Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results of a Nationwide Inquiry in Hungary

Hindawi Publishing Co po a ion Gas oen e ology Resea ch and P ac ice Volume 2012, A icle ID 956434, 6pages doi:10.1155/2012/956434 Resea ch A icle Managemen o Pep ic Ulce Bleeding in Di e en Case Volume Wo kplaces: Resul s o a Na ionwide Inqui y in Hunga y Is ´ an R´ acz,1Tibo K´ a ´ asz,1K isz ina Luk´ acs,2Fe enc R´ acz,3J´ anos Ke s´ ak,4Judi Wacha,5 Tibo Szal ´ oki,6Magdolna Sz´ asz,6Is ´ an Gyenes,7and Is ´ an Al o jay2 1Di ision o Gas oen e ology, Depa men o In e nal Medicine, Pe z Alad´ a Coun y and Teaching Hospi al, Gy˝ o 9024, Hunga y 2Depa men o Gas oen e ology, School o Medicine, Deb ecen Uni e si y, Deb ecen 4032, Hunga y 3Depa men o In e nal Medicine, J´ osa And ´ as Coun y Hospi al, Ny´ ı egyh´ aza 4400, Hunga y 4Depa men o In e nal Medicine, Municipal Hospi al, Si´ o ok 8600, Hunga y 5Depa men o Su ge y, Semmelweis Uni e si y, Budapes 1083, Hunga y 6Depa men o In e nal Medicine, J´ a o szky ¨ Od¨ on Municipal Hospi al, V´ ac 2600, Hunga y 7Depa men o In e nal Medicine, Ken´ ezy Gyula Coun y Hospi al, Deb ecen 4031, Hunga y Co espondence should be add essed o Is ´ an R´ acz, [email p o ec ed]yo .hu Recei ed 6 June 2012; Re ised 30 July 2012; Accep ed 30 July 2012 Academic Edi o : Cha les Melbe n Wilcox Copy igh © 2012 Is ´ an R´ acz e al. This is an open access a icle dis ibu ed unde he C ea i e Commons A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. The aim o his s udy was o conduc a na ional su ey o e alua e he ecen endoscopic ea men and d ug he apy o pep ic ulce bleeding (PUB) pa ien s and o compa e p ac ices in high and low case olume Hunga ian wo kplaces. A o al o 62 gas oen e ology uni s pa icipa ed in he six-mon h s udy. A o al o 3033 PUB cases and a mean o 8.15 ±3.9PUBcasespe mon h pe uni we e epo ed. In he 23 high case olume uni s (HCV), he e was a mean o 12.9±5.4 PUB cases/mon h, whe eas in he 39 low case olume uni s (LCV), a mean o 5.3±2.9 PUB cases/mon h we e ea ed du ing he s udy pe iod. In HCV uni s, endoscopic he apies o Fo es Ia, Ib, and IIa ulce s we e signi ican ly mo e o en used han in LCV uni s (86% e sus 68%; P=0.001). Among pa ien s wi h s igma a o ecen haemo hage (Fo es I, II), bolus + con inuous in usion PPI was gi en signi ican ly mo e equen ly in HCV han in LCV uni s (49.6% e sus 33.2%; P=0.001). Mo ali y in HCV uni s was less han in LCV uni s (2.7% e sus 4.3%; P=0.023). The pene a ion o e idence-based ecommenda ions o PUB managemen is s onge in HCV uni s esul ing lowe mo ali y. 1. In oduc ion Acu e uppe gas oin es inal bleeding (UGIB) is a common medical eme gency si ua ion. Pep ic ulce bleeding (PUB) is esponsible o almos hal o he cases o UGIB [1,2]. Despi e ad ances in diagnosis and ea men du ing he ecen yea s, ebleeding occu s in abou 10–30% a e p i- ma y haemos asis, and he mo ali y is s ill a ound 5–10% [1–5]. The app op ia e managemen o pa ien s wi h acu e gas oduodenal ulce bleeding has been es ablished o e he las wo decades in a numbe o andomised con olled ials and in se e al guidelines [6–13]. Recommenda ions o he managemen o PUB we e also published in Hunga y [14]. The mos impo an elemen s o hese ecommenda ions we e o o ganize and