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OC.01.1: TIMING OF ENDOSCOPY AND MORTALITY FROM NONVARICEAL UPPER GASTROINTESTINAL BLEEDING (NVUGIB): THE SOONER IS NOT ALWAYS THE BETTER
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Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264
ORAL COMMUNICATIONS OC.01.1 TIMING OF ENDOSCOPY AND MORTALITY FROM NONVARICEAL UPPER GASTROINTESTINAL BLEEDING (NVUGIB): THE SOONER IS NOT ALWAYS THE BETTER R. Marmo 1 , G. Rotondano ∗ ,2 , M. Koch 3 , M. Del Piano 4 , M.A. Bianco 2 , A. Zambelli 5 , G. Di Matteo 6 , L. Cipolletta 2 1 Ospedale
Curto, Polla, Italy; 2 Ospedale Maresca, Torre Del Greco, Italy; San Filippo Neri, Roma, Italy; 4 Ao Maggiore della Carità, Novara, Italy; 5 Ao Ospedale Maggiore, Crema, Italy; 6 Irccs De Bellis, Castellana Grotte, Italy 3 Aco
Background and aim: In patients with NVUGIB early endoscopy (as soon as possible but always <24 hours) is recommended. Aim of the study was to identify which is the optimal timing of endoscopy that is associated with a reduced risk of death and assess whether this changes according to patients’ clinical conditions. Material and methods: Three national multicentric databases (PNED 1, PNED 2 and PROMETEO) with 30-day mortality as primary outcome measure were analysed, including a total of 3207 NVUGIB patients (2114 M [65.8%], mean age [SD] 68.3 [±16.4] y.o). Rebleeding was 3.8% (123 pts), emergency surgery 1.8% (53 pts) and mortality 4.5% (143 pts). Patients were classified into low-, medium- or high risk of death according to presence/absence of 10 independent clinical prognosticators (age >80, in-hospital bleeding, hematemesis, SBP <100 mmHg, DBP <60 mmHg, HR >100 bpm, Hb <7 g/dL, presence of renal failure, cirrhosis or neoplasia). A “propensity score” was used to “correct” the estimation controlling for confounders. Timing of endoscopy was categorized in three time frames: <6 hrs, 7-12 hrs and 13-24 hrs. After stratification of cases (deceased) and controls (survived) in homogeneous clinical severity blocks, differences in mortality according to the timing of endoscopy was tested with the chi square test. Results: In high-risk patients death was systematically more frequent compared to low- or intermediate risk patients, independently of the timing of endoscopy (p<0.000). For low-risk patients, the frequency of death is not significantly different between the 3 time frames (p=0.192), though it decreases numerically as time frame lengthens (2.07% to 0.63%). In patients at intermediate risk, the frequency of death decreases not significantly in the time frame 13-24 hrs. In patients clinically categorised as high risk, the performance of the endoscopy 13-24 hrs of the bleeding episode is associated with a significantly lower mortality (p=0.001) compared to endoscopy performed sooner (<12 hrs). Timing of endoscopy ≤6 hrs 7–12 hrs 13–24 hrs
Frequency of death (%)
p
Low-risk block
Intermediate risk block
High-risk block
2.07 0.86 0.63 p = 0.192
5.74 6.00 3.93 p = 0.678
16.58 14.29 5.15 p = 0.001*
0.000 0.000 0.000
*vs. both low- and intermediate-risk patients.
Conclusions: In patients in good clinical status, timing of endoscopy has no impact on mortality; in patients with worsened health status (high-risk) waiting at least 12 hours prior to perform endoscopy seems to be the option associated with lower mortality, independently of hemodynamic status.
