Pre-Endoscopic Characteristics in Patients With Cirrhosis for Distinguishing Potentially Endoscopically Intervenable Etiologies of Upper Gastrointestinal Bleeding

Abstract

Background: Acute upper gastrointestinal bleeding (UGIB) is a common presentation in cirrhotic patients. Etiologies of UGIB are heterogeneous and differ in their need for urgent endoscopic intervention. The aim of the study is to determine the pre-endoscopic features in cirrhotic patients associated with endoscopically intervenable etiologies of UGIB and their clinical features, which may predict if the lesion is initially treatable via EGD. Methods: Cirrhotic patients presenting with suspected UGIB followed by EGD at 4 tertiary care centers between September 2015 to May 2019 were identified via ICD-10 codes and confirmed by manual retrospective chart review. Demographics, UGIB presentation, clinical characteristics and history, laboratory data, and final etiology on EGD were recorded. Continuous and categorical variables were analyzed using chi-squared, Fischer’s exact test, or T-test when appropriate. Results: 639 patients (mean age 58.9 ± 12.9 years, 36.3% female) met inclusion and exclusion criteria. From these patients, 288 (45.1%) had endoscopically intervenable etiologies of UGIB. Esophageal varices (62.8%), ulcers (11.5%), and GAVE (5.9%) were the most common etiologies. The following pre-EGD characteristics were significantly associated with endoscopically intervenable etiologies: tachycardia, hypotension, albumin, need for urgent intubation or vasopressors, AIMS65 score, prior banding procedure and hematemesis (all with p<0.05). MELD-Na and Child-Pugh score did not correlate with the presence of endoscopically intervenable etiologies. From these patients, 227 had endoscopic interventions performed, with 161 (71%) achieving complete eradication and the remaining 66 (29%) either failed to achieve eradication or could not be intervened upon with EGD therapeutics. The vast majority of patients who had incompletely eradicated lesions or could not be managed with EGD were patients who presented with esophageal varices. These patients were either medically managed (48.5%), referred to TIPS (24.2%), or had a repeat endoscopy (27.3%). Conclusion: Pre-endoscopic characteristics, notably clinical severity, initial presentation of bleeding, and prior endoscopic history, may help to predict the presence of endoscopically intervenable etiologies of UGIB that are initially treatable via EGD in cirrhotic patients. Given their more intervenable nature, priority should be given to these patients when possible towards more urgent EGDs.