failure (OR= 1.672, 95%CI: 1.447-1.945, p<0.001). Patients aged 60 and older were also less likely to receive an early EGD (OR= 0.850, 95%CI: 0.752-0.961, p= 0.009). Total hospital costs (95%CI: -1397.77 - -4005.68, p<0.001) and length of stay (95%CI: -0.428 - -0.594, p<0.001) were both lower in patients aged 18-59 years. There was no difference in the development of post-hospitalization hemorrhagic shock between the two groups (OR= 0.984, 95%CI: 0.707-1.369, p= 0.923). Conclusions Patients aged 60 and older were less likely to have an early EGD and more likely to have worse outcomes. They had increased rates of inpatient mortality, blood transfusion requirements, development of acute renal failure, increased total hospital costs, and longer lengths of stay. There were no differences in the development of post-hospitalization hemorrhagic shock between the two groups.

Relationships of hospitalization outcomes and timing to endoscopy in non-variceal upper gastrointestinal bleeding: A nationwide analysis.

The optimal timing of esophagogastroduodenoscopy (EGD) and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding (NVUGIB) remains an area of active research. To identify independent predictors of outcomes in patients with NVUGIB, with a particular focus on EGD timing, anticoagulation (AC) status, and demographic features. A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database. Patients were stratified by EGD timing relative to hospital admission (≤ 24 h, 24-48 h, 48-72 h, and > 72 h) and then by AC status (yes/no). The primary outcome was all-cause inpatient mortality. Secondary outcomes included healthcare usage. Of the 1082516 patients admitted for NVUGIB, 553186 (51.1%) underwent EGD. The mean time to EGD was 52.8 h. Early (< 24 h from admission) EGD was associated with significantly decreased mortality, less frequent intensive care unit admission, shorter length of hospital stays, lower hospital costs, and an increased likelihood of discharge to home (all with P < 0.001). AC status was not associated with mortality among patients who underwent early EGD (aOR 0.88, P = 0.193). Male sex (OR 1.30) and Hispanic (OR 1.10) or Asian (aOR 1.38) race were also independent predictors of adverse hospitalization outcomes in NVUGIB. Based on this large, nationwide study, early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage, irrespective of AC status. These findings may help guide clinical management and would benefit from prospective validation.

Increasing inpatient mortality of nonvariceal upper gastrointestinal bleeding during the COVID-19 pandemic: a nationwide retrospective cohort study

Upper gastrointestinal bleeding results in significant morbidity, mortality, and healthcare burden. This study aimed to evaluate inpatient outcomes of nonvariceal upper gastrointestinal bleeding (NVUGIB) during the year 2020 of the COVID-19 pandemic. The National Inpatient Sample databases were used to identify NVUGIB-related hospitalizations. Outcomes of interest for the year 2019 were compared to 2020 and included inpatient mortality, length of stay, mean inpatient cost, odds of getting esophagogastroduodenoscopy (EGD), mean time to EGD, early EGD (within 1 day of hospitalization), endoscopic intervention for hemostasis, and the odds of developing complications. NVUGIB-related hospitalizations increased by 8.1% in 2020. NVUGIB-related hospitalizations in 2020 were also associated with an 11.1% higher mortality (adjusted odds ratio [aOR] = 1.11, confidence interval [CI] = 1.06–1.17, P < 0.01), 0.15-day longer mean time to EGD (aOR = 0.15, CI = 0.08–0.24, P < 0.01), 4% lower odds of getting an EGD (aOR = 0.96, CI = 0.93–0.99, P = 0.02), 8% lower odds of getting an early EGD (aOR = 0.92, CI = 0.89–0.96, P < 0.01), and $6340 higher mean inpatient cost (aOR = 6340, CI = 1762–10919, P = 0.01) compared to 2019. We conclude that there was an increase in NVUGIB-related hospitalizations and mortality in 2020 when the COVID-19 pandemic started.

A Novel Prediction Tool for Endoscopic Intervention in Patients with Acute Upper Gastro-Intestinal Bleeding.

