Joseph J.Y. Sung, MD et al. Am J Gastroenterol 2010;105. R3 김민경

Peptic ulcer Peptic ulcer  Incidence is declining but peptic ulcer bleeding(PUB) remains a major prevalent and clinically significant condition world wide. the mortality associated with PUB stays at around 5-10%  Despite advances in treatment in PUB, the mortality associated with PUB stays at around 5-10%  PUB is now predominantly a disease of the elderly  more comorbid illness, more users of aspirin/NSAIDs, less tolerant of hemodynamic insult The outcome of most studies about PUB intervention:  Recurrent bleeding, repeated endoscopic therapy, surgery, transfusion Ultimate aim of treatment of gastrointestinal bleeding is to save lives  It is important to elucidate the causes of death in PUB The aim of this study is to investigate the cause of death in PUB patients Ulcer bleeding GI cause Non-GI cause mortality

Study population: Study population: patient of the Prince of Wales Hospital Date base: Date base: UGIB registry  Demographic information, characteristics of bleeding pathologies, pharmacological, endoscopic, or surgical treatment  Admitted for PUB or developed bleeding after admission for other medical conditions  Ulcer location, stigmata of recent hemorrhage, nature and number of comorbid illness, H.pylori, medication(H2B, PPI, NSAIDs, aspirin, clopidogrel), hemodynamic status, endoscopic treatment, occurrence of rebleeding Primary outcomemortality within 30days after index bleeding Primary outcome: mortality within 30days after index bleeding  Any cause of death within 30days after index bleeding (in or out of hospital after discharge)  Cause of mortality  (A) bleeding related death  (B) non-bleeding related death

1993~ ,508 UGIB episodes PUB 10,428 cases(9,375pts) Death: 612 pts(6.5%) (during Hospital stay or within 30days after index endoscopy) Death: 577(6.2%) (within 30 days after index endoscopy) 1.Characteristics of patients 2.Cause of death of 577pts 3.Univariate analysis between bleeding and non-bleeding related mortality 4.Multivariate analysis

Characteristics of patients

Bleeding related(n=106) 29.2%(n=31) Uncontrolled bleeding/Rebleeding 25.5% (n=27) Within 48 h after endoscopy circulatory failure 2.8% (n=3) During surgery for Uncontrolled bleeding 29.2%(n=31) Surgical complications or within 1 month after surgery without other cause 13.2% (n=14) Endoscopy-related Complication Cause of death within 30days after index bleeding 50.0% of patients in the bleeding related mortality group and 28.9% patients in the non-bleeding related mortality group died within 3 days of index bleeding (P<0.001) *11pts were unclassified

Non bleeding related(n=460) 13.5% (n=62) Cardiac diseases (e.g., ACS, heart failure) 23.5% (n=108) Pulmonary diseases (ex.COPD, pneumonia) 23.9% (n=110) Multi-organ failure 5.4% (n=25) Neurological diseases (ex. stroke) 33.7%(n=155) Terminal malignancy Cause of death within 30days after index bleeding *11pts were unclassified There were significantly more patients who died of non-ulcer bleeding causes(79.7%) than bleeding cause(18.4%)

Univariate analysis between bleeding and non- bleeding related mortality

Multivariate analysis between bleeding and non-bleeding related mortality These were found to be an independent variable predicting bleeding related death

13.3~39.4% No trend incidence of bleeding and non-bleeding related mortality

1.Characteristics of patients(Surviving patients) : younger, less severe comorbid illness, more to have a previous history of ulcer and H. pylori infection, more clean based ulcer : less to be users of H2bloker/PPI and NSAIDs/aspirin, less hemodynamic shock and clinical rebleeding 2.Cause of death of 577pts : non-bleeding related – 80% : bleeding related group – 18% 3.Univariate analysis between bleeding and non-bleeding related mortality : bleeding related - older, more ulcer history, more NSAID or aspirin, with hemodynamic shock, actively bleeding ulcer : Not significant - recurrent bleeding, repeated endoscopic therapy 4.Multivariate analysis between bleeding and non-bleeding related : predicting bleeding related death - NSAIDs, aspirin, endoscopic appearance of ulcer, hemodynamic shock

Although the incidence of PUB has decrease, mortality has remained constant despite the advances in endoscopic and pharmacological therapies This study indicate that most PUB linked deaths are not direct sequelae of the bleeding ulcer itself Mortality(80%) derives from non-bleeding cause(ex. MOF, cardiopulmonary conditions, or terminal malignancy) This results is paramount for the implementation of strategies that provide supportive care and prevent complications and key organ failure, as well as treat the ulcer Future studies should be directed to explore ways to improve the over all outcome of the patients

임상 및 내시경 범주를 이용해서 재출혈과 사망의 위험도를 예측한다 5~7 점 이상인 경우, 일반적으로, 재출혈과 사망 위험이 높다

내시경 소견으로 재출혈 경향을 예측하는데 이용 Ⅰ A~ Ⅱ A: 고위험군, 내시경 치료 필요함 Ⅱ B: ?? Ⅱ C~ Ⅲ : 저위험군 병변으로 내시경 지혈술이 권고 되지 않는다.

혈색소 수치, 혈압, 맥박수의 변화 정 도 및 흑색변, 간 질환, 심장 질환 등의 존재여부에 따라 점수화 하여 0~23 의 범위를 가 지며 숫자가 높을 수록 재출혈과 사 망률의 위험도를 알수 있게 하였다.

(A1) uncontrolled bleeding (A2) within 48h after endoscopy (A3) during surgery for uncontrolled bleeding (A4) surgical complications or within 1 month after surgery (A5) endoscopic related mortality (B1) cardiac cause (B2) pulmonary causes (B3) cerebrovascular disease (B4) multi-organ failure (B5) terminal malignancy