- Email: [email protected]
Outcome of Peptic Ulcer Bleeding
May 2006
LETTERS TO THE EDITOR
1. Marmo R, Rotondano G, Piscopo R, et al. Capsule endoscopy versus enteroclysis in the detection of small bowel involvement in Crohn’s disease: a prospective trial. Clin Gastroenterol Hepatol 2005;3:772–776. 2. Fireman Z, Mahajna E, Broide E, et al. Diagnosing small bowel Crohn’s disease with wireless capsule endoscopy. Gut 2003;52: 390 –392. 3. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of doubleballoon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010 –1016.
661
3. Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 2000;321:1183–1187. 4. Calvet X, Vergara M, Brullet E, et al. Addition of a second endoscopic treatment following epinepherine injection improves outcome in highrisk bleeding ulcers. Gastroenterology 2004;126:441– 450. 5. Thomopoulos KC, Vagenas KA, Vagianos CE, et al. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004;16:177–182. doi:10.1016/j.cgh.2006.02.021
doi:10.1016/j.cgh.2006.02.019
Outcome of Peptic Ulcer Bleeding Dear Editor: The article by Ramsoekh et al1 published in the September 2005 issue revealed a surprisingly high mortality rate in patients with peptic ulcer bleeding. The study focused on 2 university hospitals and 12 regional hospitals in Amsterdam’s surrounds, in which 14% of patients admitted with hematemesis, melena, or hematochezia, or who developed peptic ulcer bleeding as inpatients, died. The Amsterdam results appear to be nearly double the mortality rate of 4.5%– 8.1% reported by specialized units that emphasize prompt resuscitation, early endoscopic diagnosis, and treatment followed by dedicated multidisciplinary postoperative care.2 The improved outcome has been maintained despite a significant rise in the proportion of elderly patients who often have coexisting diseases and are more likely to be taking aspirin or NSAIDs.3 Our own recent data (2004 –2005) show that during a 12 month period, 88 patients were admitted with peptic ulcer bleeding. Seventy-three percent of the patients were older than 60 years (range, 18 –96 years), and 55% were taking aspirin and/or NSAIDs. The mortality rate in our unit was 3.4%. In regional hospitals, early assessment, appropriate fluid resuscitation, and expert endoscopic intervention might not always be available. It is logical to conclude that the likely explanation for the high mortality rate in the study by Ramsoekh et al1 relates to the management of patients with bleeding peptic ulcers in regional hospitals. In addition, most patients in this study who were given endoscopic treatment received adrenaline injection therapy alone, rather than combining this with a second hemostatic method (in those with a high-risk ulcer) to lower the rate of rebleeding and subsequent need for surgery.4 The rebleeding rate of 19% and need for surgery in 7% of this study population are higher than rates reported elsewhere and no doubt contributed to the overall mortality.5 We certainly share the view that acid suppression therapy and Helicobacter pylori eradication improve mortality. However, these patients should also be managed in a dedicated gastrointestinal unit whenever possible. SINA ALEXANDER DEBBIE M. NATHAN MELVYN G. KORMAN Gastroenterology & Liver Unit, Southern Health Clayton, Victoria, Australia 1. Ramsoekh D, van Leerdam ME, Rauws EA, et al. Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol 2005;3: 859 – 864. 2. Sanders DS, Perry MJ, Jones SGW, et al. Effectiveness of an uppergastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardization. Eur J Gastroenterol Hepatol 2004;16:487– 494.