(1) Background: Predicting which patients with upper gastro-intestinal bleeding (UGIB) will receive intervention during urgent endoscopy can allow for better triaging and resource utilization but remains sub-optimal. Using machine learning modelling we aimed to devise an improved endoscopic intervention predicting tool. (2) Methods: A retrospective cohort study of adult patients diagnosed with UGIB between 2012–2018 who underwent esophagogastroduodenoscopy (EGD) during hospitalization. We assessed the correlation between various parameters with endoscopic intervention and examined the prediction performance of the Glasgow-Blatchford score (GBS) and the pre-endoscopic Rockall score for endoscopic intervention. We also trained and tested a new machine learning-based model for the prediction of endoscopic intervention. (3) Results: A total of 883 patients were included. Risk factors for endoscopic intervention included cirrhosis (9.0% vs. 3.8%, p = 0.01), syncope at presentation (19.3% vs. 5.4%, p < 0.01), early EGD (6.8 h vs. 17.0 h, p < 0.01), pre-endoscopic administration of tranexamic acid (TXA) (43.4% vs. 31.0%, p < 0.01) and erythromycin (17.2% vs. 5.6%, p < 0.01). Higher GBS (11 vs. 9, p < 0.01) and pre-endoscopy Rockall score (4.7 vs. 4.1, p < 0.01) were significantly associated with endoscopic intervention; however, the predictive performance of the scores was low (AUC of 0.54, and 0.56, respectively). A combined machine learning-developed model demonstrated improved predictive ability (AUC 0.68) using parameters not included in standard GBS. (4) Conclusions: The GBS and pre-endoscopic Rockall score performed poorly in endoscopic intervention prediction. An improved predictive tool has been proposed here. Further studies are needed to examine if predicting this important triaging decision can be further optimized.

S674 The Disparity in Hospitalization Outcomes for Patients With Variceal Hemorrhage Based on the Patients’ Living Area Household Income: A Study of the National Inpatient Sample