OC.01.2 THE “PROMETEO” STUDY PHASE 1 & 2: CLINICAL FEATURES AND OUTCOME OF ITALIAN PATIENTS ADMITTED TO HOSPITAL FOR ACUTE NON VARICEAL UPPER GASTROINTESTINAL BLEEDING M. Del Piano ∗ ,1 , L. Cipolletta 2 , M.A. Bianco 2 , A. Zambelli 3 , F. Chilovi 4 , E. Di Giulio 5 , E. Ricci 6 , G. Frosini 7 , P. Leo 8 , G. Di Matteo 9 , L. Ficano 10 , P. Loriga 11 , A. Prada 12 , L. Buri 13 , M. Pagliarulo 1 , M. Ballarè 1 , F. Montino 1 , M. Battisti-matscher 4 , G. Rotondano 2
1 Aou Maggiore della Carità, Novara, Italy; 2 Po Maresca, Torre Del Greco, Italy; 3 Ao Ospedale Maggiore, Crema, Italy; 4 Azienda Sanitaria di Bolzano, Bolzano, Italy; 5 Ao Sant’Andrea, Roma, Italy; 6 Ospedale Morgagni Pierantoni, Forlì, Italy; 7 Ospedale Santa Maria Delle Scorre, Siena, Italy; 8 Ospedale Dell’Annunziata, Cosenza, Italy; 9 Irccs Saverio De Bellis, Castellana Grotte, Italy; 10 Policlinico Giaccone, Palermo, Italy; 11 Ospedale Ss Trinità, Cagliari, Italy; 12 Ospedale di Rho, Rho, Italy; 13 Ospedali Riuniti, Trieste, Italy
Background and aim: Epidemiology, clinical characteristics and outcome of patients with acute non-variceal upper gastrointestinal bleeding (UGIB) are usually known by retrospective studies. “Prometeo” is a prospective observational study designed to identify the etiology of bleeding, associated risk factors and clinical outcome of acute non-variceal UGIB in Italy. Material and methods: Data were collected by 13 Gastrointestinal Units in Italy from June 2006 to June 2007 (phase 1) and from December 2008 to December 2009 (phase 2): an interim analysis of data was performed between the two phases to optimize the online database. All the patients consecutively admitted for acute non-variceal UGIB were enrolled. Demographic and clinical data were collected, a diagnostic endoscopy performed, with endoscopic haemostasis if indicated. Results: 1413 patients (M=932, mean age ± SD = 66.5±15.8; F=481, mean age ± SD = 74.2±14.6) were enrolled. Comorbidities were present in 83%. 52.4% were treated with ASA or other NSAIDs: only 13.9% had an effective gastroprotection. Previous episodes of UGIB were present in 13.3%. Transfusion were needed in 45.1%. Shock was present in 9.3%. Endoscopic diagnosis was made in 93.2%: peptic lesions were the main cause of bleeding (duodenal ulcer 36.2%, gastric ulcer 29.6%, gastric/duodenal erosions 10.9%). At endoscopy, Helicobacter pylori was searched in 37.2%, and found positive in 51.3%. Early rebleeding was observed in 5.4%: surgery was required in 14.3% of them. Bleeding related death occurred in 4.0%: at multivariate analysis, the risk of death was correlated with female sex (OR=2.19, P=0.0089), presence of neoplasia (OR=2.70, P=0.0057) or multiple comorbidities (OR=5.04, P=0.0280), shock at admission (OR=4.55, P=0.0001), and early rebleeding (OR=1.47, P=0.004). Conclusions: Patients with acute non variceal UGIB are often elderly, more frequently males, and with important comorbidities. Gastroprotective drugs are underutilized during NSAIDs treatment. Mortality rate is lower than previously reported, and correlates with female sex, presence of neoplasia or multiple comorbidities, shock at admission, and early rebleeding.