main ain a 24-hou eme gency endoscopy se ices o UGIB pa ien s, o use he Fo es clas- si ica on o PUB pa ien s, endoscopic haemos a ic he apy p e e ably wi h a combined me hods obliga o y in cases wi h ac i e bleeding, and s ongly ecommended in ulce cases wi h isible essels and also wi h adhe en clo s. Acid-sup- p essan he apy was ecommended by i. . p o on-pump inhibi o s ollowing endoscopic haemos asis o 72 hou s in ulce cases wi h s igma a o ecen haemo hage. The p ima y aims o ou wo k we e o conduc a na ional su ey o e alua e he use o ecommenda ions and guide- lines in he daily ou ine managemen o PUB and also o compa e p ac ices and pa ien ou come da a in high and low case olume wo kplaces. 2Gas oen e ology Resea ch and P ac ice Table 1: Main poin s o he ques ionnai e o uppe GI bleede s in Hunga y. (1) S uc u al and ac i i y da a (i) P ac ice o ca e (a) Gas oen e ology uni (b) Su gical uni (c) Numbe o endoscopies s doing eme gency endoscopy (ii) Numbe o bleede s pe mon h (a) UGIB cases pe mon h (b) PUB cases pe mon h (2) Eme gency endoscopy indings (i) Sou ce o bleeding (ii) Numbe o ulce s and cha ac e is ics acco ding o he Fo es classi ica ion (3) Endoscopic haemos a ic he apy (i) Indica ion o endoscopic he apy (ii) Me hod o haemos a ic he apy in diffe en Fo es classes (a) Injec ion, subs ance o injec ion, mono; o in combina ion (b) The mal (c) Clip (d) Combina ion he apy; componen s o combina ion (4) Acid-supp essan he apy in diffe en Fo es classes (i) Subs ance o acid supp ession; i. . PPI o i. . H2RA (ii) Me hod o i. . PPI (a) S anda d PPI dosage (b) Bolus + PPI in usion (5) Pa ien ou come da a (i) Rebleeding a e (ii) Need o su ge y (iii) Bleeding- ela ed mo ali y 2. Ma e ial and Me hods The su ey was designed o e alua e he diffe en s eps o he managemen p ocedu e o PUB. Addi ionally, some basic pa ien ou come da a we e also collec ed (Table 1). A da abase o all Hunga ian gas oen e ology depa - men s pe o ming endoscopy and ea ing acu e GI bleeding was a ailable on he basis o he add ess lis o he Endoscopy sec ion o he Hunga ian Socie y o Gas oen e ology. The ques ionnai es we e dis ibu ed and collec ed mon hly by specially ained esea ch assis an s in hose 62 gas oen e o- logical wo kplaces (GI uni s) ha esponded posi i ely o pa icipa e in he s udy. These 62 GI uni s om 39 ci ies accoun o 71% o he GI wo kplaces exis ing in Hunga y. To ensu e he alidi y o he collec ed da a, he esea ch assis an s wi h he pa icipa ion o he local s udy coo - dina o endoscopis s e iewed and moni o ed each mon h all endoscopy epo s and pa ien iles o he endoscopy uni s sea ching o all documen ed da a o UGIB pa ien s. The aim o his igo ous da a moni o ing p o ocol was o collec easonably high-quali y da a o cu en p ac ices. All da a we e en e ed elec onically and downloaded in o a cen al eposi o y on a mon hly basis. In Hunga y, only gas oen e ologis s o su geons, when hey ha e aken a leas a wo-yea endoscopy aining cou se, may pe o m uppe o lowe endoscopy. 