Introduction: Variceal hemorrhage (VH) is a dreaded condition that requires urgent hospitalization. Multiple studies have shown that socioeconomic disparities are linked to poor healthcare outcomes. In this study, we aim to characterize the differences in the hospitalization outcomes of VH based on the household income area. Methods: Patients with a 1ry discharge diagnosis of VH were identified from the national inpatient sample (NIS) 2016-2018 data and classified based on household income for patients’ living areas as: low [LIA] (≤ 50% ) or high [HIA] ( >50%). The living area household income was provided by Claritas as a quartile classification per ZIP code and incorporated into the NIS data. Inverse probability weighting based on propensity score was used to adjust for differences between the two groups. Our outcomes include time to first esophagogastroduodenoscopy (EGD) (early: ≤ 24 hours vs late: > 24 hours), length of hospital stay (LOS), hospital charges, mortality, and discharge disposition. Results: Out of 62,775 included patients, 37,420 were identified as LIA group. These patients were more likely to be Black or Hispanic, covered by Medicare or Medicaid, admitted to larger bed-size hospitals, use tobacco, had lower Elixhauser’s comorbidity score, and diagnoses of shock compared to the HIA group (Table). In the outcome analyses, the LIA group had lower odds ratio (OR) of having early EGD (0.86, 95% CI 0.78 – 0.95, P 0.002) and higher OR of death (1.3, 95% CI 1.028 – 1.644, P 0.03). There were no differences in LOS (MD 0.12, 95% CI -0.09 – 0.34, P 0.26), hospital charges (MD $1699.61, 95% CI -1707.76 – 5106.98, P 0.33), discharge to nursing facilities (OR 1.01, 95% CI 0.82 – 1.25, P 0.9), discharge with visiting nurse (OR 1.08, 95% CI 0.9 – 1.29, P 0.42), and discharge to other hospitals (OR 0.81, 95% CI 0.619 – 1.053, P 0.11). In an interaction term analyses, the differences in the EGD timing between LIA and HIA groups did not explain the differences in death or other hospitalization outcomes (Figure) Conclusion: This notional study showed that patients who lived in LIA and were admitted with VH had less likelihood of receiving EGD within 24 hours and a higher likelihood of death despite having fewer comorbidities compared to patients who lived in HIA. However, the differences in EGD timing did not explain the differences in death. More studies are needed to confirm these findings and to help understand and minimize the disparity in the healthcare system in the United States.Figure 1.: Hospitalization outcomes for patients with VH based on the interaction term analyses of household income and EGD timing. Abbreviations: EGD = Esophagogastroduodenoscopy, LOS= Length of hospital stay, OSH= outside hospital, VNA= home visiting nurse. Table 1. - Baseline characteristics Characteristics LIA HIA P-value Total number (Weighted) 37,420 25,355 Age (mean(SD)) 56.10 (11.97) 57.02 (12.47) <0.001 Female (%) 12,060 (32.2) 8,200 (32.4) 0.9 Race (%) <0.001 White 21,125 (57.8) 16,800 (68.2) Black 2,975 (8.1) 1,015 (4.1) Hispanic 9,730 (26.6) 4,725 (19.2) Others 2,715 (7.4) 2,105 (8.5) Patient Location: NCHS Urban-Rural Code (%) <0.001 "Central" counties of ≥1 million population 11,925 (31.9) 8,900 (35.1) "Fringe" counties of ≥1 million population 4,380 (11.7) 8,760 (34.5) Counties of 250,000-999,999 population 9,840 (26.3) 5,060 (20.0) Counties of 50,000-249,999 population 4,810 (12.9) 1,765 (7.0) Not metropolitan or micropolitan counties 6,460 (17.3) 870 (3.4) Expected primary payer (%) <0.001 Medicare 12,075 (32.4) 7,995 (31.6) Medicaid 11,065 (29.7) 6,035 (23.8) Private insurance 8,150 (21.8) 8,445 (33.3) Self-pay/ Others/No charge 6,020 (16.1) 2,855 (11.3) Shock (%) 4,295 (11.5) 3,290 (13) 0.01 Acute kidney injury (%) 6,870 (18.4) 4,775 (18.8) 0.51 Acute respiratory failure (%) 4,180 (11.2) 2,690 (10.6) 0.33 Blood transfusion (%)* 0.35 (0.51) 0.38 (0.53) 0.001 FFP or clotting factors transfusion (%)* 0.13 (0.38) 0.14 (0.40) 0.03 Advanced vascular access (%)* 2,550 (6.8) 1,775 (7) 0.69 Intubation and mechanical ventilation (%)* 4,125 (11) 2,920 (11.5) 0.4 Weighted Elixhauser’s score (mean(SD)) 14.18 (11.17) 15.30 (11.15) <0.001 Alcohol use disorder 22,835 (61) 15,205 (60) 0.26 Tobacco use 10,585 (28.3) 6,215 (24.5) <0.001 Long-term (current) anticoagulant use (%) 790 (2.1) 475 (1.9) 0.35 Long-term (current) aspirin use (%) 2,140 (5.7) 1,395 (5.5) 0.6 Long-term (current) NSAID and other antiplatelets/antithrombotic use (%) 870 (2.3) 515 (2) 0.27 Bed size of the hospital <0.001 Small 5,835 (15.6) 5,305 (20.9) Medium 11,395 (30.5) 8,285 (32.7) Large 20,190 (54) 11,765 (46.4) Abbreviations: EGD = Esophagogastroduodenoscopy, FFP = Fresh frozen plasma, HIA = High income area, LIA = Low income area, NSAID = Nonsteroidal anti-inflammatory drugs, NCHS = National Center for Health Statistics, SD = Standard deviation.*Procedures were done prior on the same day of EGD.

Non-variceal upper gastrointestinal bleeding in patients with acute leukemia.