OC.01.3 A TRAINING STRATEGY TO IMPROVE DETECTION RATE AND INTEROBSERVER AGREEMENT IN CAPSULE ENDOSCOPY (CE) FOR READERS WITH DIFFERENT EXPERIENCE: RESULTS OF A MULTICENTRE STUDY E. Rondonotti 1 , M. Soncini 2 , C.M. Girelli ∗ ,3 , A. Russo 2 , G. Ballardini 4 , G. Bianchi 5 , P. Cantù 6 , L. Centenara 7 , P. Cesari 8 , C. Cortellezzi 9 , C. Gozzini 10 , M. Maino 11 , G. Mandelli 1 , N. Mantovani 12 , D. Moneghini 13 , E. Morandi 14 , R. Putignano 15 , R. Schalling 16 , M. Tatarella 17 , P. Vitagliano 18 , F. Villa 19 , S. Zatelli 20 , D. Conte 21 , E. Masci 14 , R. De Franchis 22 1 Ospedale Valduce, Como, Italy; 2 A.O. Ospedale S. Carlo Borromeo, Milano, Italy; 3 A.O. Ospedale di Circolo Busto Arsizio, Busto Arsizio, Italy; 4 Istituto Nazionale Dei Tumori, Milano, Italy; 5 A.O. Istituti Ospitalieri di Cremona, Cremona, Italy; 6 Ente Ospedaliero ‘c. Cantù, Abbiategrasso, Italy; 7 Irccs Policlinico S. Matteo, Pavia, Italy; 8 Congregazione Ancelle della Carità, Brescia, Italy; 9 A.O. Fondazione Macchi-Ospedale di Circolo Varese, Varese, Italy; 10 A.O. Salvini-P.O. di Rho, Rho, Italy; 11 A.O. S. Gerardo, Monza, Italy; 12 A.O. Carlo Poma, Mantova, Italy; 13 Università di Brescia. Spedali Civili, Brescia, Italy; 14 Università degli Studi di Milano, Irccs A. O. S. Paolo, Milano, Italy; 15 A.O. S. Antonio Abate, Gallarate, Italy; 16 Ospedale Civile Vimercate, Vimercate, Italy; 17 Casa di Cura S. Pio X, Milano, Italy; 18 Ospedale Melegnano, Melegnano, Italy; 19 Irccs Fondazione Policlinico, Mangiagalli Regina Elena, Milano, Italy; 20 Ospedale S.Giuseppe, Milano, Italy; 21 Università degli Studi di Milano Irccs Fondazione Policlinico, Milano, Italy; 22 Università degli Studi di Milano Ospedale Luigi Sacco, Milano, Italy
Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264
ORAL COMMUNICATIONS OC.01.1 TIMING OF ENDOSCOPY AND MORTALITY FROM NONVARICEAL UPPER GASTROINTESTINAL BLEEDING (NVUGIB): THE SOONER IS NOT ALWAYS THE BETTER R. Marmo 1 , G. Rotondano ∗ ,2 , M. Koch 3 , M. Del Piano 4 , M.A. Bianco 2 , A. Zambelli 5 , G. Di Matteo 6 , L. Cipolletta 2 1 Ospedale
Curto, Polla, Italy; 2 Ospedale Maresca, Torre Del Greco, Italy; San Filippo Neri, Roma, Italy; 4 Ao Maggiore della Carità, Novara, Italy; 5 Ao Ospedale Maggiore, Crema, Italy; 6 Irccs De Bellis, Castellana Grotte, Italy 3 Aco
Background and aim: In patients with NVUGIB early endoscopy (as soon as possible but always <24 hours) is recommended. Aim of the study was to identify which is the optimal timing of endoscopy that is associated with a reduced risk of death and assess whether this changes according to patients’ clinical conditions. Material and methods: Three national multicentric databases (PNED 1, PNED 2 and PROMETEO) with 30-day mortality as primary outcome measure were analysed, including a total of 3207 NVUGIB patients (2114 M [65.8%], mean age [SD] 68.3 [±16.4] y.o). Rebleeding was 3.8% (123 pts), emergency surgery 1.8% (53 pts) and mortality 4.5% (143 pts). Patients were classified into low-, medium- or high risk of death according to presence/absence of 10 independent clinical prognosticators (age >80, in-hospital bleeding, hematemesis, SBP <100 mmHg, DBP <60 mmHg, HR >100 bpm, Hb <7 g/dL, presence of renal failure, cirrhosis or neoplasia). A “propensity