Reply. Dr Alexander and colleagues state that the mortality rate of 14% in our study was surprisingly high. We agree that the outcome, including mortality, rebleeding, and surgery rate, was high in our study. Alexander et al suggest that management in the involved hospitals might have been suboptimal. However, the high mortality rate can be explained by several other reasons. First, the data from our study are based on an epidemiologic survey. The reported mortality rate is in line with the outcome of acute upper gastrointestinal bleeding in other European epidemiologic surveys, reporting a mortality rate of 14% in the United Kingdom,1 the Netherlands,2 and France3 and a mortality rate of 6% in Greece.4 Furthermore, in articles comparing different strategies in patients with peptic ulcer bleeding, there is potential for bias, because patients with severe or life-threatening comorbidity, high age, coagulation disorders, etc, are often excluded. This results in a selected population that cannot be compared with the population of epidemiologic surveys that include all patients with peptic ulcer bleeding. Second, both patients who were already admitted to hospital for other illness and patients presenting to the emergency department with upper gastrointestinal bleeding were included in our epidemiologic study. Mortality was significantly higher in patients already admitted for other illness, 28% vs 5.3% (P ⬍ .01), respectively. In the cited studies of Hunt et al,5 only patients admitted with upper gastrointestinal bleeding were included. The mortality rate of 5.3% in our study among patients admitted for peptic ulcer bleeding is consistent with the data reported from other studies. Third, severe or life-threatening comorbidity was present in 76% of the patients who died. This was most relevant in patients already admitted to hospital for other illness with concomitant severe or life-threatening disease. Of the 136 patients already admitted to hospital, 129 had severe or life-threatening disease compared with only 19 of the 225 patients presenting to the emergency department (P ⬍ .01), explaining the high mortality rate among in-hospital patients.6 A Dutch study among 232 patients with non-variceal upper gastrointestinal bleeding showed that the majority of deaths in these patients could not have been prevented, but they resulted from the comorbidity.7 We agree with Alexander et al that it is extremely important to offer patients with acute upper gastrointestinal bleeding optimal management in specialized units. In our study not all patients with high-risk ulcers (active bleeding or visible vessel) received endoscopic therapy. Whether adrenaline injection alone is sufficient needs to be studied further. Clinicians are increasingly resorting to the use of combination therapy. A recent Cochrane meta-analysis showed that proton pump inhibition reduces the rebleeding rate; however, dosefinding studies are lacking.8 In conclusion, management of peptic ulcer bleeding should be optimized. However, the high mortality rate reported in our epidemiologic survey is mainly due to the high mortality rate among patients already admitted to hospital for other illness and having
LETTERS TO THE EDITOR
1. Marmo R, Rotondano G, Piscopo R, et al. Capsule endoscopy versus enteroclysis in the detection of small bowel involvement in Crohn’s disease: a prospective trial. Clin Gastroenterol Hepatol 2005;3:772–776. 2. Fireman Z, Mahajna E, Broide E, et al. Diagnosing small bowel Crohn’s disease with wireless capsule endoscopy. Gut 2003;52: 390 –392. 3. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of doubleballoon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010 –1016.
661
3. Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 2000;321:1183–1187. 4. Calvet X, Vergara M, Brullet E, et al. Addition of a second endoscopic treatment following epinepherine injection improves outcome in highrisk bleeding ulcers. Gastroenterology 2004;126:441– 450. 5. Thomopoulos KC, Vagenas KA, Vagianos CE, et al. Changes in aetiology and clinical outcome of acute upper gastrointestinal bleeding during the last 15 years. Eur J Gastroenterol Hepatol 2004;16:177–182. doi:10.1016/j.cgh.2006.02.021
doi:10.1016/j.cgh.2006.02.019
Outcome of Peptic Ulcer Bleeding Dear Editor: The article by Ramsoekh et al1 published in the September 2005 issue revealed a surprisingly high mortality rate in patients with peptic ulcer bleeding. The study focused on 2 university hospitals and 12 regional hospitals in Amsterdam’s surrounds, in which 14% of patients admitted with hematemesis, melena, or hematochezia, or who developed peptic ulcer bleeding as inpatients, died. The Amsterdam results appear to be nearly double the mortality rate of 4.5%– 8.1% reported by specialized units that emphasize prompt resuscitation, early endoscopic diagnosis, and treatment followed by dedicated multidisciplinary postoperative care.2 The improved outcome has been maintained despite a significant rise in the proportion of elderly