Objective: Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant. Inadequate early resuscitation is believed to be a major factor in the persistently high mortality rate in patients with UGIB. In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study.
Methods: A consecutive series of patients with UGIB complicated by hemodynamic instability related to bleeding were enrolled in the study. An initial cohort of patients (Observation Group) was followed by a team of physicians to collect data. After recording demographic information, the time interval between presentation with UGIB and the correction of hemodynamic instability, hematocrit (HCT), and coagulopathy was prospectively recorded. Medical treatment, endoscopic intervention, and subsequent outcome were also prospectively recorded. A subsequent cohort of patients (Intensive Resuscitation Group) was then prospectively followed and similar demographic and outcome data were collected. However, in this cohort, the physicians involved in collecting the data also provided guidance to the health care team managing the patients. The goal for this group of patients was to allow a more rapid correction of hemodynamic instability, HCT, coagulopathy, and medical/endoscopic intervention.
Results: Seventy-two patients were included in the study, 36 males, 36 females, mean age 70 yr (range 21-94). Thirty-six patients were followed in the Observational Group, and 36 in the Intensive Resuscitation Group. There were no significant differences with regard to age, gender, number and type of comorbid diseases, history of prior gastrointestinal bleeding, or etiology of bleeding between the two groups. Patients treated in the Intensive Resuscitation Group had a significant decrease in the time interval from admission to the stabilization of hemodynamics and the correction of HCT. There were no significant differences in the time interval from admission to endoscopic intervention, length-of-stay (LOS), or the number of units of blood given. Fewer patients in the Intensive Resuscitation Group suffered myocardial infarction (p= 0.04). Mortality was lower in the Intensive Resuscitation Group (one death) compared to the Observational Group (four deaths), (p= 0.04).
Conclusion: Early intensive resuscitation of patients with upper gastrointestinal bleeding significantly decreases mortality. Physicians involved in the care of patients with UGIB should focus on early and rapid correction of hemodynamics, HCT, and underlying coagulopathy.