|Year : 2018 | Volume
| Issue : 1 | Page : 13-18
Clinical and endoscopic profile of the patients with upper gastrointestinal bleeding in central rural India: A hospital-based cross-sectional study
Jyoti Jain1, Anoop Rawool1, Shashank Banait2, Chetna Maliye3
1 Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
2 Department of Ophthalmology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
3 Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Web Publication||3-Apr-2018|
Dr. Jyoti Jain
Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Acute Upper Gastrointestinal bleeding (UGIB) is one of the common causes with which the patients present to emergency. The upper gastrointestinal (UGI) endoscopy remains a crucial tool in identification of UGIB. The aim of the present study was to determine the endoscopic profile of UGIB in adult population of rural central India admitted with history of UGIB (hemetemesis and/or malena). Methods: This prospective, cross sectional study was conducted in rural hospital in central India and we enrolled all consecutive patients aged 18 years and above who were admitted in the hospital ward with the history of UGIB. After obtaining the demographic data, all patients underwent clinical examination, laboratory investigations and video-endoscopy. We used Student's t test to compare means, Chi-square test to compare proportions and Mann-Whitney test to compare medians. P value <0.05 will be considered significant. Results: The mean age of our study population (N = 118) was 46.2 years. Among 118 patients who underwent endoscopy, 47.4% had esophageal varices, 27.1% had portal hypertensive gastropathy, 14.4% had gastric erosions, 5.9% each had duodenal ulcers and esophagitis, 5% had gastric ulcer disease, 4.2% each had Mallory-Weiss tear and had gastric malignancy, 1.7% had esophageal malignancy and 16.1% had normal endoscopic findings. Conclusion: Esophageal varices were the most common cause of UGIB in the adult population of rural central India presenting with UGIB, when diagnosed by video-endoscopy.
Keywords: Esophageal varices, hematemesis, malena, upper gastrointestinal bleeding, upper gastrointestinal endoscopy
|How to cite this article:|
Jain J, Rawool A, Banait S, Maliye C. Clinical and endoscopic profile of the patients with upper gastrointestinal bleeding in central rural India: A hospital-based cross-sectional study. J Mahatma Gandhi Inst Med Sci 2018;23:13-8
|How to cite this URL:|
Jain J, Rawool A, Banait S, Maliye C. Clinical and endoscopic profile of the patients with upper gastrointestinal bleeding in central rural India: A hospital-based cross-sectional study. J Mahatma Gandhi Inst Med Sci [serial online] 2018 [cited 2019 Jul 18];23:13-8. Available from: http://www.jmgims.co.in/text.asp?2018/23/1/13/229157
| Introduction|| |
Acute upper gastrointestinal bleeding (UGIB) is one of the common causes with which patients present to emergency department worldwide. The extensive clinical spectrum of gastrointestinal (GI) bleeding may encompass many different clinical scenarios with reported mortality of 5%–15%. UGIB can occur from multiple different lesions and different sites in the GI tract and may be massive or trivial, obvious, or hidden. The most common cause of acute UGIB is peptic ulcer. In a recent study, it was shown that gastroduodenal ulcers were responsible for UGIB in nearly 50% of cases. However, other UGI tract mucosal lesions also account for substantial proportion of cases.
Upper GI endoscopy has a crucial role in the diagnosis and treatment of UGIB because of its better diagnostic yield, especially for various superficial lesions. It also offers the opportunity for interventions such as band ligation, clipping, sclerotherapy, and biopsy of lesions. However, epidemiological studies are still limited and data for developing countries and that too for countries like India are still lacking. To the best of our knowledge, no study has been reported from rural Central India regarding the epidemiology and prevalence of UGIB in this region.
Thus, the present prospective study was aimed to evaluate the clinical, biochemical, and endoscopic profiles in patients of more than 18 years of age presenting with UGIB to the tertiary care hospital in rural Central India.
| Methods|| |
The study was approved by the ethics committee of Mahatma Gandhi Institute of Medical Sciences (MGIMS) (IRB00003623). We obtained a written informed consent from all study participants before enrolling them in the study.
