Prospective Observational Study on Clinical and Epidemiological Profile of Adult Patients Presenting to the Emergency Department with Upper Gastrointestinal Bleed

doi:10.21203/rs.3.rs-2338195/v2

Background and objective: Bleeding from the upper gastrointestinal (GI) tract is one of the common medical emergencies. In this study, we assessed patients' socio-demographic and clinical characteristics and the association of clinical characteristics with treatment outcomes among patients with upper gastrointestinal bleed (UGIB) presenting to the emergency department (ED). At present, there is a scarcity of data on UGIB in Northern part of India.

Material and method: The study was a single-center,prospective observational study conducted at an urban tertiary care center. Consecutive patients with UGIB were enrolled in the study from August 2020 to February 2022. A detailed history was obtained, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction, and drug history. Pre-endoscopic Rockall and Glasgow-Blatchford Score were calculated for each patient. The patients were subsequently followed up till discharge from the hospital. The final outcomes with regard to mortality, need for blood transfusion, length of ED, and hospital stay and discharge were noted.

Result: 141 patients were included in the study. The mean age of the patients with UGIB was 48 ± 14 years. 115 (81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%). The most frequent presenting complaint in this study was hematemesis (96; 68.1%), followed by melena (76;53.9%). The mean (SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15 in patients with UGIB.

Conclusion: In our study, hematemesis was the most prevalent symptom of an UGIB, followed by melena. Portal hypertension was the more common cause of UGIB. Alcohol intake, NSAIDs abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes are statistically significantly associated with UGIB. By doing early endoscopy we can find and treat the cause of bleeding, thereby we can prevent morbidity, mortality and decrease the length of hospital stay.

Emergency

Hematemesis

Gastrointestinal endoscopy

Melena

Portal hypertension .

The incidence of UGIB is around 5-10 per one million population annually. The elderly population is more affected [1]. Hematemesis and/or melena are symptoms of UGIB, defined as bleeding from a source proximal to the Treitz ligament [2]. It might be anything from a significant hemorrhage to subacute bleeding with or without a change in hemodynamics. Bright red blood indicates hemorrhage within the last 24 hours. "Coffee ground" result from the influence of stomach acid on the blood. Melena is a black, tarry stool caused by upper GI hemorrhage that can extend to the cecum. It relates to the impact of the GI tract and bacteria on the blood. Hematochezia is bright red blood in the stool, usually caused by a lower GI hemorrhage, but it can also occur due to a large, rapid UGIB. Colorectal bleeding is the most common cause of hematochezia, although it can also occur due to a large, rapid UGIB [3]. Increased mortality, recurrent bleeding, and the need for endoscopic hemostasis or surgery are associated with the risk factors such as age of more than 60 years, co-morbidities, active bleeding (e.g., witnessed hematemesis, red blood per nasogastric tube, fresh blood per rectum), hypotension, transfusion of more than or equal to six units of red blood cells [4]. There is no such study done in ED related to GI bleed in northern part of India, so we are doing our study to find clinical and epidemiological profile of adult patients with GI bleed presenting to ED.

Study design and settings

This single-center, observational study of adult patients presenting with UGIB to the ED of a tertiary care center was conducted with patient recruitment period from November 2020 to December 2021. All patients aged 18 years and above presenting to the emergency with suspected or confirmed UGIB were included in the study. The study was approved by the Institutional Ethical Committee, AIIMS Rishikesh. (Ref No.- AIIMS/ IEC/ 20/ 513)

Sample size

We included all patients which comes to ED with UGIB during the specified study period and who fulfil inclusion criteria, so 141 patients were recruited, after taking informed written consent from all the patients