score” was used to “correct” the estimation controlling for confounders. Timing of endoscopy was categorized in three time frames: <6 hrs, 7-12 hrs and 13-24 hrs. After stratification of cases (deceased) and controls (survived) in homogeneous clinical severity blocks, differences in mortality according to the timing of endoscopy was tested with the chi square test. Results: In high-risk patients death was systematically more frequent compared to low- or intermediate risk patients, independently of the timing of endoscopy (p<0.000). For low-risk patients, the frequency of death is not significantly different between the 3 time frames (p=0.192), though it decreases numerically as time frame lengthens (2.07% to 0.63%). In patients at intermediate risk, the frequency of death decreases not significantly in the time frame 13-24 hrs. In patients clinically categorised as high risk, the performance of the endoscopy 13-24 hrs of the bleeding episode is associated with a significantly lower mortality (p=0.001) compared to endoscopy performed sooner (<12 hrs). Timing of endoscopy ≤6 hrs 7–12 hrs 13–24 hrs
Frequency of death (%)
p
Low-risk block
Intermediate risk block
High-risk block
2.07 0.86 0.63 p = 0.192
5.74 6.00 3.93 p = 0.678
16.58 14.29 5.15 p = 0.001*
0.000 0.000 0.000
*vs. both low- and intermediate-risk patients.
Conclusions: In patients in good clinical status, timing of endoscopy has no impact on mortality; in patients with worsened health status (high-risk) waiting at least 12 hours prior to perform endoscopy seems to be the option associated with lower mortality, independently of hemodynamic status.
OC.01.2 THE “PROMETEO” STUDY PHASE 1 & 2: CLINICAL FEATURES AND OUTCOME OF ITALIAN PATIENTS ADMITTED TO HOSPITAL FOR ACUTE NON VARICEAL UPPER GASTROINTESTINAL BLEEDING M. Del Piano ∗ ,1 , L. Cipolletta 2 , M.A. Bianco 2 , A. Zambelli 3 , F. Chilovi 4 , E. Di Giulio 5 , E. Ricci 6 , G. Frosini 7 , P. Leo 8 , G. Di Matteo 9 , L. Ficano 10 , P. Loriga 11 , A. Prada 12 , L. Buri 13 , M. Pagliarulo 1 , M. Ballarè 1 , F. Montino 1 , M. Battisti-matscher 4 , G. Rotondano 2
1 Aou Maggiore della Carità, Novara, Italy; 2 Po Maresca, Torre Del Greco, Italy; 3 Ao Ospedale Maggiore, Crema, Italy; 4 Azienda Sanitaria di Bolzano, Bolzano, Italy; 5 Ao Sant’Andrea, Roma, Italy; 6 Ospedale Morgagni Pierantoni, Forlì, Italy; 7 Ospedale Santa Maria Delle Scorre, Siena, Italy; 8 Ospedale Dell’Annunziata, Cosenza, Italy; 9 Irccs Saverio De Bellis, Castellana Grotte, Italy; 10 Policlinico Giaccone, Palermo, Italy; 11 Ospedale Ss Trinità, Cagliari, Italy; 12 Ospedale di Rho, Rho, Italy; 13 Ospedali Riuniti, Trieste, Italy
Background and aim: Epidemiology, clinical characteristics and outcome of patients with acute non-variceal upper gastrointestinal bleeding (UGIB) are usually known by retrospective studies. “Prometeo” is a prospective observational study designed to identify the etiology of bleeding, associated risk factors and clinical outcome of acute non-variceal UGIB in Italy. Material and methods: Data were collected by 13 Gastrointestinal Units in Italy from June 2006 to June 2007 (phase 1) and from December 2008 to December 2009 (phase 2): an interim analysis of data was performed between the two phases to optimize the online database. All the patients consecutively admitted for acute non-variceal UGIB were enrolled. Demographic and clinical data were collected, a diagnostic endoscopy performed, with endoscopic haemostasis if indicated. Results: 1413 patients (M=932, mean age ± SD = 66.5±15.8; F=481, mean age ± SD = 74.2±14.6) were enrolled. Comorbidities were present in 83%. 