This cross-sectional study was carried out in endoscopy unit in the Department of Medicine at MGIMS a hospital in rural Central India. This is a 720-bed teaching hospital at Wardha in Central India which cares for about 400,000 outpatients and 50,000 inpatients yearly. Wardha is the dry district of India and legally it does not allow anyone to drink alcohol. Physicians typically order UGI endoscopy in patients presented with UGIB. We enrolled patients from inpatient settings in this study.
Beginning October 2009 till March 2011, we enrolled all consecutive patients of more than 18 years of age, admitted with a history of UGIB, resident of Wardha district, in this cross-sectional study.
UGIB was defined as both hematemesis and/or malena based on history. Criteria for exclusion were presence of any contraindication for endoscopy, i.e., unconscious patient, orodental abnormalities, recent myocardial infarction, cardiac failure, pulmonary edema, suspicion of perforated viscus, and patient not willing for consent.
Data collection tools
All study participants included in the study underwent a relevant clinical history and examination. Interview of all study participants was undertaken by the same research associate and was pilot tested. Demographic data, including age, sex, place of residence and education; history of associated symptoms such as pain abdomen, nausea, vomiting, retching, jaundice, and syncope were obtained during baseline interview. We elicited information about risk factors habits such as alcohol consumption, smoking, recent or chronic consumption of nonsteroidal anti-inflammatory drugs (NSAIDS) to all study participants and serological tests for hepatitis B, hepatitis C infection to selected study participants. Current smokers were defined as persons who reported smoking for at least 3 months in their life and who currently smoke at least on some days of a week. Current alcohol consumption was defined as persons who reported alcohol consumption in last 3 months while past drinkers were those who have not consumed alcohol in last 3 months. All study participants received the standard line of management for UGIB. Relevant investigations such as hematologic parameters, random blood glucose, coagulation profile, renal function tests, liver function tests (serum bilirubin, alanine aminotransferase [ALT] and aspartate aminotransferase [AST]), and ultrasonography of abdomen were obtained by conventional methods in all study participants to diagnose the underlying etiology for UGIB.
Video endoscopy was performed using with videoendoscope GE 20/FP developed by Fujinon in all study participants in the Department of Medicine. Video endoscopy was performed by the same investigator with training in and 10-year-experience of performing UGI endoscopy. The procedure room is well equipped with oxygen and suction; focused light. Endoscopy was performed in the left lateral position, with study participants head is supported after pharyngeal anesthesia using 4% topical xylocaine. Reports of all procedure by the endoscopist are entered in the electronic hospital information system.
Endoscopic lesions for the purpose of diagnosis in this study were defined as follows in study participants to minimize diagnostic error. Esophageal varices (OV) were defined as abnormally dilated veins, in the long axis of the esophagus, that project directly as tortuous bluish mounds covered with relatively normal mucosa, which were graded by their size according the method of Paquet. Esophagitis was defined as superficial erosions covered with exudates associated with underlying friable erythematous mucosa while Mallory–Weiss tear was diagnosed if a 5–20 mm longitudinal mucosal tear in the gastric mucosa, either side of or across the gastroesophageal junction or in the esophagus or in the stomach just slightly below the junction. Gastroesophageal reflux disease defined as mucosal damage visualized as erosions in the lower esophagus along with laxity of gastroesophageal sphincters. Gastric ulcer and gastric erosions were defined respectively as any breech in the continuity involving the deficit in the entire thickness and as partial thickness deficit, small (<5 mm diameter) and shallow, with no sign of scarring in an epithelial surface of the mucosa of the stomach. Portal hypertensive gastropathy (PHG) included changes in the mucosa of the stomach such as friability, characteristic mosaic appearance, and presence of ectatic blood vessels at the surface. Duodenal ulcer (DU) and duodenitis were defined, respectively, as any breech in the continuity involving the deficit in the entire thickness and inflammation of the mucosa of the duodenum in the form of presence of congestion, redness, and secretions. Polyp was identified as any pedunculated growth with smooth surface, attached to the lumen from the mucous lining of the esophagus, stomach, or duodenum. Malignancy was defined as any irregular, friable mass or growth, invading the surrounding tissue and into the lumen and bleeds to touch.