Clinical evaluation

The study's primary objective was to assess the socio-demographic and clinical characteristics of patients with UGIB presenting to the ED. The secondary objective of the study was to assess the treatment outcomes in patients with UGIB presenting to the ED and to determine the association of clinical characteristics with treatment outcomes among patients presenting to the ED with an UGIB. Detailed history, including demographic data such as age and sex, presenting complaints, history of presenting illness, history related to co-morbidities, addiction (such as recent alcohol intake within one week or chronic/regular alcohol consumption), and drug history, was obtained. Detailed physical and systemic examination was done in all the patients, and findings were noted. Laboratory tests obtained included total blood count, arterial blood gas, liver function tests, renal function tests, prothrombin time, international normalized ratio, and aPTT. Shock index (HR/SBP) was calculated for each patient. Upper GI endoscopy was done in all the patients who are clinically suspected or confirmed to have UGIB. Upper GI endoscopy was performed emergently for major bleeding even at night and those patients with minor bleed endoscopy is mostly performed at daytime. Rockall and Blatchford's score was calculated for each patient. The parameters of each score are shown in Tables 1 and 2.

Table 1 Clinical (pre-endoscopic) Rockall score: [5]

Components	Score
	0	1	2	3
Age(years)	< 60	60-79	>80	-
Hemodynamics	HR <100 SBP >100	HR>100 SBP>100	SBP <100	-
Co-morbidities	None	none	Ischemic heart disease, congestive heart failure Any Major co-morbidities	Renal failure Liver disease Metastasis

Pre-endoscopic Rockall score –

Score Risk (for Re-bleeding, mortality, or surgery)

< 3 low risk

3-4 moderate risk

>4 high risk

Table 2 Glasgow-Blatchford Score: (5)

Risk factors	Threshold	Score
Blood Urea Nitrogen(mmol/l)	6.5-7.9	2
	8.0-9.9	3
	10.0-25	4
	>25	6
Hemoglobin for men (g/dl)	12.0-12.9	1
	10.0-11.9	3
	<10	6
Hemoglobin for women(g/dl)	10.0-11.9	1
	<10	6
Systolic blood pressure(mmHg)	100-109	1
	90-99	2
	<90	3
Other markers	Pulse rate >100 bpm	1
	Presentation with melena	1
	Presentation with syncope	2
	Hepatic disease	2
	Cardiac failure	1

Score Risk (needing intervention,

transfusion, endoscopy, or surgery)

< 3 Low risk

>/= 3 High risk

Statistical analysis

The data was analyzed using SPSS software version 24. Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean (SD) and median (IQR) depending on the distribution of the data after assessing normality by the Shapiro-Wilk test. Categorical variables were analyzed with a chi-square test. The level of significance was set at p< 0.05. Continuous variables are analyzed using Spearman correlation coefficient and Pearson correlation coefficient. The receiver operating characteristic curves was plotted for each of the two scores and the area under the curves was analyzed.

Clinical evaluation was performed on 141 patients after obtaining written consent.

Baseline characteristics of the study population

The mean age of the patients with UGIB was 48 ± 14 years. 115(81.6%) patients were male. The most common co-morbidity was chronic liver disease (40;28.4%), followed by diabetes mellitus (19;13.5%), hypertension (20;14.2%), and 20(14.2%) patients who had a previous history of UGIB as shown in table 3.

Table 3 Profile of socio-demographic parameters of patients with UGIB.

Parameters	Mean ± SD
Age	48.62 ± 14.63
Gender	No. (%)
Male	115 (81.6)
Female	26 (18.4)
Co-morbidities	No. (%)
Hypertension	20 (14.2)
Type 2 Diabetes mellitus	19 (13.5)
Chronic liver disease	40 (28.4)
Alcohol use	68 (48.2)
Chronic kidney disease	10 (7.1)
Coronary artery disease	7 (5.0)
Previous UGIB	20 (14.2)
Antiplatelet use	8 (5.7)
NSAIDs use	9 (6.4)
Hepatitis C virus	12 (8.51)
Hepatitis B virus	5 (3.54)

Clinical profile of patients

The most frequent presenting complaint in this study was hematemesis (96; 68.1%) and melena (76;53.9%). 41(29%) patients complained of both hematemesis and melena. The mean shock index was 0.90 ± 0.29. 38(26.9%) patients had shock index >1. The mean (SD) of the Rockall Score was 2.46 ± 1.75. The mean (SD) of the Glasgow Blatchford Score was 12.46 ± 3.15, as shown in table 4.