2.1. S a is ical Analysis. Da a we e collec ed and analysed using he s a is ical package SPSS e sion 11.0 (SPSS In. Chicago, IL, USA). Desc ip i e s a is ics we e used o analyse and epo he da a. The chi-squa ed and he Fishe es s we e used o de e mine diffe ences be ween low and high case olume GI uni s and also o he analysis o wo and mul i- dimensional con ingency ables. Mul iple logis ic eg ession was applied o e alua e he independen ela ions o selec ed ac o s o he use o combined haemos a ic me hods ol- lowed by bolus plus con inuous in usion o PPI. The signi i- cance h eshold was se a P<0.05. 3. Resul s 3.1. Gene al Da a and Case Volume Diffe ences. A o al o 62 GI uni s p o ided da a by comple ing he ques ionnai es in a six-mon h pe iod du ing 2009 and 2010. A 24-hou eme gency endoscopy se ice was gua an eed in 90% (n= 54) o he wo kplaces, and specialised endoscopy nu ses we e a ailable in 85% (n=51) o 24 hou s. A o al o 6,473 acu e uppe GI bleedings including 3,033 (46.9%) PUB cases we e epo ed. O he esponded PUB cases, 89.2% we e managed by gas oen e ologis s and 10.8% by su geons. Ameano 17.4±8.2UGIBand8.15 ±3.9 PUB cases pe mon h pe uni we e epo ed, espec i ely. The e we e 23 uni s ha epo ed mo e han 8.15 PUB cases pe mon h, and he emaining 39 uni s had ewe PUB cases mon hly han his mean. This selec ion offe ed he possibili y o di ide he epo ing GI uni s in o high case olume (HCV) and low case olume (LCV) uni s acco ding o he mon hly mean o ulce bleede s o which hey ook ca e. In he 23 HCV uni s, a o al o 1,789 PUB cases (mean 12.9±5.4 cases/mon h), whe eas in he 39 LCV uni s, a o al o 1,244 PUB cases (mean: 5.3±2.9 cases/mon h) we e managed du ing he s udy pe iod. These da a e lec ha he HCV uni s had mo e han wice as many PUB cases and expe iences pe mon h compa ed o he LCV wo kplaces. The Fo es classi ica ion was uni o mly used bo h in HCV and LCV uni s. The p opo ion o eme gency endo- scopy indings acco ding o he Fo es classi ica ion we e simila compa ing esul s ob ained om HCV and LCV wo kplaces (Figu e 1). The a io o high- isk lesion bleede s (Fo es Ia-IIa) was also simila (n=717; 40%) in HCV and LCV (n=479; 38.5%) uni s. 3.2. Endoscopic Haemos a ic The apy. Endoscopic haemo- s a ic he apy was gi en o ulce s wi h spu ing bleeding (Fo es Ia), oozing bleeding (Ib), nonbleeding isible essels (IIa), adhe en clo (IIb), black haema in-co e ed ulce base (IIc), and clean ulce base (III) in, espec i ely, 94%, 83%, 69%, 43%, 15%, and 4% o all esponded PUB cases. In HCV uni s, endoscopic he apy was signi ican ly mo e o en used in Fo es Ia, Ib and Fo es IIa cases (n=613; 85.4%) com- pa ed wi h simila Fo es g ade cases in LCV uni s (n=327; 68.2%) (Table 2). The mos equen ly used haemos a ic ea men modal- i y ei he in mono o in combina ion was injec ion wi h dilu ed (1 : 10.000) epineph ine (n=1108; 92.6%). As Gas oen e ology Resea ch and P ac ice 3 0 5 10 15 20 25 30 (%) Fo es Ia Fo es Ib Fo es IIa Fo es IIb Fo es IIc Fo es III HCV uni s LCV uni s 15.7% 24.7% 14% 25.1% 22.2% 19.3% 16.5% 16.6% 17.5% 17.3% 6.3% 4.8% Figu e 1: P opo ion o bleeding ulce s acco ding o Fo es classi ica ion in high case olume (HCV) and low case olume (LCV) uni s. Table 2: Compa ison o selec ed i ems in high and low case olume uni s. HCV uni s (n=23) LCV uni s (n=39) P alue Numbe o PUB cases 1789 1244 no applicable Mean numbe o PUB cases/endoscopis s/mon h 3.2 ±1.1 2.4 ±0.9 ns I em %(n)%(n) Endoscopic haemos a ic ea men In Fo es Ia, Ib, and IIa 86 (613) 68 (327) 0.001 In