e19041 Background: Patients with acute leukemia are prone to various hemorrhages, most frequently due to thrombocytopenia from disease activity or chemotherapy. However, there is minimal literature evaluating non-variceal upper gastrointestinal bleeding (NVUGIB) in leukemia patients. This study evaluates the outcomes of NVUGIB in hospitalized acute leukemia patients. Methods: The United States Nationwide Inpatient Sample was used to extract hospitalization data of patients admitted between Jan 1st, 2016, to Dec 31st, 2019. Using International Classification of Diseases 10th revision codes, we identified adults with a discharge diagnosis of NVUGIB and a concomitant acute leukemia diagnosis, acute myelogenous leukemia and acute lymphoblastic leukemia. The control group included non-leukemia patients with NVUGIB. Primary outcome was in-hospital mortality. Secondary outcomes were length of stay (LOS), hospital charges, and effect of early esophagogastroduodenoscopy (EGD) within the first 24 hours of admission. Multivariate logistic regression was used to adjust for comorbidities and demographic variables. Results: A total of 1,208,885 discharges were identified with NVUGIB. Of those, 1019 had acute leukemia. Leukemia patients had higher mortality than the general population (12.5% vs. 3%, respectively; P &lt;0.01). After adjusting for comorbidities and demographic variables, acute leukemia patients had significantly higher mortality (adjusted odds ratio [AOR] 3.75, 95%CI 2.37-5.94 P &lt;0.01). Mean length of stay and hospital charges increased by 6.87 days (95%CI 3.99-9.75, P &lt; 0.01) and 128,437$ (95%CI 68,633$-188,240$, P &lt; 0.01), respectively, in the acute leukemia group. Additionally, acute leukemia patients who had an early EGD had significantly less mortality, length of stay, and hospital charges compared to delayed EGD as shown in the attached table. Conclusions: Acute leukemia patients admitted with NVUGIB have significantly higher in-hospital mortality and health care burden. Early EGD in these patients is associated with lower in-hospital mortality, shorter length of stay, and lower total hospital costs. However, given the retrospective nature of this study, we cannot determine that early EGD is a causal factor for the improved outcomes. Future prospective studies will be required in acute leukemia patients admitted with NVUGIB to further evaluate these findings.[Table: see text]

Pros and Cons of Performing Early Endoscopy in Geriatric Patients Admitted with Non-variceal Upper Gastrointestinal Bleeding: Analysis of the US National Inpatient Database.

Age greater than 65years is a well-defined risk factor for increased mortality in patients with non-variceal upper gastrointestinal bleeding (NVGIB). Endoscopy is indicated in most patients at any age but presents unique risks in the elderly cohort, and ideal timing is unclear. This study examined the association between outcomes and early (within 24h) esophagogastroduodenoscopy (EGD) among elderly patients with NVGIB. All patients over age 65 admitted primarily for NVGIB who underwent EGD were included from the National Inpatient Sample 2016-2017. Clinical outcomes stratified by early EGD versus late EGD were compared after adjustment for comorbidities and bleeding severity using inverse probability of treatment weighting with survey-adjusted linear and logistic regression. Out of estimated 625,530 admissions with a primary diagnosis of NVGIB, 120,835 met eligibility criteria; 24,830 underwent early EGD. Mean length of stay and total charges decreased by 1.17days (95%CI 1.04-1.30, P < 0.001) and $5717.24 (95%CI 4034.57-7399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95%CI 1.06-1.64, P 0.01) and transfer to other hospitals 1.48 (95%CI 1.22-1.81, P < 0.001). No change was seen in the requirement for surgery or angiography. Rates of discharge to a nursing facility or home health were similar. In a comprehensive cohort of geriatric patients with NVGIB, early EGD is associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer. Further research is needed to determine the optimal management of this vulnerable population.

Does timing of endoscopy affect outcomes in patients with upper gastrointestinal bleeding: a systematic review and meta-analysis.

The timing of esophagogastroduodenoscopy (EGD) for the management of upper gastrointestinal bleeding (UGIB) remains controversial. Early EGD (E-EGD) (within 24 h of presentation) has been compared to late EGD (L-EGD) (after 24 h) in numerous studies with conflicting results. The previous systematic review included three randomized controlled trials (RCTs); however, the cutoff time for performing EGD was arbitrary. We performed an updated systematic review and meta-analysis of the studies comparing the outcomes of E-EGD and L-EGD group. A comprehensive search of PubMed, EMBASE, Cochrane Library, and Web of Science was undertaken to include both RCTs and cohort studies. Primary outcomes including overall mortality and secondary outcomes (recurrent bleeding, need for transfusion, and length of stay) were compared. Risk ratios and standardized mean difference (SMD) with 95% confidence interval (CI) were calculated. A total of 13 observational studies (with over 1.8 million patients) were included in the final analysis. No significant difference in overall mortality (risk ratio: 0.97; CI, 0.74-1.27), recurrent bleeding (risk ratio: 1.12; CI, 0.62-2.00), and length of stay (SMD: -0.07, CI, -0.31 to 0.18) was observed for E-EGD group compared to L-EGD group. The possibility of endoscopic intervention was higher in E-EGD group (risk ratio: 1.70, CI, 1.28-2.27). Consistent results were obtained for subgroup analysis of studies with 100% nonvariceal bleed (NVB) patient (risk ratio: 1.12; CI, 0.84-1.50). Given the outcomes and limitations, our meta-analysis did not demonstrate clear benefit of performing EGD within 24 h of presentation for UGIB (particularly NVB).