Table 4 Clinical profile of patients with UGIB presenting in the ED.

Symptoms	No. (%)
Hematemesis	96 (68.1)
Malena	76 (53.9)
Hematemesis + Hematochezia	13 (9.2)
Recent alcohol binge	24 (17.0)
Syncope	1 (0.7)
Vomiting	28 (19.9)
Abdominal distension	48 (34.0)
Diarrhoea	4 (2.8)
Body pallor	15 (10.6)
Jaundice	29 (20.6)
Abdominal pain	50 (35.5)
Shortness of breath	10 (7.1)
Fever	12 (8.5)
Altered mental status	17 (12.1)
Anasarca	13 (9.2)
Decrease urine output	16 (11.3)
Examination parameters	Mean ± SD
Pulse rate (BPM)	98 ± 17
Shock index	0.90 ± 0.29
Rockall score	2 ± 1
Glasgow Blatchford score	12 ± 3

Biochemical and hematological profile of patients

Majority of patients presented with anemia and hyperbilirubinemia in the study. The mean hemoglobin was 8.67 ± 2.7 g/dl, and the mean total bilirubin was 2.77 ± 3.7 mg/dl. 58 (41.1%) patients had coagulopathy. The mean prothrombin time was 20.95 ± 16.03 seconds, and the mean INR was 1.65 ± 0.73 seconds. The mean lactate level was 2.69 ± 2.60 mmol/l, and the anion gap was 13.32 ± 5.82. In our study, anemia, hypoalbuminemia, raised lactate and underlying coagulopathy were common findings in patients with an UGIB as shown in table 5.

Table 5 Biochemical and hematological profile of patients with UGIB.

Parameters	Mean ± SD
Hemoglobin (g/dL)	8.6 ± 2.6
Hematocrit (%)	26.4 ± 7.3
Platelet Count (x10³/µL)	129.5 ± 74.2
Total Leucocyte Counts (x10³/µL)	9.5 ± 5.7
Urea (mg/dL)	63.7 ± 58.8
Creatinine (mg/dL)	1.6 ± 2.2
Total Bilirubin (mg/dL)	2.7 ± 3.7
Prothrombin Time (s)	20.9 ± 16.0
International Normalized Ratio	1.6± 0.7
Aspartate aminotransferase (U/L)	126.8 ± 351.8
Alanine aminotransaminase(U/L)	57.5 ± 74.3
Alkaline phosphatase (U/L)	214.3 ± 134.1
pH	7.39 ± 0.08
HCO₃ (mmol/L)	18.9 ± 4.5
Lactate (mmol/L)	2.6 ± 2.6
Anion Gap	13.3 ± 5.8

Upper GI endoscopy/colonoscopy findings

Upper GI endoscopy was done only in 104 out of 141 patients, as during our study period COVID-19 surge occurred so those patients whose gastric lavage was negative for blood were not considered for endoscopy by gastroenterology team. Concomitant colonoscopy was done in eight (three hemorrhoids, two ulcerative colitis and three no obvious source of bleed) patients as in those patients upper GI endoscopy did not showed any bleeding source. Esophageal varices (55;52.9%) were the most common finding, followed by gastric ulcer (12;11.5%), duodenal ulcer (6;5.8%), esophageal ulcer (6;5.8%), esophagitis (5;4.8%), and gastric carcinoma (2;1.9%). Thus, portal hypertension was seen in more than 50% of cases of UGIB in our study, as shown in table 6.