We entered the data electronically by Microsoft Excel and analyzed by STATA software (Version 10, Stata Corporation, Texas, USA). We performed the analysis of all clinical features present in UGIB patients and calculated the cumulative percentage frequency of all clinical features. We analyzed normally distributed continuous variables by Student's t-test, proportions by Chi-square test, and continuous variables with skewed distribution by Mann–Whitney test.
| Results|| |
We used strengthening the reporting of observational studies in epidemiology statement to report this study. We screened 132 consecutive patients presented with UGIB and finally included 118 patients, who were eligible for study. Study participants present with both hematemesis and malena in (50) 43%, malena in (41) 32%, and hematemesis in (27) 23%.[Figure 1] The baseline characteristics with respect to demographic profile and risk factor profile are shown in [Table 1]. The mean age of the patients was 46.2 + 15.3 years and 77.8% were male. Risk factors in the study participants include alcohol in 47%, smoking in 30%, recent consumption (within a week) of NSAIDS in 20%, and past history of jaundice in 19%.
[Figure 2] shows the clinical features of study participants. The most common presenting symptom in these study participants was pain in abdomen in 62.7% followed by retrosternal burning sensation in 47.5%, vomiting in 39%, nausea in 28.6%, and syncope in 13.6%. Among the clinical signs of study participants', pallor was the most common finding in 80.5%, followed by abdominal tenderness 46.6%, ascites in 27.1%, hepatomegaly in 12.7%, and splenomegaly in 25.4%.
Hematological and biochemical profile of study participants are shown in [Table 2]. Anemia was found in 87.3% of study participants with mean hemoglobin of 8.4 g/dl. The difference in the value of hemoglobin was found to be statistically significant as compared to patients with no lesions found on endoscopy. Mean corpuscular volume and platelet count were abnormal in 66.9% and 52.5% of the study participants, respectively. Platelet count was significantly lower in the study participants with PHG and upper GI malignancy as compared to study participants with no lesions found on endoscopy (P< 0.05). In majority (83.6%) of the study participants, random blood sugar levels were normal, and serum creatinine was raised in more than half of the study participants. Liver function tests of study participants revealed hyperbilirubinemia in 48.7% and increased ALT, AST, and Prothrombin time in 40.6%, 55.9%, and 46.2%, respectively.
Regarding endoscopic profile 47.5% of the study participants had OV followed by PHG in 27.1%, gastric erosions in 14.4%, DU in 5.9%, gastric ulcer in 5.1, Mallory–Weiss tear and gastric malignancy in 4.2% each, esophageal erosions in 3.4, and esophageal malignancy in 1.7%. In 19 (16.1) patients, no endoscopic lesion for UGIB could be identified [Table 3]. Among 56 patients found to have OV, 13 (23.2%) had Grade-I varices, 12 (21.4%) had Grade-II varices, and 31 (55.3%) had Grade-III OV. Liver-related parameters of study participants with bleeding from PHT compared to the remaining study participants, i.e., without PHT are provided in [Table 4].
|Table 4: Liver-related parameters of study participants with bleeding from portal hypertension and the remaining study participants|
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All patients were treated on standard line of management in the form of proton pump inhibitors, H2 receptor antagonist, H. pylori eradication therapy, antacids, antiemetics, beta blockers, diuretics, etc., as required. Patients underwent band ligation were 23.1% (13/56) and sclerotherapy were 3.6% (2/56) for OV. A biopsy was done in all patients suspected to have malignancy.
| Discussion|| |
We carried out this cross-sectional study with the aim to determine the clinical and etiological profile of UGIB by endoscopy in adult population in rural central India admitted with a history of hematemesis and/or malena. The most common cause of UGIB in our study patients was found to be OV. Similar results were obtained by recent studies by Dewan et al. Jaka et al. Suba et al. Sarwar et al. and Shrestha and Sapkota. In contrast to several studies which have reported as peptic ulcer to be the most common cause of UGIB.,,,,, The possible explanation for decreased prevalence of peptic ulcers may be due to early initiation and adequate use of proton pump inhibitors in patients with GI symptoms. Another explanation in our study population may be higher prevalence of chronic alcohol consumption and development of cirrhosis.