S0594 The Effect of Early Endoscopy on Geriatric Patients Admitted With Non-Variceal Upper Gastrointestinal Bleeding

INTRODUCTION: The annual incidence of hospital admission for nonvariceal upper gastrointestinal bleeding (NVGIB) in the United States is estimated to be 48 to 160 per 100,000 population, with an associated mortality rate of 2.5 to 5%. Age greater than 65 years is a well-defined risk factor for increased mortality in patients with NVGIB. In this study, we utilized a nationwide database from 2016-2017 to study if early esophagogastroduodenoscopy (EGD), within 24 hours of hospital admission, improves outcomes among elderly patients with all causes of NVGIB. METHODS: We utilized the Nationwide Inpatient Sample database between January 2016 and December 2017 and included all the patients who were admitted with a primary diagnosis of NVGIB and underwent at least one EGD. Propensity scores were calculated using patient demographic factors, Elixhauser comorbidity index, bleeding severity indicators, and hospital characteristics. Inverse probability of Treatment Weighting (IPTW) was calculated based on the propensity scores and used to adjust for confounders. RESULTS: 625,530 patients were admitted to hospitals in the United States with a primary diagnosis of NVGIB between 2016 and 2017. Of those patients, 120,835 met our eligibility criteria; 24,830 underwent early EGD, and 96,005 patients underwent late EGD, Figure 1. Baseline characteristics of both groups are illustrated in Table 1. Our analysis showed that the adjusted mean difference of length of stay and total charges decreased by 1.17 days (95% CI 1.04–1.30, P < 0.001), and $5,717.24 (95% CI 4,034.57 – 7,399.91, P < 0.001), respectively, in the early EGD group. Early EGD increased the odds ratio of death 1.32 (95% CI 1.06–1.64, P 0.01) and hospital transfer 1.48 (95% CI 1.22–1.81, P < 0.001). There was no significant difference between the two groups regarding discharge to nursing facility, home health aide utilization after discharge, and the need for surgery or interventional radiology procedures, Table 2. CONCLUSION: In a nationwide study of geriatric patients with NVGIB, we found that early upper EGD is associated with decreased hospital stay and hospital charges, but also with increased mortality and hospital transfer. Further research is indicated to determine the optimal management of this vulnerable patient population.Table 1.: Baseline characteristicTable 2.: Secondary outcomesFigure 1.: Flow chart of the study population. *Total excluded discharges surpass the actual number of excluded patients due to overlap.

S0614 Are Early Esophagogastroduodenoscopy and Anticoagulation Status Predictors of Hospitalization Outcomes in Non-Variceal Upper Gastrointestinal Bleeding? A Nationwide Analysis

S0614 Are Early Esophagogastroduodenoscopy and Anticoagulation Status Predictors of Hospitalization Outcomes in Non-Variceal Upper Gastrointestinal Bleeding? A Nationwide Analysis

Impact of Insurance Status and Race on Outcomes in Nonvariceal Upper Gastrointestinal Hemorrhage: A Nationwide Analysis.