Table 6 Upper GI endoscopy/colonoscopy findings

UGI endoscopy / Colonoscopy findings	No. (%)
Esophageal varices	55 (52.9)
Gastric ulcer	12 (11.5)
Duodenal ulcer	6 (5.8)
Esophageal ulcer	6 (5.8)
Esophagitis	5 (4.8)
Post EVL ( endoscopic variceal ligation) ulcer	3 (2.9)
Hemorrhoids	3 (2.9)
Ulcerative colitis	2 (1.9)
Carcinoma stomach	2 (1.9)
Ulcer at the gastroesophageal junction	2 (1.9%)
Candidiasis	1 (1.0%)
Gastropathy	1 (1.0%)
Alcohol-induced gastritis	1 (1.0%)
Mallory Weiss tear	1 (1.0%)
Esophageal diverticulum	1 (1.0%)
No active source of the bleed	3 (2.9%)
Normal study	6 (5.8%)

Treatment profile and outcome of patients with UGIB

In our study majority of patients (108;77.7%) received intravenous fluids (crystalloids), 37 (26.6%) patients received packed red blood cells, 13(9.4%) patients received fresh frozen plasma, whereas only three (2.2%) patients received random donor platelets. Upper GI endoscopy was done in (104,73.75%) patients. Endoscopic variceal ligation was done in 35(33.7%) patients to control active bleeding. 8 (5.8%) patients were intubated in ED because of poor Glasgow Coma Score (GCS) (< 8).

Out of all 141 patients presenting with UGIB, 93(66.0%) patients got admitted. 24(25.8%) patients were admitted to ICU out of total admitted. Among 22(15.6%) patients who succumbed to death, four (18%) expired in the ED, five (22.7%) deaths occurred within 24 hours, and 16(72.72%) within seven days after admission. Among patients admitted to ICU, 18(75%) succumbed to death, one(0.07%) patient left against medical advice, as shown in table 7.

Table 7 Treatment profile and outcome of patients with UGIB

Treatment		No. (%)
UGIE		104 (73.75%)
Endotracheal intubation		8 (5.8%)
Intravenous fluids		108(77.7%)
Blood transfusion	PRBC	37 (26.6%)
	FFP	13 (9.4%)
	RDP / platelets	3 (2.2%)
Endoscopic variceal ligation		35 (33.7%)
Outcomes		No. (%)
Admission		93 (66.0%)
ICU admission out of total admitted		24 (25.8%)
Discharge		43 (30.5%)
Mortality (out of those admitted in ICU)		18 (75%)
Mortality (in hospital)		22 (15.6%)
Mortality in ED		4 (18%)
Mortality in 24 hours		5 (22.7%)
Mortality in 7 days		16 (72.72%)
Left against medical advice		1 (0.7%)

Cause of Mortality in patients with UGIB in ED

Septic shock (13;61.9%) was the most common cause of mortality, followed by metabolic acidosis (3;14.3%), hypovolemic shock (2;9.5%), and acute respiratory distress syndrome (2;9.5%), as shown in table 8.

Table 8 Cause of mortality in patients with UGIB in ED

Causes	No. (%)
Septic shock	13 (61.9)
Hypovolemic shock	2 (9.5)
Metabolic acidosis	3 (14.3)
ARDS (acute respiratory distress syndrome)	2 (9.5)
Ventricular fibrillation	1 (4.8)
AKI with Septic shock	1 (4.8)

Association of clinical and biochemical parameters with the length of ED stay

Parameters such as the previous history of UGIB decreased urine output, and ALP (alkaline phosphatase) level was found to be significantly associated with length of stay in the ED. (p < 0.05) as shown in table 9.

Table 9 Association of clinical and biochemical parameters with the length of ED stay

Parameters	p-value (length of ED stay)
Previous UGIB	0.021
Decreased Urine Output	0.036
Pulse Rate (BPM)	0.010 (r = -0.22)
Shock Index	0.018 (r = -0.2)
Urea (mg/dL)	0.045 (r = -0.17)
ALP (U/L)	0.002 (r = -0.27)
Ascites	0.013
Splenomegaly	0.019
Ulcer at GEJ (UGIE)	0.035

Association of diagnostic parameters with the length of stay

Parameters such as hemoglobin, creatinine, ascitic fluid - and absolute neutrophil count were significantly associated with hospital length of stay. Similarly, Upper GI endoscopy findings, such as esophageal varices and esophagitis, were significantly associated with the length of hospital stay (p<0.05), as shown in table 10.