Fo es IIb 45 (154) 39 (97) 0.015 Endoscopic ea men modali y in Fo es Ia, Ib, and IIa Injec ion mono he apy 46 (285) 65 (311) 0.001 Haemoclip o he mocoagula ion mono he apy 20 (121) 16 (51) 0.002 Combina ion 34 (207) 19 (61) 0.001 Acid-supp essan he apy a e endoscopy wi h i. . PPI O e all 79 (1413) 81 (1002) 0.490 In pa ien s wi h Fo es I-II Wi h s anda d dosages 28 (494) 48 (601) 0.001 Wi h bolus + con inuous PPI 50 (888) 33 (415) 0.001 Rebleeding a e 10.1 (179) 9.5 (118) 0.680 Need o su ge y 5.1 (92) 6.4 (79) 0.181 Mo ali y O e all 2.7 (48) 4.3 (53) 0.023 In Fo es Ia, Ib 6.8 (29) 7.6 (21) 0.791 a combina ion ea men gene ally, injec ion and haemoclips o injec ion and coagula ion we e combined. Fo high- isk ulce s (Fo es Ia, Ib, IIa), he combined haemos a ic a emp s we e signi ican ly mo e equen ly used in HCV han in LCV uni s (n=207; 34% e sus n=61; 19%; P<0.01), whe eas he opposi e esul was de ec ed ega ding injec ion mono he apies, which we e signi ican ly mo e o enusedinLCV haninHCVuni s(n=311; 65% e sus n=285; 46%; P<0.001) (Table 2). 3.3. Acid-Supp essan The apy. In ou ques ionnai e we asked only o he pos endoscopy acid-supp essi e d ugs because he p eendoscopy i. . PPI ea men policy was no ye es ablished a he ime o he su ey. 4Gas oen e ology Resea ch and P ac ice Table 3: Mul iple logis ic eg ession module o selec ed ac o s o he use o combined haemos a ic me hods ollowed by bolus plus con inuous in usion o PPI in high- isk ulce pa ien s. Odds a io P alue 95% CI 24-hou eme gency endoscopy se ice a ailable 0.82 0.738 0.92–1.12 Gas oen e ology e sus su gical uni 0.99 0.767 0.96–1.03 Uni e si y e sus municipal hospi al 0.73 0.684 0.13–2.82 Mean numbe o endoscopies s pe uni doing eme gency endoscopy, <3 e sus≥3 2.28 0.078 0.91–5.76 Mean numbe o UGIB cases pe mon h, <8.15 e sus ≥8.15 5.48 0.012 1.88–18.42 Acid-supp essi e d ugs ollowing he endoscopy we e adminis e ed in a enously (i. .) in he majo i y o PUB cases (n=2516; 83.0%), mos ly using PPI (n=2425; 79.9%) and only seldomly using H2- ecep o an agonis s (n=91; 3.0%). In less han hal o all PUB cases (n=1095; 45.2%), i. . PPI was gi en in s anda d dosages wice o h ee imes daily, whe eas bolus PPI ollowed by a con inuous in usion o 8 mg PPI pe hou was used sligh ly mo e o en (n=1301; 53.6%). Among pa ien s wi h s igma a o ecen haemo hage (Fo es I-II), bolus + con inuous in usion PPI was gi en signi ican ly mo e equen ly in HCV han in LCV uni s (n=888; 49.6% e sus n=413; 33.2%; P<0.001) (Table 2). Acco ding o mul i a ia e analysis, he mon hly PUB case olume o uni s was he only signi ican p edic o ac o o he use o bes e idence combined endoscopic haemos asis ollowed by bolus plus in usion PPI in high- isk ulce s (Table 3). 3.4. Clinical Ou come. O e all ebleeding a es we e compa- able in HCV (n=179; 10.1%) and in LCV (n=118; 9.5%) uni s. Also ebleeding a es in high- isk ulce s (Fo es Ia-IIa) we e simila in HCV (n=141; 19.7%) and in LCV (n=63; 19%) uni s. Because o pe sis en bleeding o endoscopically un ea - able se e e ebleeding, su ge y was needed sligh ly mo e e- quen ly in LCV (n=79; 6.4%) han in HCV (n=92; 5.1%) uni s. In cases wi h endoscopically un ea able spu ing bleedings, an immedia e su ge y was signi icanly (P<0.05) mo e o en wa an ed in LCV (n=29; 49.2%) compa ed o HCV (n=36; 32.1%) uni s. The bleeding- ela ed mo ali y a e o all PUB pa ien s was 3.3% (n=101). Mo ali y in HCV uni s (n=48; 2.7%) was signi ican ly (P=0.023) less han he mo ali y in LCV uni s (n=53; 4.3%). Those pa ien s wi h ini ial spu ing (Fo es Ia) and oozing (Fo es Ib) bleedings had highe mo ali y a e (n=21; 7.6%) in he LCV han in HCV uni s (n=29; 6.8%), bu his diffe ence was no signi ican (Table 2). 