We found that the more than three fourth of the study participants presenting with UGIB were males and mean age of 46.2 years. Our results are comparable to numerous studies conducted in past.,,, However, in one study, mean age of the patients was much higher and old age is found as an independent risk factor for mortality in patients with UGIB. Lower age of presentation in our study participants could be explained by early development of cirrhosis due to initiation of alcohol consumption and early age.
In our study, UGI endoscopy was normal in 16.1% of the study participants. Alema et al. in 16.1% and Cotton et al. in 13.9% also reported normal UGI endoscopy in patients presenting with UGIB. In present study higher number of normal UGI endoscopy may be because of unavailability of enteroscopy/capsule endoscopy facility, thereby missing lesions beyond the second part of duodenum. Another reason for this could be delayed endoscopy in some of the study participants.
The mean hemoglobin of all study participants with endoscopic lesions and those with normal UGI endoscopy was 8.4 g/dl and 9.3 g/dl, respectively. The possible reason for less hemoglobin in these patients could be nutritional deficiency along with alcohol consumption. We found that the mean platelet count was significantly lower in the patients with PHG and UGI malignancy as compared to patients with no lesions found on endoscopy (P< 0.05). This difference could be explained by hypersplenism in patients with PHG. This finding is consistent with the results of before study done by Zimmerman et al. where risk factors and warning signs of mortality was studied; it was found that thrombocytopenia, renal failure, and higher bilirubin were important predictor of mortality in patients admitted to hospital with acute UGI hemorrhage. Conflicting results have been published by various authors regarding correlation between hematocrit and mortality., According to different authors, the hemoglobin level, especially when followed over time, is a useful indicator of the severity of bleeding, in hospital continued bleeding, rebleeding, and the need for packed erythrocyte transfusions. However, in our study, we did not followed hemoglobin level in all the study participants.
In a study by Booker et al., it was found that variables such as blood urea, hemoglobin, pulse rate, systolic blood pressure, prolonged prothrombin time, and elevated serum creatinine were all strongly predictive of outcome-rebleed and death (P< 0.001). However, in the present study, we did not study the predictors of mortality in study subjects.
In our study participants, the alcohol consumption was found to be significantly higher in patients with endoscopic findings than patients with normal endoscopy. Percentage of alcohol use was significantly higher when compared to general population. Deshmukh et al. reported that the prevalence of alcohol use among those aged 18 years and above in rural Wardha (Central India) is 1.6%. We found that alcoholism was strongly associated with Mallory–Weiss tear, malignancy and OV (P< 0.05); however, there was no significant association seen between alcoholism and gastric ulcer, gastric erosions, malignancy and PHG. Wilcox et al. studied the causes of bleeding as compared between alcohol consumers and alcohol nonconsumers found that alcohol consumers were more likely to bleed from varices (P = 0.024) or other portal hypertension-related causes (P< 0.01), whereas peptic ulcer was more common in alcohol nonconsumers when compared with chronic alcohol consumers (67 vs. 53%; P < 0.01). They also found that esophagitis (P = 0.95) and Mallory–Weiss tear (P = 0.15) prevalence were not significantly different between the two groups.
We recognize the limitations of the present study. The most important of them being that sample size though adequate for detection of endoscopic lesions, was inadequate for the subgroup analysis. The end-point of the study was endoscopic diagnosis and the patients were not followed subsequently. The present study was a single center study and hence not reflects the whole population. Band ligation could not be done in all patients with bled from OV because of financial constrained. These patients were managed conservatively on medical management. Finally, enteroscopy, capsule endoscopy, and other modalities could not be done in patients with obscure bleeding because of unavailability. The study had few strengths as well. However, being a single-center study, it provides credibility to the study as all consecutive patients with UGIB were included in the study, eliminating a selection bias.
| Summary and Conclusion|| |
To summarize, this cross-sectional study shows that OV were the most common cause of UGI bleeding in the adult population of rural Central India presenting with UGIB when diagnosed by UGI videoendoscopy. It is thus recommended that aggressive public education should be initiated with close monitoring in patients who are found to have alcohol-related liver diseases. With increasing life expectancy, care of more elderly and patients with comorbid conditions should be taken, which contributes to the high mortality from GI bleeding.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]