CLINICAL CHARACTERISTICS AND OUTCOME OF PATIENTS WITH UPPER GASTROINTESTINAL BLEEDING AT THE EMERGENCY DEPARTMENT OF A TERTIARY HOSPITAL IN NIGERIA

A. Rukewe1,2, J.A. Otegbayo3, and A. Fatiregun4

  1. Department of Anaesthesia, University College Hospital, Ibadan, Nigeria.
  2. Dept. of Anaesthesia & Critical Care, University of Botswana, Gaborone, Botswana.
  3. Dept. of Medicine, College of Medicine, University of Ibadan &University College Hospital, Ibadan, Nigeria.
  4. Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria.

Abstract

Background: Upper gastrointestinal bleeding is a potentially life threatening condition with multiple causes. There is scarcity of health data depicting the clinical characteristics of the condition in African countries. This study was
designed to describe the demographic, clinical characteristics and outcome of the patients who presented to our Emergency Department.

Methods: The records of cohort of all patients admitted with upper gastrointestinal tract bleeding from 1 January 2011 to 31 December 2012 were retrospectively reviewed from admission to discharge or death.

Results: There were 169 patients with median age of 44.0 years (range 13-89); 25 (15.0%) of them were known peptic ulcer disease patients. Most (69.2%) of the patients were males. The most common presenting symptom was haematemesis (34.9%) followed by melaena (16.6%). There was a history of NSAIDs use in 16.8% and alcohol ingestion in 12%. Upper Gastrointestinal Endoscopy was performed in 6.8% cases. Twenty-three (13.6%) patients died. There was association between mortality and diastolic blood pressure; more deaths (1/7; 14.3%) occurred in those with diastolic blood pressure > 90mmHg compared with <90mmHg (5/70; 7.1%) (P = 0.002). There were more deaths among patients who did not receive blood transfusion (4/40; 10.0%) compared with those who had blood transfusion (2/37; 5.4%) (P=0.008).

Conclusions: The common presentations were haematemesis and melaena, mainly in middle aged men with mortality in one out of seven patients. The high mortality may be due to co-morbidities and poor support services.

Keywords: Upper gastrointestinal bleeding, Emergency department, Characteristics, Outcome.

Correspondence:

Dr. Ambrose Rukewe
Dept. of Anaesthesia & Critical Care,
University of Botswana,
Gaborone.
Telephone: 26773993020.
Email: ambyrukewe@gmail.com

Introduction

Upper gastrointestinal bleeding (UGIB) is a potentially fatal, time-critical presenting complaint in the emergency department (ED).1,2 The burden it presents can be compounded in resource poor settings, where patients often pay out-of-pocket for care, thereby hampering appropriate early intervention to determine the location and severity of bleeding. The incidence is approximately 1% of all ED admissions.3 The increasing use of low dose aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) may affect the incidence, age of presentation, site of bleeding and outcome of UGIB. NSAIDs cause gastrointestinal mucosa damage, ulceration and ulcer complication by the inhibition of endogenous prostaglandin synthesis via cyclo-oxygenase-1 enzyme.4,5 Despite improvement in diagnosis and management such as the introduction of therapeutic endoscopies and interventional radiology, mortality remains high 5-10%.6,7 There is a dearth of health data depicting the clinical characteristics of the condition in African countries. To the best of our knowledge, few studies have looked into ED presentations of UGIB in Nigeria hence we set out to describe the demographic, clinical characteristics and outcome of these cases.

METHODS
After obtaining institutional ethical approval, we retrospectively reviewed records of cohort of patients who presented to the ED of the University College Hospital, Ibadan, with UGIB between 1 January 2011 and 31 December 2012 from point of admission to discharge or death. This study was carried out at a university teaching hospital emergency department, which receives over 10,000 unrestricted emergencies annually with an admission rate of 47%. All medical, surgical, obstetric, gynaecological emergencies above 12 years as well as paediatric trauma cases were attended to at our centre, which serves as a referral centre to other hospitals in the locality. UGIB refers to vomiting blood (haematemesis) or coffee-ground substance (melaenemesis) and/or black tarry stools (melaena). At presentation, initial evaluation was conducted to assess severity of bleeding, comorbidities and risk factors. The patient’s cardiovascular vital signs were recorded to assess haemodynamic stability and necessary resuscitation commenced. The data obtained from the departmental e-register included age, presenting symptoms, history of acid peptic disease, NSAID use, alcohol ingestion, time and duration of ED admission, discharge and admission towards for further review or death. Information such as history of previous UGIB, co-morbidities, diagnostic endoscopy, duration of bleeding before presentation, haematocrit value at presentation, packed cell volume measurements are recorded in patient’s case notes.

Data were analysed using Statistical Package for Social Sciences (SPSS version 17.0; Chicago, IL, USA). Simple descriptive statistics were used. Mean and standard deviation was generated for continuous variables, while chi-square test was used to explore the relationship between mortality and the demographic/clinical characteristics. P values <0.05 were considered statistically significant.