High dependency care and close monitoring with central venous pressure recording appears to have been used sparingly during the first phase of the study. No patient was admitted to the HDU/ITU after initial assessment and, overall, only 10% of the patients had achieved monitoring of central venous pressure during this phase. Twenty-four patients (42%) had been monitored by urinary output measurement. During the second phase two patients were admitted to the HDU/ITU and 6% of the patients had central venous pressure monitoring. However, 46 patients (87%) had documented urinary monitoring during this phase of the study.
The impact of management of patients with upper GI bleeding, in the HDU with agreed management protocol and close monitoring, on mortality appears to be somewhat contradictory. Masson et al reports a significantly low mortality rate when patients are cared for in dedicated units with specialized staff and close monitoring. Kapur et al, on the other hand, failed to demonstrate any reduction in mortality from upper GI hemorrhage following the introduction of HDU care and agreed protocol.
In the majority of the patients with an upper GI hemorrhage, the bleeding stops spontaneously. Patients with continued or recurrent bleeding remain a therapeutic challenge. Therapeutic endoscopy constitutes the cornerstone of modern therapy of these patients. Over half of these patients will respond to endoscopic treatment with injection, thermocoagulation or laser. Twenty of 57 patients in the first phase and 13 of 53 patients in the second phase of the study had an injection of adrenaline at endoscopy. This high incidence of injection therapy may explain the very small number of patients requiring surgery. The incidence of surgical intervention was much lower than that in the National upper GI hemorrhage audit. A total of 181 of 2332 (7.8%) in the first phase and 111 of 1625 (6.8%) in the second phase of the national audit of acute upper GI hemorrhage had surgical intervention. Liberal use of endoscopic injection therapy is known to be associated with a low operation rate. Continue reading
The agreed protocol used in the study was based on the guidelines for good practice in the management of upper GI hemorrhage recommended by the joint working group of the British Society of Gastroenterology, the Research Unit of the Royal College of Physicians of London and the Audit Unit of the Royal College of Surgeons of England. Continue reading
First phase: Two patients, both males over the age of 75 years with a risk score of more than four, required surgery. They had diagnostic and therapeutic endoscopies within 24 h of admission and were each found to have a duodenal ulcer. Both required a second therapeutic EGD for rebleed and had oversewing of the bleeding ulcer at surgery. They were admitted to the HDU. One of them had severe respiratory comorbidity and died from respiratory failure postoperatively. The second patient was successfully discharged home three weeks after surgery. Continue reading
First phase: Eighty-six percent of all patients underwent endoscopy some time during their admission. Of the eight patients who did not have an EGD, three refused endoscopic examination, two were young and stable and had a questionable diagnosis of upper GI bleed, one had EGD planned but died of a cerebrovascular accident and two had suspected Mallory-Weiss tears and no endoscopic examination was contemplated. Thirty-four (60%) patients had an EGD within 24 h and 22% had an EGD outside of normal working hours. Eleven (33%) of the high risk group failed to have an endoscopic examination within 24 h. Consultants/staff grade carried out endoscopy in 17 patients whereas in 32 patients specialist registrars performed the endoscopy. All endoscopies were performed by a surgeon. Twenty patients had therapeutic procedures at endoscopy and there were no complications from EGD. Continue reading
First phase: Fifty-seven patients had a presumptive diagnosis of upper GI hemorrhage during the study period. Their mean age was 69 years and median of 76 years, range 16 to 95 years, with a male to female ratio of 3:2.
Second phase: Fifty-two patients were admitted with a diagnosis of upper GI bleed. Their mean age was 62 years, median age 69 years and mode 81 years with a range of 15 to 92 years. Continue reading
All patients admitted with a presumptive diagnosis of upper GI hemorrhage or all patients who bled acutely from the upper GI tract while in hospital for treatment of some other condition at FPH between January and April 2000 and then between June to September 2000 were included in the study. All patients had historical and/or clinical evidence of hematemesis and/or melena. Upper GI hemorrhage has been defined in this study as vomit containing red blood (or coffee ground like material, observed by a doctor or a nurse), and/or the stool has been black or red-black confirmed by observation or rectal examination. Continue reading
Most audits of acute upper gastrointestinal (GI) hemorrhage usually involve an initial retrospective study to determine the management and outcome, followed by a prospective analysis that attempts to ascertain the impact of specific alteration in clinical practice, making comparison complex and unreliable. A prospective audit was started at Frimley Park Hospital (FPH), United Kingdom, in January 2000. Continue reading