Table 10 Association of diagnostic parameters with the length of stay.

Parameters	p-value
Intubation	0.048
Hemoglobin (g/dL)	0.031 (r = -0.21)
Creatinine (mg/dL)	0.022 (r = -0.23)
AF-ANC	0.017 (r = -0.6)
Esophageal varices (UGIE)	0.017
Esophagitis (UGIE)	0.038

Correlation between the Rockall score and Glasgow Blatchford score with outcome parameters

The mean duration of ED stay was 12.45 ± 11.78 hours

The mean hospital stay of patients with UGIB was 6.27 ± 5.03 days.

Table 11 shows the correlation between the Rockall score and Blatchford score and outcome parameters such as length of hospital stay (days), length of ED stay (hours), and blood transfusion. There was no significant association between Rockall and Blatchford score and hospital stay. Rockall and Blatchford scores were significantly associated with the need for blood transfusion and products.

Table 11 Correlation between the Rockall score and Glasgow Blatchford score with outcome parameters

Parameter	Rockall score	Glasgow Blatchford score
Parameter	Spearman Correlation Coefficient (P Value)	Spearman Correlation Coefficient (P Value)
Length of hospital stay (days)	-0.1 (0.622)	0.1 (0.403)
Length of ED stay (hours)	-0.1 (0.389)	-0.1 (0.539)
Blood transfusion	Point-Biserial Correlation (P Value)	Point-Biserial Correlation (P Value)
PRBC	0.25 (0.012)	0.47 (<0.001)
FFP	0.16 (0.065)	0.27 (<0.001)
RDP	0.22 (0.015)	0.14 (0.060)

Association between clinical parameters with mortality

There was a significant association between mortality and clinical variables such as high respiratory rate, low SpO2, high pulse rate, low systolic blood pressure, low diastolic blood pressure, low GCS, and high shock index. Also, hematological and biochemical parameters, such as low hemoglobin, low hematocrit, low platelet count, high total leucocyte count, high lactate level, elevated blood urea, and serum creatinine level, were significantly associated with mortality, as shown in table 12.

Table 12 Association between clinical parameters with mortality

Parameters	Death		p-value
Parameters	non-survival (n=22)	survival (n=119)	p-value
Respiratory rate	21.20 ± 2.71	20.18 ± 2.64	0.042
SpO2(%)	91.64 ± 15.19	97.36 ± 2.54	0.027
Pulse rate	109.86 ± 11.33	96.27 ± 17.19	<0.001
Systolic blood pressure	95.59 ± 33.79	115.08 ± 21.63	<0.001
Diastolic blood pressure	66.07 ± 16.51	74.21 ± 12.39	0.009
GCS	12.82 ± 3.67	14.50 ± 1.66	0.010
Shock index	1.18 ± 0.27	0.86 ± 0.27	< 0.001
Endotracheal Intubation	4 (18.2%)	4 (3.4%)	0.022
Hemoglobin(g/dl)	7.21 ± 2.35	8.94 ± 2.67	0.004
Hematocrit (%)	22.45 ± 6.56	27.15 ± 7.29	0.004
Platelet Count (x10³/µL)	93.46 ± 71.05	136.21 ± 73.13	0.001
Total leucocyte count(x10³/µL)	13.81 ± 6.43	8.75 ± 5.31	<0.001
Bicarbonate(mmol/l)	16.47 ± 5.04	19.44 ± 4.37	0.015
Lactate(mmol/l)	5.21 ± 4.25	2.22 ± 1.84	< 0.001
Anion gap	15.46 ± 4.78	12.93 ± 5.93	0.008
Urea(mg/dl)	77.39 ± 46.93	61.27 ± 60.58	0.021
Creatinine(mg/dl)	2.08 ± 1.37	1.60 ± 2.34	0.006
Prothrombin time(s)	27.86 ± 12.43	19.67 ± 16.34	< 0.001
INR	2.37 ± 1.00	1.52 ± 0.59	<0.001
Aspartate aminotransferase(U/L)	244.53 ± 584.57	105.13 ± 288.06	0.016
Rockall score	3.45 ± 1.63	2.28 ± 1.72	0.005
Glasgow Blatchford Score	14.82 ± 2.17	12.03 ± 3.12	< 0.001

