Data of 1118 patients aged ≥18 years who visited the ER owing to UGIB for >5 years were reviewed. We excluded 213 patients from the study for the following reasons: 23 patients had non-UGIB, 155 had variceal bleeding, 15 had postprocedure-associated bleeding, and 20 had obscure GI bleeding. In total, 905 patients were selected for evaluation. Of these, 131 and 774 patients were included in the high- and low-to-moderate-risk groups, respectively (Fig 1).
Of the 905 included patients, 674 (74.5%) were men and 231 (25.5%) were women, with a mean age of 65.4±14.7 years. Upper GIT endoscopy was performed in all included patients. 710 patients (78.4%) underwent endoscopy within 12 hours during the admission in the emergency room, 160 patients (17.7%) underwent endoscopy within 12-24 hours and 35 patients (3.9%) underwent endoscopy after 48 hours. There were 35 patients who did not undergo endoscopy within 48 h of the first visit; most endoscopy procedures were performed after intensive care unit (ICU) hospitalization due to unstable vital signs. Among the total patients who underwent endoscopy, 735 received endoscopic hemostasis therapy; of these, patients underwent surgery (n=11), trans-arterial embolization due to failure of the endoscopic treatment (n=32), or both (n=2). Among the patients who received endoscopic hemostasis, 128 had re-bleeding during the second endoscopy. Emergency endoscopic procedures were performed in most cases where patients had rebleeding during hospitalization and rebleeding after discharge. Thus, urgent endoscopic procedures within 12 hours were performed in patients with rebleeding, and the mean average endoscopy timing in relation to rebleeding is 2.75 hours.
Calculation of pre-RS, GBS, AIMS65, PNED, and INBS was possible in all cases. Table 2 shows the patients’ characteristics, chief complaint at first visit, treatment, and outcomes. The comorbidity scores were classified as ASA scores. The commonest endoscopic diagnosis was GU (67.8%), and the second commonest was DU (19.3%). There were 467 (51.6%) patients admitted to the hospital within 8 hours. The average length of hospital stay for all patients was approximately 8.7 days. Among the 905 enrolled patients, only 31 patients (3.4%) were hospitalized for >30 days A total of 44 patients (4.9%) died within 30 days in hospital. A total of 44 patients died in the hospital within 30 days. Of these, 14 had a direct association with non-variceal upper gastrointestinal bleeding, 12 died of heart failure, 11 of septic shock, 4 of liver failure, 2 of cerebral infarction, and 1 of cerebral hemorrhage. The mean INBS scores in the mortality and survivor groups were 8.38 ±3.12 and 3.86±2.56 (P value=0.027), respectively.
Comparison of bleeding scores’ discriminative ability to predict the 30-day mortality
In this study, INBS had the highest discriminative ability (area under the receiver operating characteristic (AUROC) curve 0.958 [95% confidence interval (CI), 0.943-0.970]) in predicting mortality within 30 days compared with the AIMS65 (0.832; P <0.001), PNED score (0.865; P <0.001), Pre-RS (0.802; P<0.001), and GBS (0.765; P <0.001). The cut-off score was >7 with a sensitivity of 97.73% and a specificity of 89.79% (Table 3 and Fig 2). Table 4 shows the discriminative ability of the evaluated scoring systems to predict length of hospital stay, rebleeding, and endoscopic hemostasis failure.
The cut-off value was used to divide the patients into the high- and low-to-moderate-risk groups. A total of 131 patients (14.5%) were in the high-risk group; of these, 43 (32%) died within 30 days. The low-to-moderate-risk group comprised 774 patients (85.5%).
Multivariate analysis for 30-day mortality
On the basis of the risk factors mentioned in the scoring system for UGIB patients, we performed logistic regression to identify predictors associated with mortality in patients who visited our hospital. In the univariate regression analysis, the variables that were meaningful were male sex, old age, smoking, ASA score of 4, hypertension, acute respiratory distress syndrome (ARDS), disseminated malignancy, liver cirrhosis, sepsis, disseminated intravascular coagulation, systolic blood pressure, heart rate, hemoglobin, platelet count, blood urea nitrogen (BUN), creatinine, international normalized ratio, syncope at first visit, endoscopic failure at first admission in 48 hours, endoscopic hemostasis failure, and re-bleeding at the second endoscopy. Multivariate regression analysis was performed with the abovementioned variables that were significant in the univariate regression analysis (Table 5). Hypertension and systolic blood pressure could be duplicated, and only one was added. The multivariate analysis revealed that an ASA score of 4, ARDS, disseminated malignancy, creatinine, albumin, syncope at first visit, and endoscopic failure within 24 hours during the first admission were associated with 30-day mortality.
Re-bleeding and length of hospital stay in the high-risk group
An INBS cut-off value >7 was used to categorize patients into the high-score group (131 patients, 14.4%) and low-score group (774 patients, 85.5%). The high-score group had a relatively longer length of hospital stay and higher re-bleeding and endoscopic hemostasis failure rates than the low-score group (Table 6).