4. Discussion This is he i s clinical inqui y conduc ed in Hunga y illus- a ing he daily ou ine endoscopic and pha macological managemen o PUB. Simila su eys we e pe o med p e- iously in he Ne he lands, F ance, and ecen ly in Ge many wi h he esponse a es o 73%, 34%, and 49%, espec i ely, posi ioning ou su ey wi h a 71% esponse a e in be ween hese o he su eys [15–17]. In he p esen s udy, unlike he p e ious su eys, epi- demiological and p ac ice diffe ences o high case olume and low case olume uni s we e compa ed as a p ima y aim. Ne e heless, he high and low olumes o endoscopy uni s we e no a p io i and nume ically de ined in he ques ion- nai es bu jus based on he collec ed da a e lec ing mean numbe o PUB cases pe mon h pe uni s. This compa ison was a ional because in HCV uni s, mo e han wice as many PUB cases pe mon h we e ea ed compa ed o he LCV uni s; one may suspec ha he diffe ing olumes would al e he daily p ac ices. In ou s udy, en i ely eme gency o ea ly endoscopy cases wi h endoscopic p ocedu es wi hin he i s 24 hou s a e he admissions we e epo ed [18]. The Fo es classi ica ion is he mos equen ly used bleeding ulce classi ica ion sys em wo ldwide [19,20]. The Fo es classi ica ion was used in 100% o he epo ed cases, bo h in HCV and LCV uni s. This inqui y shows a s ong simila i y in he p opo ion o ulce s acco ding o he Fo es g ades when compa ing he da a o HCV and LCV uni s. Ulce s wi h ac i e bleeding (Fo es Ia, Ib) occu ed in 23.8% in HCV uni s and in 22.1% in LCV uni s, whe eas he p opo ion o ulce s wi h nonbleeding isible essels (Fo es IIa) we e almos iden ical (16.5% e sus 16.6%). P e ious guidelines and con e ence epo s ecom- mended ha all ulce s classi ied as Fo es Ia–IIb should be ea ed endoscopically [5,14,21]. A new me a-analysis by Laine and McQuaid e ised he indica ion o endoscopic he apy in hose Fo es IIb lesions wi h clo s ha esis ig- o ous insing [22]. By he modi ied ecommenda ion, only pa ien s wi h se e e como bidi ies should ecei e endoscopic he apy, and PPI he apy may be sufficien . In ou su ey, ac i ely bleeding ulce s and ulce s wi h nonbleeding isible essels we e ea ed endoscopically wi h a su p isingly low equency in LCV uni s because oughly one hi d o hese cases we e le un ea ed. Al hough hese esul s a e no much in e io o he F ance su ey da a [16], whe e Fo es IIa pa ien s we e endoscopically ea ed in 79%, we may d aw he conclusion ha mainly in LCV uni s ei he he echnical acili ies o he pene a ion o cu en guidelines a e subop imal. The combina ion o haemos a ic me hods was used a he seldomly (34%) e en in HCV uni s in ou su ey. Despi e he ac ha combina ion haemos a ic he apy was Gas oen e ology Resea ch and P ac ice 5 used signi ican ly mo e o en in HCV uni s han in LCV uni s, one should conclude ha o closing in e na