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Patients With Non-Variceal Upper Gastrointestinal Bleed Should Be Re-Assessed For Co-Morbidity

Individuals who have experienced a major bleed from their stomach or oesophagus (known as an ) may be more likely to die from other causes, particularly malignant tumours and , than those without an , according to a study by UK researchers published in this week’s PLOS Medicine.

These findings are important as they suggest that an upper gastrointestinal bleed may be either a cause or an indicator of a decline in a coinciding, serious medical condition.

The researchers, led by Colin Crooks from the University of Nottingham, reached these conclusions by identifying a population- based sample of patients who were admitted to hospitals in England for treatment of an upper gastrointestinal bleed between 1997 and 2010 and their recorded . They excluded individuals who had bleeding from esophageal varices, which are caused by liver cirrhosis. They then used over 80,000 matched controls and a statistical model to calculate the excess .

Over this period, the researchers identified 16,355 people who had an upper gastrointestinal bleed, of whom 6242 subsequently died, giving a crude mortality rate of 16.0 per 100 person-years in the first 5 years. In the first month after a bleed, the death rate was increased for all causes of death, but the highest mortality rate was from non-malignant digestive disease mostly linked to causes related to the upper . For the remainder of the first year, the highest death rates were from malignant tumors, followed by deaths due to circulatory and respiratory diseases.

In their analysis, the researchers calculated that the total 5-year risk of death due to gastrointestinal causes ranged from 3.6% in people ≤50 years to 15.2% in people ≥80 years, representing an of death between 3.6% and 13.4%, respectively. The total 5-year risk of death due to non-gastrointestinal causes ranged from 4.1% in people ≤50 years to 46.6% in people ≥80 years, representing an of death between 3.8% and 19.0%, respectively.

The authors say: “We found a considerable excess of all causes of death in individuals following a non-variceal upper gastrointestinal bleed, and over half of these deaths were due to non-gastrointestinal co-morbidity, particularly neoplastic and cardiovascular disease.”

They continue: “This excess in deaths was not explained by co-morbidity such as cancer or cardiovascular disease diagnosed prior to the admission. Therefore, an upper gastrointestinal bleed may be a marker of disease or an indicator of a deterioration in non-gastrointestinal co-morbidity. ”

The authors add: “Consequently, this analysis suggests that for patients who have a non-variceal upper gastrointestinal bleed, re-assessment of co-morbidity should be considered in the follow-up period.”


Funding: This work was supported by personal fellowships: CJC is a research fellow and gastroenterology trainee supported by a Medical Research Council Population Health Scientist fellowship (grant number G0802427); TRC is a Clinical Associate Professor and Consultant Gastroenterologist; JW is a Clinical Associate Professor, Reader in Epidemiology, and Consultant Gastroenterologist supported by a University of Nottingham/Nottingham University Hospitals NHS Trust Senior Clinical Research fellowship. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests: TRC’s wife is an employee of Takeda, and was previously employed by Astra Zeneca. The authors declare no other competing interests.

Citation: Crooks CJ, Card TR, West J (2013) Excess Long-Term Mortality following Non-Variceal Upper Gastrointestinal Bleeding: A Population-Based Cohort Study. PLoS Med 10(4): e1001437. doi:10.1371/journal.pmed.1001437

ACCESS TO THE FREELY AVAILABLE PAPER: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001437

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