We examined the interaction between race, insurance, and important outcomes in nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Adults with NVUGIH were selected from the National Inpatient Sample. in-hospital mortality. treatment modalities [esophagogastroduodenoscopy (EGD), early EGD, and endoscopic or radiologic therapy], and resource utilization (length of hospital stay and total hospitalization charges). Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 1.15 95% confidence interval (CI) 0.90 to 1.47), P=0.24], but higher for under/uninsured patients [aOR: 1.84 (CI: 1.42 to 2.40), P<0.01]. Compared with Medicare, patients with private insurance had more EGDs [aOR: 1.35 (CI: 1.23 to 1.48), P<0.01], early EGDs [aOR: 1.29 (CI: 1.21 to 1.38), P<0.01], and endoscopic [aOR: 1.19 (CI: 1.11 to 1.27), P<0.01], or radiologic therapy [aOR:1.35 (CI: 1.06 to 1.71), P=0.01]. Patients who were under/uninsured had less EGDs [aOR: 0.84 (CI: 0.76 to 0.91), P<0.01] or endoscopic therapy [aOR: 0.74 (CI: 0.68 to 0.81), P<0.01], but similar odds of early EGD [aOR: 0.95 (CI: 0.88 to 1.02), P=0.13] or radiologic therapy [aOR: 1.01 (CI: 0.75 to 1.37), P=0.75]. Compared with whites, blacks had lower [aOR: 0.73 (CI: 0.58 to 0.93), P=0.01] and Native Americans higher mortality [aOR: 2.60 (CI: 1.57 to 4.13), P<0.01]. Blacks were less likely [aOR: 0.86 (CI: 0.79 to 0.94), P<0.01] and Asians more likely [aOR: 1.24 (CI: 1.05 to 1.47), P=0.01] to have EGDs. Both blacks and Hispanics had lower, whereas Asians had higher early EGD rates. Patients with private insurance had lower total charges [adjusted mean difference: -$2761 (CI: -$4617 to -$906), P<0.01]. Insurance and race have independent effects on NVUGIH mortality, therapeutic modalities used, and resource utilization. Black and under/uninsured patients have the worst outcomes.

A survey study with assessment of esophageal screening and genetic counseling in patients with Howel-Evans syndrome

It is important to better understand the role that environmental risk factors play on the development of esophageal cancer in Howel-Evans families. Additionally, there is little published about appropriate esophageal cancer screening practices in families genetically confirmed to have this condition. Surveys were distributed to 47 addresses of an American family with Howel-Evans syndrome, of which 29 responded and met inclusion criteria. Data was collected about demographics, environmental risk factors, and medical history of participants. We report characteristics of family members with tylosis, rates of esophageal cancer, rates of genetic counseling, and levels of environmental risk factors. Of the survey respondents, 43% reported features of tylosis, 71.4% were male and 28.6% were female and 28.6% reported leukoplakia. Only 21.4% of tylotic family members smoked, 65% drank alcohol, and 28.6% drank well water. More than half (57.1%) of the tylotic individuals had never had an esophagogastroduodenoscopy (EGD) and no one had been diagnosed with esophageal carcinoma. Only 3.4% of respondents had ever received genetic testing for Howel-Evans syndrome, despite genetic confirmation of their relatives. We encourage dermatologists to discuss smoking-cessation, genetic counseling, and early EGD with affected families.

Early esophagogastroduodenoscopy is associated with better Outcomes in upper gastrointestinal bleeding: a nationwide study

Background and study aims We analyzed NIS (National Inpatient Sample) database from 2007 – 2013 to determine if early esophagogastroduodenoscopy (EGD) (24 hours) for upper gastrointestinal bleeding improved the outcomes in terms of mortality, length of stay and costs. Patients and methods Patients were classified as having upper gastrointestinal hemorrhage by querying all diagnostic codes for the ICD-9-CM codes corresponding to upper gastrointestinal bleeding. For these patients, performance of EGD during admission was determined by querying all procedural codes for the ICD-9-CM codes corresponding to EGD; early EGD was defined as having EGD performed within 24 hours of admission and late EGD was defined as having EGD performed after 24 hours of admission. Results A total of 1,789,532 subjects with UGIH were identified. Subjects who had an early EGD were less likely to have hypovolemia, acute renal failure and acute respiratory failure. On multivariable analysis, we found that subjects without EGD were 3 times more likely to die during the admission than those with early EGD. In addition, those with late EGD had 50 % higher odds of dying than those with an early EGD. Also, after adjusting for all factors in the model, hospital stay was on average 3 and 3.7 days longer for subjects with no or late EGD, respectively, then for subjects with early EGD. Conclusion Early EGD (within 24 hours) is associated with lower in-hospital mortality, morbidity, shorter length of stay and lower total hospital costs.

