Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: A cohort study

摘要

Background & Aims: Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy. Methods: From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test. Results: In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n = 26) and 29.7% (n = 30), respectively. The overall 6-week and 3-month mortality was 31.7% (n = 32) and 38.6% (n = 39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p = 0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p = 0.028) and mortality (27% vs. 52.8%, p = 0.031) were lower in those with early (≤12 h) than delayed (>12 h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p = 0.944) and mortality (11.8% vs. 9.1%, p = 0.861). Conclusions: It is likely that early endoscopy (≤12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.