In the present study, anemia in high-risk NUGIB patients was not associated with therapeutic outcomes of endoscopic intervention in mortality, re-bleeding rates,adverse effect and days in ICU. The span of hospitalization in the severe group was significantly longer than in the moderate and mild groups (P < 0.05). In addition, anemia in high-risk NUGIB patients underwent endoscopic intervention tended to be associated with more transfusion.
Hemoglobin level has been considered as an independent factor on the outcomes of NUGIB patients [1, 8–12]. However, the impact of hemoglobin level in high-risk patients underwent endoscopic intervention has not been clarified. In the entire cohort, 56.4% (88/156) patients had hemoglobin < 7 g/L, 28.9% (45/156) between 7 ~ 9 g/dl and 14.8% (23/156) ≥ 9 g/dl before endoscopic intervention, supporting that anemia is the common symptom of high-risk NUGIB patients.
No significant difference was found in mortality, re-bleeding rates,adverse effect and days in ICU among 3 groups of high-risk NUGIB patients underwent endoscopic intervention. In our study, the baseline of each group was comparable, including age, gender, shock, location of bleeding, endoscopic treatment and GBS score with the median of 10. The mortality rate was 2%, and all three patients were in the severe group, which was comparable to the reported NUGIB mortality of about 1–5% . The re-bleeding rate (21%) was higher than in other researches (about 10%) [13, 15, 16]. This difference may be related to the higher proportion of high-risk patients with Forrest I, Forrest IIa/b and Dieulafoy patients in this study. The percentage of ICU admission in this study (13%) is similar to the results of other research (13.2%), supporting the efficacy of endoscopic intervention. Studies have shown that AIMS65, a clinical prediction factor that includes albumin, INR, mental status, systolic BP and age, but not hemoglobin level, is the best predictor for ICU admission. This may explain why there is no difference in ICU admission among the three groups. On the contrary, the median span of hospitalization in the severe group was significantly longer than in the mild group. This was acceptable since patients in the severe group need more time for comprehensive treatment and drug treatment in hospital, which are also indispensable for UGIB therapy. Overall, our results showed that anemia did not associate with the mortality and rebleeding of high-risk NUGIB patients underwent endoscopic intervention.
There is no doubt about the benefits of RBC transfusion for patients with severe UGIB improving the tissue oxygen supply in the circulation. A target threshold for red cell transfusion of 7–9 g/dl for severe UGIB patients (known as the restrictive transfusion strategy) is popularly recommended [9, 17]. In our cohort study, most patients were treated following the recommendation of restriction transfusion[4, 18], except for two older patients who were had RBC transfused at the condition of hemoglobin higher than 9 g/dL. The transfusion requirements among the mild, moderate and severe groups were statistically different and increased successively. Correlation tests showed that low hemoglobin level at administration, before intervention, and the lowest level during hospital stay were predictors for further RBC transfusion and plasma transfusion. Therefore, under the effective and safe endoscopic intervention, blood transfusion is still an indispensable strategy for high-risk patients with anemia.
Studies have shown that massive bleeding can cause the loss of a large amount of blood-clotting factor and platelets, causing the coagulation function to decrease, especially in those with an acute condition. Consistently, our studies reported that the INR and PT of severe patients were statistically higher than in mild patients. Compared with the thrombocytopenia frequently seen in populations with liver cirrhosis and hematologic malignancies, platelets in the severe group were not significantly different from the mild group, whereas platelets in the moderate group were significantly higher than in the mild group[20–22].
Our study had several limitations. First, selection bias existed in this retrospective single-center study at a tertiary academic hospital. Patients with variceal bleeding and serious comorbidities were not included in the cohort study. Therefore, the external validity of the result is limited, owing to these inclusion and exclusion criteria. Second, the interventions were all performed by experienced endoscopists in the tertiary center. Their extensive experience optimized diagnosis and treatment and reduced the rate of adverse events, which led to the excessively low mortality and complication rates in this study. Third, the sample size of this study was quite small, since severe bleeding with urgent endoscopic intervention is rare in the general population. However, in our study, characteristics, GBS score and endoscopic hemostasis of patients among 3 groups were comparable, which supported the impact of anemia as an independent factor to affect the outcomes of endoscopy. Based on our retrospective study, further prospective multicenter studies looking into the comparative outcomes of patients with severe anemia should be the next step to verify our findings and determine the appropriate hemoglobin threshold for safe and effective endoscopic procedures.