ional s anda ds, he combined haemos a ic me hods should be mo e p omo ed and also esou ced [23]. Acco ding o cu en guidelines, in a enous bolus ol- lowed by con inuous-in usion PPI should be used in pa ien s wi h s igma a ha ing unde gone success ul endoscopic he - apy [5,24,25]. Howe e , only 80% o he PUB cases we e ea ed by i. . PPI in ou su ey, which is a lowe alue compa ed o any o he na ional inqui y on he same opic. Mo eo e , he bes e idence 72-hou PPI adminis a ion policy [12,13,26] was ollowed in less han e e y o he pa ien in bo h ypes o uni s. This de ici o a PPI ea men policy in ou s udy may e lec he a i ude o mo e ocus on endoscopic he apy and less in e es in medical ea men in he managemen o PUB pa ien s. When compa ing HCV and LCV uni s, signi ican di - e ences exis ed in some i ems o PUB managemen . In pa icula , haemos a ic he apy wi h combina ion and PPI ea men by con inuous in usion we e used mo e equen ly in hose uni s wi h mo e PUB cases. Mul i a ia e analysis showed ha he only signi ican p edic o ac o o he use o hese e idence-based s anda ds o ca e was he mon hly PUB case olume in he uni s. Some o hese diffe ences may be explained by poo e aining o by less expe ience in lowe case wo kplaces. Addi ionally, ce ain anomalies could be explained by he lack o inancial esou ces in low case uni s, which mos ly exis in smalle hospi als. I is impo an o no e ha he inancial eimbu semen o haemos a ic endoscopy has been a he low and inbal- anced up o ecen ly in Hunga y which may be one o he easons why in smalle hospi als he adhe ence o guidelines we e subop imal. The main clinical ou come measu es ega ding he whole PUB coho o his su ey a e compa able o p e iously published la ge da abases [2,27,28]. In pa allel wi h he end ha HCV uni s we e close o he bes clinical p ac ice consequences was seen on majo clinical ou comes. Al hough ebleeding a es and he need o su ge y we e simila in he wo uni s ypes, a signi ican ly lowe mo ali y a e was seen in HCV uni s compa ed o ha in LCV uni s. Conside ing hese da a, he ques ion a ises whe he i is easonable o manage PUB pa ien s in LCV uni s o o cen alize eme gencies in HCV uni s is app op ia e o many aspec s like be e offe o expe ienced endoscopies s and op imal u iliza ion o inancial sou ces a e a ailable. Ou s udy has some limi a ions simila ly o o he su eys dealing wi h PUB managemen in he daily ou ine. I is unce ain how has he egis a ion in luenced he esul s, and also he e is no da a whe he he egis a ion pe se inc eased compliance wi h he guidelines. Al hough he inhe en limi a ions o he su ey, he compa ison o diffe en case olume wo kplaces adds some new knowledge. In conclusion, ou hypo hesis ha PUB case olumes ha e an effec on managing s anda ds was mos ly con i med. Pene a ion o na ional ecommenda ion and in e na ional guidelines is s onge in HCV uni s han in LCV uni s. Lowe mo ali y o PUB pa ien s in HCV uni s migh be associa ed wi h be e s anda ds o ca e in hose uni s. The esul s o his s udy could mo i a e medical socie ies and au ho i ies o discuss whe he PUB managemen needs u he quali y assu ance effo s and be e esou ces o imp o e daily p ac ices. Re e ences [1] L. E. Ta gownik and A. 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