Early versus late bedside endoscopy for gastrointestinal bleeding in critically ill patients

Background/AimsGastrointestinal (GI) bleeding is a life-threatening complication in critically ill patients. The aim of this study was to determine the efficacy of bedside endoscopy in an intensive care unit (ICU) setting, and to compare the outcomes of early endoscopy (within 24 hours of detecting GI bleeding) with late endoscopy (after 24 hours).MethodsWe retrospectively reviewed the medical records of patients who underwent bedside endoscopy for nonvariceal upper GI bleeding and lower GI bleeding that occurred after ICU admission at Seoul National University Hospital from January 2010 to May 2015.ResultsTwo hundred and fifty-three patients underwent bedside esophagogastroduodenoscopy (EGD) for upper GI bleeding (early, 187; late, 66) and 69 underwent bedside colonoscopy (CS) for lower GI bleeding (early, 36; late, 33). Common endoscopic findings were peptic ulcer, and acute gastric mucosal lesion in the EGD group, as well as ischemic colitis and acute hemorrhagic rectal ulcers in the CS group. Early EGD significantly increased the rate of finding the bleeding focus (82% vs. 73%, p = 0.003) and endoscopic hemostasis (32% vs. 12%, p = 0.002) compared with late EGD. However, early CS significantly decreased the rate of identifying the bleeding focus (58% vs. 82%, p = 0.008) and hemostasis (19% vs. 49%, p = 0.011) compared with late CS due to its higher rate of poor bowel preparation and blood interference (38.9% vs. 6.1%, p = 0.035).ConclusionsEarly EGD may be effective for diagnosis and hemostatic treatment in ICU patients with GI bleeding. However, early CS should be carefully performed after adequate bowel preparation.

Early Upper Endoscopy for Admission of Foreign Body in Esophagus Significantly Decreases Complications and Mortality: Presidential Poster

Introduction: Current ASGE guidelines recommend emergent removal of esophageal food bolus impactions and foreign bodies though this is two star (low quality evidence) guideline and further research has been recommended in this area. We aim to study the differences in outcomes based on early versus late esophagogastroduodenoscopy (EGD) among patients presenting with a foreign body in esophagus using a large national inpatient sample database. Methods: The National Inpatient Sample (NIS) databases (2002-2011) is the largest all payer inpatient care database, containing around 5 to 8 million hospitalizations from approximately 1000 hospitals in the USA. The patients presented with foreign body in esophagus and EGDs were identified using the ICD-9 codes. Early EGD was defined as being performed on the day of admission. Various outcomes such as inpatient mortality, acute respiratory failure (ARF)/aspiration pneumonia (AP), iatrogenic pneumothorax, endotracheal intubation, length of stay (LOS), and total hospitalization cost were evaluated. Multivariate logistic regression analysis adjusted for age, sex, race, complications and Elixhauser comorbidities was used to identify independent predictors of inpatient mortality. Results: Our study included 21,475 hospitalizations related to a foreign body in esophagus. The mean age of the study population was 51.2 years with 71.8% white and 54.9% male. Overall 55.8% of hospitalizations had an early EGD. There was a significantly lower rate of ARF and AP requiring endotracheal intubation >96 hours among hospitalizations with early EGD (ARF/AP: 9.2% vs 12.6%, p < .001; intubation: 0.7% vs 1.3%, p < .001). Hospitalizations with early EGD had a significantly lower rate of inpatient mortality. (0.6% vs 1.9%, p < .001). Multivariate logistic model identified age, delay in EGD, requiring endotracheal intubation, ARF/AP and having multiple comorbid conditions as independent risk factors associated with inpatient mortality (Table 1). Overall hospitalization mean LOS and financial charges were significantly lower among hospitalizations with early EGD. (LOS: 2.0 vs 4.2 days, p < .001; financial cost: $16,634 vs $24,390, p < .001).Table 1: Independent risk factors associated with inpatient mortality among hospitalizations with foreign body in esophagusConclusion: Our study showed significantly reduced finalcial burden, and lower rates of complications and inpatient mortality related to foreign body in esophagus among individuals who undergo early EGD. Our study adds high quality evidence to current ASGE guideline by utilizing a large nationally representative hospitalization sample.

