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Endoskopie heute 2012; 25(3): 196-204
DOI: 10.1055/s-0032-1325412
Originalarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Behandlungsergebnisse der akuten oberen nicht varikösen gastrointestinalen Blutung in Relation zum Zeitpunkt der Endoskopie: Resultate einer landesweiten Studie

Outcomes Following Acute Nonvariceal Upper Gastrointestinal Bleeding in Relation to Time to Endoscopy: Results from a Nationwide Study
V. Jairath
1   NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
6   Translational Gastroenterology Unit, John Radcliffe hospital, Oxford, UK
,
B. C. Kahan
2   MRC Clinical Trials Unit, London, UK
3   NHS Blood and Transplant Clinical Studies Unit, Cambridge, UK
,
R. F. A. Logan
4   Division of Epidemiology and Public Health and Nottingham Digestive Disease Centre, University of Nottingham, UK
,
S. A. Hearnshaw
5   Royal Victoria Infirmary, Newcastle, UK
,
C. J. Doré
2   MRC Clinical Trials Unit, London, UK
3   NHS Blood and Transplant Clinical Studies Unit, Cambridge, UK
,
S. P. L. Travis
6   Translational Gastroenterology Unit, John Radcliffe hospital, Oxford, UK
,
M. F. Murphy
1   NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
,
K. R. Palmer
7   Western General Hospital, Edinburgh, UK
› Author Affiliations
Further Information

Publication History

Publication Date:
12 October 2012 (online)

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Zusammenfassung

Hintergrund und Studienziele: Der Nutzen der therapeutischen Endoskopie bei der nicht varikösen oberen gastrointestinalen Blutung (NVOGIB) ist unbestritten. Der optimale Zeitpunkt hingegen ist unklar. Ziel der vorliegenden Studie war die Untersuchung des Zusammenhangs zwischen Endoskopiezeitpunkt und klinischem Behandlungsergebnis bei Patienten mit NVOGIB.

Patienten und Methoden: Dieser Studie liegen prospektive Erhebungen in 212 britischen Krankenhäusern zugrunde. Mit einem Regressionsmodell wurde der Zusammenhang zwischen dem Zeitpunkt der Endoskopie (time to endoscopy) und der Mortalität einer Rezidivblutung, der Operationsnotwendigkeit und der Dauer der stationären Behandlung untersucht.

Ergebnisse: Bei 4478 Patienten war eine frühzeitige Endoskopie (< 12 Stunden) nicht mit einer geringeren Mortalität oder Operationshäufigkeit assoziiert im Vergleich zu einer späteren Endoskopie (> 12 Stunden) (Odds Ratio [OR] für die Mortalität 0,98, 95 %-Konfidenzintervall [CI] 0,88 – 1,09 für eine Endoskopie > 24 Stunden vs. < 12 Stunden, p = 0,70). Für Patienten, die eine therapeutische Endoskopie erhielten, ergab sich bei späterer Endoskopie ein Trend zu häufigerer Rezidivblutung (OR 1,13, 95 % CI 0,97 – 1,32 für Endoskopie > 24 Stunden vs. < 12 Stunden). Ein umgekehrter Trend wurde bei Patienten ohne endoskopische Behandlung beobachtet (OR 0,83, 95 % CI 0,73 – 0,95 für Endoskopie > 24 Stunden vs. < 12 Stunden, p = 0,003). Eine spätere Endoskopie (> 24 Stunden) war mit einer risikoadjustierten Erhöhung der stationären Behandlungsdauer assoziiert (1,7 Tage länger, 95 % CI 1,39 – 1,99 vs. < 12 Stunden; p < 0,001).

Schlussfolgerungen: Eine frühere Endoskopie war nicht mit einer Reduktion der Mortalität oder der Operationsnotwendigkeit assoziiert. Die Assoziation mit einer erhöhten Effizienz der Behandlung und einer potenziell verbesserten Blutungskontrolle bei Hochrisikopatienten unterstützt einen früheren Endoskopiezeitpunkt in der Routine-Praxis, wenn keine spezifischen Kontraindikationen existieren. Diese Resultate können für Diskussionen über die Organisation des Notfallendoskopiediensts hilfreich sein.

Abstract

Background and study aims: Despite the established efficacy of therapeutic endoscopy, the optimum timeframe for performing endoscopy in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) remains unclear. The aim of the current audit study was to examine the relationship between time to endoscopy and clinical outcomes in patients presenting with NVUGIB.

Patients and methods: This study was a prospective national audit performed in 212 UK hospitals. Regression models examined the relationship between time to endoscopy and mortality, rebleeding, need for surgery, and length of hospital stay.

Results: In 4478 patients, earlier endoscopy ( < 12 hours) was not associated with a lower mortality or need for surgery compared with later ( > 24 hours) endoscopy (odds ratio [OR] for mortality 0.98, 95 % confidence interval [CI] 0.88 – 1.09 for endoscopy  > 24 hours vs.  < 12 hours; p  =  0.70). In patients receiving therapeutic endoscopy, there was a nonsignificant trend towards an increase in rebleeding associated with later endoscopy (OR 1.13, 95 %CI 0.97 – 1.32 for endoscopy  > 24 hours vs.  < 12 hours), with the converse seen in patients not requiring therapeutic endoscopy (OR 0.83, 95 %CI 0.73 – 0.95 for endoscopy  > 24 hours vs. < 12 hours; interaction p  =  0.003). Later endoscopy ( > 24 hours) was associated with an increase in risk-adjusted length of hospital stay (1.7 days longer, 95 %CI 1.39 – 1.99 vs. < 12 hours; p < 0.001).

Conclusions: Earlier endoscopy was not associated with a reduction in mortality or need for surgery. However, it was associated with an increased efficiency of care and potentially improved control of hemorrhage in higher risk patients, supporting the routine use of early endoscopy unless specific contraindications exist. These results may help inform the debate about emergency endoscopy service provision.

Schlüsselwörter

obere gastrointestinale Blutung - therapeutische Endoskopie - Endoskopiebereitschaftsdienst - Rezidivblutung - Mortalität - Hospitalisierungsdauer

Key words

upper gastrointestinal Bleeding - therapeutic endoscopy - emergency endoscopy service - rebleeding - mortality - length of hospital stay
 

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