52.4% were treated with ASA or other NSAIDs: only 13.9% had an effective gastroprotection. Previous episodes of UGIB were present in 13.3%. Transfusion were needed in 45.1%. Shock was present in 9.3%. Endoscopic diagnosis was made in 93.2%: peptic lesions were the main cause of bleeding (duodenal ulcer 36.2%, gastric ulcer 29.6%, gastric/duodenal erosions 10.9%). At endoscopy, Helicobacter pylori was searched in 37.2%, and found positive in 51.3%. Early rebleeding was observed in 5.4%: surgery was required in 14.3% of them. Bleeding related death occurred in 4.0%: at multivariate analysis, the risk of death was correlated with female sex (OR=2.19, P=0.0089), presence of neoplasia (OR=2.70, P=0.0057) or multiple comorbidities (OR=5.04, P=0.0280), shock at admission (OR=4.55, P=0.0001), and early rebleeding (OR=1.47, P=0.004). Conclusions: Patients with acute non variceal UGIB are often elderly, more frequently males, and with important comorbidities. Gastroprotective drugs are underutilized during NSAIDs treatment. Mortality rate is lower than previously reported, and correlates with female sex, presence of neoplasia or multiple comorbidities, shock at admission, and early rebleeding.
OC.01.3 A TRAINING STRATEGY TO IMPROVE DETECTION RATE AND INTEROBSERVER AGREEMENT IN CAPSULE ENDOSCOPY (CE) FOR READERS WITH DIFFERENT EXPERIENCE: RESULTS OF A MULTICENTRE STUDY E. Rondonotti 1 , M. Soncini 2 , C.M. Girelli ∗ ,3 , A. Russo 2 , G. Ballardini 4 , G. Bianchi 5 , P. Cantù 6 , L. Centenara 7 , P. Cesari 8 , C. Cortellezzi 9 , C. Gozzini 10 , M. Maino 11 , G. Mandelli 1 , N. Mantovani 12 , D. Moneghini 13 , E. Morandi 14 , R. Putignano 15 , R. Schalling 16 , M. Tatarella 17 , P. Vitagliano 18 , F. Villa 19 , S. Zatelli 20 , D. Conte 21 , E. Masci 14 , R. De Franchis 22 1 Ospedale Valduce, Como, Italy; 2 A.O. Ospedale S. Carlo Borromeo, Milano, Italy; 3 A.O. Ospedale di Circolo Busto Arsizio, Busto Arsizio, Italy; 4 Istituto Nazionale Dei Tumori, Milano, Italy; 5 A.O. Istituti Ospitalieri di Cremona, Cremona, Italy; 6 Ente Ospedaliero ‘c. Cantù, Abbiategrasso, Italy; 7 Irccs Policlinico S. Matteo, Pavia, Italy; 8 Congregazione Ancelle della Carità, Brescia, Italy; 9 A.O. Fondazione Macchi-Ospedale di Circolo Varese, Varese, Italy; 10 A.O. Salvini-P.O. di Rho, Rho, Italy; 11 A.O. S. Gerardo, Monza, Italy; 12 A.O. Carlo Poma, Mantova, Italy; 13 Università di Brescia. Spedali Civili, Brescia, Italy; 14 Università degli Studi di Milano, Irccs A. O. S. Paolo, Milano, Italy; 15 A.O. S. Antonio Abate, Gallarate, Italy; 16 Ospedale Civile Vimercate, Vimercate, Italy; 17 Casa di Cura S. Pio X, Milano, Italy; 18 Ospedale Melegnano, Melegnano, Italy; 19 Irccs Fondazione Policlinico, Mangiagalli Regina Elena, Milano, Italy; 20 Ospedale S.Giuseppe, Milano, Italy; 21 Università degli Studi di Milano Irccs Fondazione Policlinico, Milano, Italy; 22 Università degli Studi di Milano Ospedale Luigi Sacco, Milano, Italy