| Background and ObjectionAcute upper gastrointestinal hemorrhage is a common acute disease,with a total mortality rate of 5-14%.The main cause of acute upper gastrointestinal bleeding is peptic ulcer bleeding,accounting for 31-67%.The recurrent hemorrhage rate of peptic ulcer hemorrhage was 13.9%within 7 days,and the mortality rate was 8.6%in 30 days.At present,most domestic and foreign guidelines recommend Forrest classification to describe and evaluate the hemorrhage risk of peptic ulcer hemorrhage.Forrest classification has more than 40 years of history,which is defined as follows:spurting hemorrhage(FIa),oozing hemorrhage(FⅠb),nonbleeding visible vessel(FⅡa),an adherent clot(FⅡb),flat pigmented spot(FⅡc),and clean base ulcer(FⅢ).And the risk of re-bleeding decreased.Nowadays,the treatment of patients with nonbleeding adherent clots on ulcers is controversial.The current guidelines recommends that peptic ulcers with an adherent clot be considered for endoscopic clot removal.Once the clot is removed,any identified underlying active bleeding or nonbleeding visible vessel should receive endoscopic hemostasis.But it is weak recommendation and moderate quality evidence.And the risk of recurrent ulcer hemorrhage is high,the further bleeding rate of F Ⅱ b ulcer is 22%.Despite successful hemostasis,some patients were re-bleeding,the rate of further bleeding is 10-30%.Further bleeding is an independent risk factor for mortality.It is very important to analyze the risk factors for re-bleeding."Weekend effect" refers to increased mortality in patients presenting to hospital at weekends or holiday.Whether there is a "weekend effect" in patients with acute upper gastrointestinal bleeding is controversial.There are several reasons for this phenomenon,such as lower staffing levels,less senior staff,and a lower likelihood that invasive procedures will be undertaken at weekends.Other studies suggested that patients presenting in weekend may be more critically ill than those presenting during the weekdaysThe purposes of this study were:(1)compare medical with endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clots,and(2)analysis of factors that influenced re-bleeding before discharge,and(3)to test the hypothesis that weekend presentation affected outcomes in patients with adherent clots.MethodMedical records of consecutive patients,seen from April 2012 to April 2017,with acute ulcer hemorrhage and adherent clots were retrospectively collected.(1)The decision for endoscopic therapy or medical therapy was left to the discretion of the endoscopists.The patients were divided into the medical treatment group and the endoscopic treatment group.(2)According to whether there was re-bleeding before discharged,the patients were divided into re-bleeding group and no re-bleeding group,and the influence of different factors on re-hemorrhage was discussed.(3)According to the day of presentation,the patients were divided into the weekend group and the weekday group.All statistical analyses were performed using SPSS 22.0 software,a two-tailed p value of<0.05 was considered statistically significant.Result1.The medical therapy compare with endoscopic therapy to prevent recurrent ulcer hemorrhage in patients with adherent clotsDuring the 5-year study period,149 patients with non-bleeding adherent clots were included.Among these 149 patients,81 had medical therapy alone and 68 were managed with endoscopic therapy.The level of blood urea nitrogen in the medical treatment group was higher(14.58mmol/L vs.10.99mmol/L,P=0.012).The remaining basic characteristics did not differ significantly between the two groups.Recurrence of bleeding within 72 hours of endoscopy was significantly less frequent in the endoscopic therapy group than the medical therapy group,but the differences was not statistically significant(7.4%vs.13.6%,P=0.221).Before discharge,the re-bleeding rate of medical treatment group was 17.3%,and the re-bleeding rate of the endoscopic treatment group was 16.2%,but the difference was not statistically significant(P=0.857).The need for ulcer surgery or transcatheter arterial embolization,the mortality rates the length of hospital stay,expenses and the number of blood transfusions after endoscopy were similar in the endoscopic therapy and medical therapy.In our study,there were five endoscopic hemostasis methods,respectively,injection method,thermal method,mechanical method,combination method,spraying method.There was no significant difference in re-bleeding rate between the five treatment methods within 72h after endoscopy(P>0.05).Similarly,there was no statistically significant difference in re-bleeding rate between these endoscopic hemostasis methods during hospitalization(P>0.05).2.Risk Factors Associated with Re-bleeding in Patients with adherent clots.During the 5-year study period,149 patients with non-bleeding adherent clots were included.Among these 149 patients,re-bleeding occurred in 25(16.8%)patients in the duration of hospital stay.These patients were divided into re-bleeding group and no re-bleeding group.Univariate analysis identified age,serum creatinine,and albumin<35g/L and hemoglobin as variables that were associated with risk of recurrent hemorrhage.Multivariate logistic regression analysis identified age more than 55 years old as variables that was associated independently with an increased risk of recurrent hemorrhage(OR:13.36:95%CI[1.64-108.81],P=0.015,).3.Evaluating the "weekend effect" on outcomes in patients with adherent clotsData was obtained from Nanfang hospital from April 2012 to April 2012.A total of 178 patients with adherent clot,of these,56 patients were excluded,leaving 122 patients for the analyses.Among these 122 patients,36 patients were presented at weekend or holiday(weekend group),the others were presented at weekday(weekday group).The proportion of duodenal ulcer in weekday group was significantly higher than that in the weekend group(80.2%vs.52.8%,P=0.002).The two groups were also significantly different in the treatment options.Only 27.8%of the patients in the weekend group chose the combined endoscopic treatment,significantly lower than the weekday group(27.8%vs.50.0%,P=0.024).There was no difference in other clinical features.Mortality before discharge remained significantly higher for patients admitted with adherent clots at weekends,although the difference was not statistically significant(2.8%vs.1.2%,P=0.505).During the hospitalization,the re-bleeding rate of patients in the weekend group was 16.7%,and the re-bleeding rate of the weekday group was 12.8%.The difference between the two groups was not statistically significant(P=0.573).There was no statistical difference between the weekend group and the weekday group in terms of length of hospitalization,the need for ulcer surgery or transcatheter arterial embolization,expenses and the number of blood transfusions after endoscopy.Conclusion1.Compare with medical therapy,patients with nonbleeding adherent clots on ulcers treated with endoscopic therapy does not reduce the risk of re-bleeding.In conclusion,our results suggest that the medical therapy has efficacy comparable to that of endoscopic therapy for preventing recurrent bleeding in patients with adherent clots in the ulcer base.2.The need for ulcer surgery or transcatheter arterial embolization,the mortality rates the length of hospital stay,expenses and the number of blood transfusions after endoscopy were similar in the endoscopic therapy and medical therapy.Therefore,medical therapy can be a valid alternative to endoscopic therapy.3.Univariate analysis identified age>55 years as variables that was significantly associated with an increased risk of recurrent hemorrhage before discharge.Whereas,inpatient at the onset of bleeding,and the serum albumin less than 35g/L wasn’t associated with the risk of re-bleeding.4.There was no association between weekend admission and mortality among patients with adherent clots.Weekend admission does not effect the risk of re-bleeding,the rate of surgery or transcatheter arterial embolization,the length of hospital stay,expenses and the number of blood transfusions after endoscopy.Therefore,there’s no "weekend effect" in the patients with adherent clots. |
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