A Preliminary Investigation of Laparoscopic Fundoplication Treatment on Gastroesophageal Reflux Disease-related Respiratory Symptoms

Extraesophageal syndromes are more difficult to identify and treat than the usual esophageal symptoms. The current study explores the efficacy of laparoscopic Nissen fundoplication (LNF) on gastroesophageal reflux disease (GERD)-related respiratory symptoms (RSs) during a 12-month follow-up observation. From April 2008 to September 2009, LNF was performed on 198 patients (107 men and 91 women) with GERD-related RSs according to underlying esophageal motility. A questionnaire form ranging from 0 to 5 was the basic requirement for recording pretreatment and posttreatment and for making detailed evaluation of the symptoms. All scores of GERD-related RSs, such as heartburn, regurgitation, coughing, breathe holding, wheezing, shortness of breath, and choking, significantly decreased at the 12th month. All the patients who participated in the current study were adults and elders aged 22 to 84 years with a mean age of 49 ± 12.89. The median length of stay was 4.3 days with a range of 2 to 8 days. The median score of heartburn, regurgitation, coughing, wheezing, shortness of breath, choking, and chest pain decreased from 4.92 ± 1.99, 4.98 ± 1.81, 7.23 ± 1.87, 7.50 ± 1.88, 5.83 ± 2.13, 5.94 ± 2.22, and 4.92 ± 1.88 to 1.62 ± 2.33, 0.64 ± 1.43, 2.79 ± 2.82, 2.53 ± 2.96, 1.37 ± 2.10, 1.28 ± 2.09, and 1.57 ± 2.55 (P<0.01), respectively. A total of 173 patients had various relieved symptom scores, 16 patients (8.1%) had different scale recurrence of symptoms after laparoscopic fundoplication treatment, and 13 patients had to retreat to omeprazole as an auxiliary medical therapy. Three other patients rejected any therapy, and no deaths occurred. A single patient converted from laparoscopic surgery to open surgery. Several short-term symptoms included retrosternal uneasiness or pain (n = 63; 31.8%), dysphagia (n = 45; 22.7%), abdominal distension (n = 87; 43.9%), and diarrhea (n = 23; 11.6%). Early dysphagia lasting <6 weeks was common, and 45 patients (22.7%) underwent an early esophagogastroduodenoscopy or contrast swallow. Five patients (2.5%) who had prolonged dysphagia during the 6-month clinical review required esophageal dilatation, and the outcomes were successful. LNF can be an effective means for treating RSs in patients with GERD.

Do hospitalists affect clinical outcomes and efficiency for patients with acute upper gastrointestinal hemorrhage (UGIH)?

Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and nonhospitalists. The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (ie, recurrent bleeding, intensive care unit [ICU] transfer, decompensation, transfusion, reendoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS). Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson comorbidity index. Unadjusted clinical outcomes between hospitalists and nonhospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; P = 0.02) or be readmitted within 30 days (7.3% vs. 3.3%; P = 0.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and nonhospitalists (4 days; P = 0.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; P < 0.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; P = 0.15) and costs remained higher for the hospitalist-led teams (P < 0.03). Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.

Usefulness of early endoscopy for predicting the development of stricture after corrosive esophagitis in children

Purpose: This study was performed to demonstrate the usefulness of early endoscopy for predicting the development of stricture following corrosive ingestion in children. Methods: We conducted a retrospective study on 34 children who were brought to Seoul National University Childrens Hospital and Seoul National University Bundang Hospital for corrosive ingestion from 1989 to 2007. Results: The corrosive burns were classified as grade 0 in 8 patients, grade 1 in 2, grade 2a in 7, grade 2b in 13, and grade 3 in 4. There was no significant correlation between the presence of esophageal injury and symptoms including vomiting, dysphagia, and drooling. There was a statistically significant relation between the presence of oropharyngeal injury and esophageal injury (P=0.014). There were no complications including hemorrhage and perforation related to endoscopy. Strictures of the esophagus or the stomach developed in 12 patients (36.4%). Esophageal stricture was observed in 11 patients and pyloric stenosis in 1 patient. The endoscopic grade of mucosal injury was significantly related to the frequency of development of esophageal stricture (P=0.002). Two of eleven patients with esophageal stricture responded to repeated dilation. The remaining seven patients underwent surgery. Conclusion: Early esophagogastroduodenoscopy is not only a safe and useful diagnostic tool for children with accidental caustic ingestion but also a necessity for determining the degree and the extent of caustic burns and for predicting the development of late complications. (Korean J Pediatr 2009;52:446-452)