A retrospective and prospective study on the safety of discharging selected patients with duodenal ulcer bleeding on the same day as endoscopy,☆☆,

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Abstract

Background: Low risk of rebleeding has been observed in patients with gastrointestinal bleeding due to peptic ulcer without high-risk stigmata of recent hemorrhage. We aimed to evaluate the safety and acceptability of an aggressive early discharge policy in those patients admitted with upper gastrointestinal bleeding due to duodenal ulcers without high-risk stigmata of recent hemorrhage. Method: Retrospective analysis was carried out in bleeding ulcer patients less than 60 years of age with stable vital signs and no stigmata or only flat spots on endoscopy. A prospective study was then performed that included only duodenal ulcer patients less than 60 years of age with stable vital signs, no concomitant serious medical illness, and no stigmata of recent hemorrhage. These patients were discharged on the same day that endoscopy was performed. Results: During a period of 18 months, 72 patients satisfied the criteria in the retrospective study. The mean hospital stay was 1.4 days (range, 1 to 5). There were no episodes of rebleeding nor significant drops in hemoglobin level 2 weeks after discharge (10.8 gm/dL ± 1.4 vs 11.0 gm/dL ± 1.5). Seventy-five patients were recruited into the prospective study. None of them had rebleeding nor significant drops in hemoglobin 1 week after discharge (12.1 gm/dL ± 1.8 vs 11.7 gm/dL ± 2.5). Conclusion: We conclude that patients with gastrointestinal bleeding who have clean-based duodenal ulcers and are stable on admission can be safely discharged on the same day as endoscopy. (Gastrointest Endosc 1997;45:26-30.)

Section snippets

Retrospective analysis

A retrospective analysis was carried out on all patients that had undergone endoscopy over an 18-month period between January 1991 and June 1992. The hospital inpatient and endoscopy records of all the patients with a history of hematemesis and/or melena and endoscopic findings of peptic ulcer were reviewed. A subgroup analysis was performed in those who were judged to have low rebleeding risk defined as follows: (1) age less than or equal to 60 years; (2) hemoglobin level above 9.0 gm/dL on

Retrospective study

Over the 18-month period, 459 patients presented with upper gastrointestinal bleeding. Of these, 284 patients had peptic ulcers and 72 patients satisfied the inclusion criteria for early discharge. The characteristics of the patients are shown in Table 1.

Seventy-two patients were discharged at the discretion of the responsible physician, depending on concomitant medical illnesses and the condition of the patients. Only two thirds (65.3%) of patients were discharged on the day of endoscopy. The

DISCUSSION

Clinical and endoscopic parameters are highly predictive of recurrent hemorrhage.2, 8, 9, 10, 11, 12, 13, 14 It has been proposed that patients with clean-based ulcers can be discharged soon after volume resuscitation, stabilization, and institution of anti-ulcer therapy.1 One recent study assessed the outcome of outpatient care after emergency endoscopy in this category of patients with gastrointestinal bleeding and documented the low rate of rebleeding and lack of need for emergency surgery.

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      Low-risk patients included patients with pigmented dots or clean base ulcers.7,19 Among the latter, a subgroup of very low-risk patients were identified when they also met a set of published clinical criteria1,20–23 that allowed discharge after endoscopy (with an empirical attribution of LOS of 1 day). The base-case scenario used estimated proportions from a Cochrane review11 (which included preliminary data from Lau et al presented in abstract form), whereas an alternate scenario adopted assumptions on the basis of the recent full publication by Lau et al10 with regard to the proportions of patients with different endoscopic appearances in both pre- and post-endoscopy PPI patient groups.

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    From the Division of Gastroenterology, Department of Medicine, University of Hong Kong, Hong Kong.

    ☆☆

    Reprint requests: Dr. Kam-Chuen Lai, Gastroenterology, Rm 301, New Clinical Building, Queen Mary Hospital, Pokfulam, Hong Kong.

    37/1/75961

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