Active Bleeding, Bleeding Peptic Ulcer, Gastrointestinal Bleeding
Conditions
Keywords
Glasgow-Blatchford score, Gastrointestinal bleeding
Brief summary
Acute upper gastrointestinal bleeding (UGIB) is one of the commonest medical emergencies. The condition accounts for 150 per 100,000 populations. A National United Kingdom reported a crude overall mortality rate of 10%. While bleeding stops spontaneously in majority of patients at their presentation, there remains a subgroup of patients who continue to bleed or develop recurrent bleeding. In these patients, the mortality increases manifolds. If these high-risk patients can be identified, early interventions may improve their outcomes. Several prognostic indices are in use for the purpose of patient stratification. They include the Rockall, Glasgow-Blatchford (GBS) and the Baylor scores. The Rockall score is a composite score which incorporates clinical parameters as well as findings during endoscopy which was derived to predict mortality. The GBS is a pre-endoscopy or a clinical score for the prediction for the need of further intervention loosely defined as the need for transfusion, endoscopy or surgery. It has been shown to be accurate in identifying low risk patients for early discharge.
Detailed description
The GBS, being a pre-endoscopy score with clinical parameters, is more suitable for patient triage leading to urgent endoscopy and a higher level of care. A GBS of 0 has been shown to identify patients with upper gastrointestinal bleeding who may be managed safely as outpatients. The proportion of patients requiring endoscopic therapy increases with a higher score. A cut-off score that identifies high-risk patients who may benefit from urgent intervention however has not been determined. Guidelines from Societies around the world recommend early endoscopy within 24 hours of presentation for acute upper gastrointestinal bleeding (AUGIB). The guidelines also state that a proportion of patients need emergency out-of-hours endoscopy, without defining the high-risk group. A recent international consensus on the management of NVUGIB recommended early endoscopy within 24 hours for Non-Variceal Upper Gastro Intestinal Bleeding (NVUGIB), and noted no additional benefit associated with urgent endoscopy (\<12 hours) vs. early endoscopy (\>12 hours) in unselected patients with NVUGIB. However, there are only limited data on the role of urgent endoscopy in the selected subgroup of patients with high-risk NVUGIB.
Interventions
OTHERUrgent endoscopy
Defined by oesophagogastroduodenoscopy within 6 hours of first presentation of Prince of Wales Hospital
OTHEREarly endoscopy
Defined by oesophagogastroduodenoscopy within 24 hours of first presentation of Prince of Wales Hospital
Sponsors
Chinese University of Hong Kong
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
DIAGNOSTIC
Masking
NONE
Intervention model description
Patients are randomized in a 1:1 ratio. The patient is randomized to receive; 1. Urgent endoscopy (defined by endoscopy within 6 hours from first consultation by GI specialists at PWH) or 2. Early endoscopy (defined by endoscopy next morning and within 24 hours from first consultation by GI specialists at PWH)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Overt signs of upper gastrointestinal bleeding (i.e., melena or hematemesis with or without hypotension) 2. GBS of ≥12 3. In-patients admitted for reasons other than AUGIB who develop bleeding are also considered for trial enrollment. 4. Patients in Hypotensive shock (SBP ≤90 mmHg or pulse ≥110 bpm) are initially resuscitated and then considered for trial entry if their condition can be stabilized.
Exclusion criteria
1. continued shock despite initial volume resuscitation (refractory shock) undergo urgent endoscopy 2. \< 18 years of age 3. Unable to provide written informed consent 4. Pregnant or lactating women 5. Moribund patients from terminal illnesses. (active treatment not considered)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Mortality | 30 days | Death from all causes 30 days from randomization |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Need for transfusion | Within 30days of randomization | To measure if transfusion of blood products is needed within 30days of randomization |
| Recurrent bleeding as defined | Within 30days of randomization | To measure if any clinical or endoscopic recurrent bleeding is identified. |
| Duration of hospital stay of index bleeding | Within 30 days of randomization | To measure the number of days of hospital stay upon randomization, only counted the hospitalization days of index bleeding. |
| ICU stay | Within 30days of randomization | To measure if ICU admission is required at the index bleeding. |
| Need for endoscopic therapy at index endoscopy | At the time of index endoscopy | To measure if endoscopic therapy is needed at the index endoscopy |
| Emergency surgery or interventional radiology to achieve hemostasis | Within 30days of randomization | To measure if emergency surgery or interventional radiology is needed at index bleeding or recurrent bleeding to achieve hemostasis |
| Rates of recurrent bleeding | Within 30 days of randomization | To measure recurrent bleeding in both study arms |
| Rate of adverse events | Within 30 days of randomization | To measure the adverse events in either group, e.g. myocardial event, cerebrovascular event and acute renal failure. |
| Need for further endoscopic treatment | Within 30days of randomization | To measure if further endoscopic treatment if required at recurrent bleeding |
Countries
China
Outcome results
None listed