patients who often have coexisting diseases and are more likely to be taking aspirin or NSAIDs.3 Our own recent data (2004 –2005) show that during a 12 month period, 88 patients were admitted with peptic ulcer bleeding. Seventy-three percent of the patients were older than 60 years (range, 18 –96 years), and 55% were taking aspirin and/or NSAIDs. The mortality rate in our unit was 3.4%. In regional hospitals, early assessment, appropriate fluid resuscitation, and expert endoscopic intervention might not always be available. It is logical to conclude that the likely explanation for the high mortality rate in the study by Ramsoekh et al1 relates to the management of patients with bleeding peptic ulcers in regional hospitals. In addition, most patients in this study who were given endoscopic treatment received adrenaline injection therapy alone, rather than combining this with a second hemostatic method (in those with a high-risk ulcer) to lower the rate of rebleeding and subsequent need for surgery.4 The rebleeding rate of 19% and need for surgery in 7% of this study population are higher than rates reported elsewhere and no doubt contributed to the overall mortality.5 We certainly share the view that acid suppression therapy and Helicobacter pylori eradication improve mortality. However, these patients should also be managed in a dedicated gastrointestinal unit whenever possible. SINA ALEXANDER DEBBIE M. NATHAN MELVYN G. KORMAN Gastroenterology & Liver Unit, Southern Health Clayton, Victoria, Australia 1. Ramsoekh D, van Leerdam ME, Rauws EA, et al. Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol 2005;3: 859 – 864. 2. Sanders DS, Perry MJ, Jones SGW, et al. Effectiveness of an uppergastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardization. Eur J Gastroenterol Hepatol 2004;16:487– 494.
Reply. Dr Alexander and colleagues state that the mortality rate of 14% in our study was surprisingly high. We agree that the outcome, including mortality, rebleeding, and surgery rate, was high in our study. Alexander et al suggest that management in the involved hospitals might have been suboptimal. However, the high mortality rate can be explained by several other reasons. First, the data from our study are based on an epidemiologic survey. The reported mortality rate is in line with the outcome of acute upper gastrointestinal bleeding in other European epidemiologic surveys, reporting a mortality rate of 14% in the United Kingdom,1 the Netherlands,2 and France3 and a mortality rate of 6% in Greece.4 Furthermore, in articles comparing different strategies in patients with peptic ulcer bleeding, there is potential for bias, because patients with severe or life-threatening comorbidity, high age, coagulation disorders, etc, are often excluded. This results in a selected population that cannot be compared with the population of epidemiologic surveys that include all patients with peptic ulcer bleeding. Second, both patients who were already admitted to hospital for other illness and patients presenting to the emergency department with upper gastrointestinal bleeding were included in our epidemiologic study. Mortality was significantly higher in patients already admitted for other illness, 28% vs 5.3% (P ⬍ .01), respectively. In the cited studies of Hunt et al,5 only patients admitted with upper gastrointestinal bleeding were included. The mortality rate of 5.3% in our study among patients admitted for peptic ulcer bleeding is consistent with the data reported from other studies. Third, severe or life-threatening comorbidity was present in 76% of the patients who died. This was most relevant in patients already admitted to hospital for other illness with concomitant severe or life-threatening disease. Of the 136 patients already admitted to hospital, 129 had severe or life-threatening disease compared with only 19 of the 225 patients presenting to the emergency department (P ⬍ .01), explaining the high mortality rate among in-hospital patients.6 A Dutch study among 232 patients with non-variceal upper gastrointestinal bleeding showed that the majority of deaths in these patients could not have been prevented, but they resulted from the comorbidity.7 We agree with Alexander et al that it is extremely important to offer patients with acute upper gastrointestinal bleeding optimal management in specialized units. In our study not all patients with high-risk ulcers (active bleeding or visible vessel) received endoscopic therapy. Whether adrenaline injection alone is sufficient needs to be studied further. Clinicians are increasingly resorting to the use of combination therapy. A recent Cochrane meta-analysis showed that proton pump inhibition reduces the rebleeding rate; however, dosefinding studies are lacking.8 In conclusion, management of peptic ulcer bleeding should be optimized. However, the high mortality rate reported in our epidemiologic survey is mainly due to the high mortality rate among patients already admitted to hospital for other illness and having