Figure 1 shows the area under the ROC curve (AUROC) for Rockall Score predicting mortality was 0.687 (95% CI: 0.574 - 0.801). It was statistically significant (p = 0.005). At a cutoff of Rockall Score ≥2, it predicted death, with a sensitivity of 86% and a specificity of 41%.

Figure 2 shows the area under the ROC curve (AUROC) for Glasgow Blatchford Score predicting outcomes was 0.767 (95% CI: 0.665 - 0.868). It was statistically significantly associated with mortality (p = <0.001). At a cutoff of Glasgow Blatchford Score ≥14, it predicted mortality with a sensitivity of 73% and a specificity of 69%.

An UGIB is a potentially life-threatening medical emergency. These patients either come with frank hematemesis or melena. They also visit the primary family physician. The etiology of UGIB can be subdivided into variceal and non-variceal bleeding [5]. The most common etiology of UGIB is gastric ulcer, followed by variceal bleeding in patients with alcoholic liver disease. The approximate incidence of UGIB is 100-200 cases per 1 lakh population. Around 65-80 percent of all bleeding incidents occur in the upper intestine [6].

Demographic parameters

In our study, males (115;81.6%) outnumbered females (26;18.4%). The mean age of patients with UGIB was 48.62 ± 14.63 years. A cross-sectional study carried out by Surendran M et al. at a tertiary care hospitalin southern India foundthat males (107;77.5%) outnumbered females (31;22.5%) with an average age of 53.5 ± 13.17 years [7]. Similar results were reported by Shenoy V et al. [8]. It is discernable from the above studies that UGIB is more prevalent in men than in women. In India, it has been observed that alcoholism is more prevalent among males, which is a major cause of variceal bleeding in these patients [9].

Co-morbidities

In our study, the most common co-morbiditywas chronic liver disease (40;28.4%), followed by chronic kidney disease (10;7.1%), chronic hepatitis C (12;8.51%), hepatitis B (5;3.54%), hypertension (20;14.2%) and type 2 diabetes mellitus (19;13.5%). According to the previous study conducted by Mahajan et al., a significant association was observed between co-morbidities such as diabetes mellitus, coronary artery disease, and mortality [10]. Another study by Bhattarai et al. observed that 45.5% of patients with UGIB had chronic liver disease, 3.7% had chronic hepatitis B, and 1.5% had hepatitis C, which was comparable to our study [11]. It has been observed by a previous study that chronic liver disease was more commonly seen in patients with variceal bleeding, whereas co-morbidities like cardiac disease, cerebrovascular accidents, and malignancies were more prevalent in patients with non-variceal bleeding [12]. Thus, co-morbidities screening is important in patients with UGIB as they add to the risk of mortality in these patients.

Clinical features

In our study, the most common presenting feature in patients with UGIB was hematemesis (96;68.1%), followed by melena (76;53.9%), pain abdomen (50;35.5%), abdominal distension 48(34.0%) and both hematemesis and melena (41;29%). 29(20.6%) patients had features of jaundice, 9(6.4%) had hematochezia. Minakari M et al. found that hematemesis (63.5%) was the most common presentation [13]. Similar results were reported by Rajanss et al. and Shah H et al. [5,14]. This hospital is a tertiary care and referral center. It caters to the majority population of Uttarakhand and neighborly states. Most of the patients have a rural background. Often, the patients do not notice the initial symptoms and signs of melena and visit the hospital when massive hematemesis occurs.

