Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: A cohort study

Background & Aims

Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with “active” esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy.

Methods

From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan–Meier method and log rank test.

Results

In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n = 26) and 29.7% (n = 30), respectively. The overall 6-week and 3-month mortality was 31.7% (n = 32) and 38.6% (n = 39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p = 0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p = 0.028) and mortality (27% vs. 52.8%, p = 0.031) were lower in those with early (⩽12 h) than delayed (>12 h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p = 0.944) and mortality (11.8% vs. 9.1%, p = 0.861).

Conclusions

It is likely that early endoscopy (⩽12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.

Introduction

Esophageal variceal bleeding (EVB) is one of the most life-threatening complications of liver cirrhosis [1], [2]. Despite advances in management and therapy, mortality with each episode of EVB is still about 20–25% [3], [4]. Several prognostic indicators, including the Child-Turcotte-Pugh (CTP) score, the model for end-stage liver disease (MELD) score, active bleeding at endoscopy, hypovolemic shock, hepatic venous pressure gradient, hepatocellular carcinoma (HCC), portal vein thrombosis, serum bilirubin, and creatinine and albumin levels, have been identified to predict mortality after EVB [5], [6], [7], [8]. However, most risk factors are derived from studies without fulfilling the recent standard therapeutic protocol of prophylactic antibiotics and combination vasoactive agents, endoscopic ligation and subsequent non-selective beta-blocker for secondary prevention.

Active bleeding, either spurting or oozing from esophageal varices at endoscopy, occurs in 10–68% of EVB patients [9], [10], [11], [12], [13], and is persistently identified as an important predictor of failure to control bleeding, early re-bleeding, and mortality [4], [5], [14], [15], [16]. However, further assessment of the prognostic indicators in such high-risk patients is not determined.

The optimal timing of endoscopic treatment for EVB patients is empirical. Current guidelines of major professional societies recommend that endoscopy should be performed as soon as possible (within 12 h of admission) in cirrhotic patients with EVB, but the suggestion is based on expert opinion and requires corroborating evidence [2].

The aim of this study is to determine the prognostic indicators of 6-week re-bleeding and mortality in patients with “active” EVB on current standard treatment, with particular emphasis on presenting symptoms and timing of endoscopy.