Non-Variceal Upper GI Bleeding in Patients Already Hospitalized for Another Condition Tanja Muller, MD, Alan N. Barkun, MD, CM, MSc, Myriam Martel , BSc.

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Non-Variceal Upper GI Bleeding in Patients Already Hospitalized for Another Condition Tanja Muller, MD, Alan N. Barkun, MD, CM, MSc, Myriam Martel , BSc and the RUGBE investigators Am J Gastroenterol 2009;104:330–339 R3 Ju-Woong Son/Prof. Jae-Young Jang

INTRODUCTION Acute upper gastrointestinal bleeding Earlier studies 170 cases per 100,000 adults per year Earlier studies patients presenting to the emergency room with non-variceal upper gastrointestinal bleeding (NVUGIB) only few have focused on the development of NVUGIB that occurs after hospital admission

INTRODUCTION The aim of this study to analyze and compare differences in the baseline characteristics between patients having started to bleed as outpatients (OPs) and patients already hospitalized for another reason (inpatients, IPs)

METHODS Patient population Between September 1999 and December 2001 1,878 patients presented with a history of hematemesis / coffee-ground vomiting, melena, hematochezia Outpatients (OPs) A patient presenting to a medical facility because of a new onset of NVUGIB Inpatients (IPs) a patient developing NVUGIB while already hospitalized for an unrelated illness Exclusion esophageal, gastric, or duodenal varices

METHODS The observed outcomes the occurrence of continued bleeding Rebleeding Surgery transfusion requirements length of hospital stay mortality

RESULTS

Outpatients total (n=1395) Initial management Inpatients total (n=469) Outpatients total (n=1395) P value Mean (median) Resuscitation with IV fluid 70% 81% P<0.001 Hemodynamic instability 29% 33% NS Transfusion 3.0±1.9U 2.9±1.6U 57% 54%

Timing of endoscopy following admission/onset of bleeding The first 24 h after onset of bleeding - 60% of IPs compared with 82% of OPs (p<0.001)

Comparison of endoscopic findings in in- and outpatients The combined proportions of ulcers and erosions - 83% of IPs compared with 85% of OPs (p=0.314)

Outpatients total (n=1395) Pharmacotherapy Inpatients total (n=469) Outpatients total (n=1395) P value Mean (median) First dose of medication 8.3±13.4h 11.5±17.6h PPI 88% 83% P=0.009 Mean daily doses of PPI 57±58mg 57±52mg NS H2 blocker 23% 25% PPI & H2 blocker 19% Endoscopic Tx and medication 37% 33% P=0.169

Outpatients total (n=1395) H. Pylori treatment Inpatients total (n=469) Outpatients total (n=1395) P value Mean (median) Prior diagnosis of H. Pylori 0.9% 4.4% P<0.001 H. Pylori infection 35% 51% Gastroduodenal ulcer 35.4% 47% Eradiacation therapy (initiated in hospital) 8.6% 10% P=0.278 62.2±47h 73±130h

Outpatients total (n=1395) Outcomes Inpatients total (n=469) Outpatients total (n=1395) P value Mean (median) Length of hospital stay 7.2±7.4day 5±5.4day P<0.001 ICU 40.5% 16% Continued bleeding or Rebleeding 15.7% 13.4% P=0.227 Surgery 6.9% 6.4% P=0.717 Mortality 11% 3.5%

Conclusion IPs developing NVUGIB are much sicker and are hospitalized longer than OPs. Endoscopic hemostasis and PPI therapy favorably affect rebleeding in IPs, whereas patient characteristics principally determine the threefold greater IPs mortality.