Laboratory parameters:

In our study, most patients had anemia, mild thrombocytopenia, acute kidney injury, hyperbilirubinemia, and mild coagulopathy. Bhattarai et al. also reported anemia in the majority of patients with UGIB [11]. Similar results were reported by Sharma V et al. [15]. Bressler B et al. observed that the formation of esophageal varices is associated with thrombocytopenia (<200000/mm³) and hyperbilirubinemia (>20 μmol/l). It also concluded that if the patient has no history of UGIB and the laboratory report shows these values, then should screen the patient for esophageal varices [16]. Anemia is common in patients with UGIB due to ongoing blood loss. Patients with chronic liver disease may have underlying megaloblastic anemia and pancytopenia due to hypersplenism. Urea and creatinine are raised in these patients as a result of blood being metabolized into protein, and this protein is transported to the liver, where it is converted to blood urea nitrogen. Blood urea nitrogen increases due to the decrease in hydration and hypovolemia. Blood urea nitrogen and creatinine ratio can be increased in, decrease in renal perfusion and acute UGIB.

Upper GI endoscopy findings

In our study, upper GI endoscopy was done in 104(73.75%) patients. The most common finding was esophageal varices (55;52.9%). Similar results were observed in previous studies; Surendran M et al. found that esophageal varices (51.4%) were the most common finding, followed by gastritis (15.2%) [7]. Paudal MS et al. observed that a duodenal ulcer (29%) was the most common finding, followed by varices of 23% [17]. In contrast to our study, Kashyap R et al. observed that peptic ulcer was present in 61% of patients [18]. This discrepancy can be attributed to more incidence of alcoholic liver disease in our state.

Interventions

There are many treatment modalities for acute UGIB. Injections of epinephrine (1:10 000 dilution), injections of sclerosants such as 100% ethanol, thermal contact devices such as bipolar electrocoagulation probes or heater probes, and clips are recommended for bleeding ulcers. In our study, endoscopic variceal ligation was done in 35(33.7%) patients, glue injection for one patient, hemoclip for one patient, and endoscopic suturing also done for one patient. Packed red blood cell (PRBC) transfusion was done in 37(26.6%), fresh frozen plasma (FFP) in 13 (9.4%), and random donor platelets (RDP) in 3(2.2%) patients. Shenoy V et al. observed that PRBC transfusion was done in 46.7% of patients [19]. Miscellaneous Indian studies found that 20-50% of patients who presented with UGIB required blood transfusion [20,21,22].

Outcomes

In our study 141 patients presented with UGIB, and 93 (66.0%) patients were hospitalized. Similarly, J P Hreinsson et al. found that out of 156 patients with UGIB 71% were hospitalized [20].

Thus, it has been observed that the majority of patients with acute UGIB require hospitalization for hemodynamic stabilization and immediate intervention.

In our study, five (22.7%) succumbed to death within 24 hours of presentation. Around half of the patients expired within seven days of presentation. Four (18%) expired during ED stay. A study conducted by Rajan et al. observed that 34.8% of patients with UGIB succumbed to death within 24 hours of presentation, and 18.7% succumbed in seven days [5]. Moledina S et al. found that around 24.6% of patients succumbed within 24 hours of admission, and 49.1% died within 72 hours after admission [22]. As observed, in previous studies, a greater number of patients expired within 24 hours than in our study. This highlights the importance of early intervention, which can significantly improve the outcome of patients with UGIB.

In our study, the mean ED stay of patients with UGIB was 12.45 ± 11.78 hours, and the mean hospital stay was 6.27 ± 5.03 days. In other studies, Mungan Z et al. observed that the length of the hospital stay was 5.63 ± 4.91 days, per our study [23]. Thus, it has been observed that these patients with UGIB require immediate stabilization and intervention and that underlying etiology should be explored. These patients after stabilization are continued on intravenous octreotide infusion or terlipressin injection for 48 to 72 hours as per guidelines.

In our study, the area under the ROC curve (AUROC) for Rockall Score predicting mortality was 0.687 (95% CI: 0.574 - 0.801). Sharma V et al. observed that the clinical Rockall score (AUROC= 0.677, 95 percent CI: 0.583- 0.770, p= 0.001) was useful in predicting mortality [15]. This was comparable to our study findings.

UGIB is one of the common emergencies. These patients present to family medicine physicians as well as emergency physicians. UGIB can have varied etiology such as gastric ulcer, chronic liver disease, and coagulopathies. Immediate priorities should be given to these patients to stabilize these patients primarily, early upper GI endoscopy should be done, and appropriate intervention should be planned. The primary care physician and the emergency medicine physician should actively manage these patients.

As our study was a single center time-bound study, that can be the limitation of our study.

Portal hypertension is one of the most important causes of UGIB. Early intervention should be planned in these patients to prevent mortality and morbidity.

In our study, hematemesis was the most prevalent symptom of an UGIB followed by melena. Around a third of patients required blood transfusion. Alcohol intake, NSAIDs abuse, and co-morbidities such as underlying chronic liver disease, hypertension, and diabetes are statistically significantly associated with UGIB. Early upper GI endoscopy can lower the morbidity, mortality, and length of hospital stay in patients with UGIB. Thus, knowledge of etiology, risk factors, and predictors of mortality in patients with UGIB can help the ED physician control the acute bleeding and counsel the patients in taking preventive measures.

Ethics approval and consent to participation

The study was conducted after getting approval from the Institutional Ethics Committee of All India Institute of Medical Sciences, Rishikesh (Ref No.- AIIMS/ IEC/ 20/ 513).

We certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was taken from all participants of the study or if participants are under 16, from a parent or legal guardian.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declared no conflict of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors' contributions

A. R and N. K wrote the main manuscript text. H. P, I. P, Y. B, and S. J were involved in the patient care along with the critical reviewing and editing of the manuscript K. S, S. G, and S. P collected, interpreted, and statistically analyzed the data for the study. All authors reviewed the final manuscript. The author(s) read and approved the final manuscript.

Acknowledgement

It gives me great pleasure to express my gratitude to everyone who contributed to the completion of this study.

I express my gratitude to Dr. Nidhi Kaeley, Associate Professor, Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, for her intellectual mentoring, lively curiosity, clinical understanding, and constructive criticism. I finished this research because of her dedication and hard work.

Dr. V.Subramaniyam, Dr.Itish Patnaik, Dr.Yogesh Bahurupi, Dr.Bharat Bhushan Bhardwaj, Dr.Poonam Arora, Dr.Ankita Kabi, and Dr.Naman Agrawal, who gave vital advice, direction, inspiration, and encouragement to help me perform better, have my most tremendous appreciation.

I am grateful to the Almighty for providing me with the opportunity to work at the All India Institute of Medical Sciences in Rishikesh.

Author details

A. R Junior Resident, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

N. K Head of Department, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: *Correspondence: [email protected]

H. P Junior Resident, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

I. P Associate Professor, Department of Gastroenterology, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

Y. B Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

S. J Junior Resident, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

K. S Junior Resident, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

S. G Junior Resident, Department of Emergency Medicine, All India Institute of Medical Sciences Rishikesh, Rishikesh, Uttarakhand 249203, India. Email: [email protected]

S. P Assistant Professor, Department of Emergency Medicine, Nootan Medical College, Gujarat 384315, India. Email: [email protected]

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No competing interests reported.

Prospective Observational Study on Clinical and Epidemiological Profile of Adult Patients Presenting to the Emergency Department with Upper Gastrointestinal Bleed

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