1. Edward S. Huang, MD, MPH, Sundip Karsan, MD, MPH, Fasiha Kanwal, MD, MSHS, Inder Singh, MD, Marc Makhani, MD, Brennan M. Spiegel, MD, MSHS Boston, Massachusetts; Los Angeles, California; St. Louis, Missouri, USA Gastrointest Endosc Nov 2011; 74: 971-80 소화기내과 R3. 신아리 Impact of nasogastric lavage on outcomes in acute GI bleeding Journal conference 2011.11.07

2. Upper GI bleeding - common cause of emergency hospitalization - nearly 400,000 hospital admissions in the United States annually - mortality rate : 3% to 14% per admission. Guidelines for managing Acute Nonvariceal Upper GI Bleeding (NVUGIB) - Initial resuscitation and stabilization - Early endoscopy within the first 24 hours of presentation - Use of proton pump inhibitors to minimize recurrent hemorrhage - Routine pre-endoscopic nasogastric lavage (NGL) ?? Uncertain whether early NGL improves patient outcomes Background

3. Some data suggest NGL may enhance risk stratification & management ; bloody aspirate on NGL - predicts active bleeding, high-risk lesions, and higher rates of recurrent hemorrhage. active exsanguination & higher mortality rate - but, other outcomes, such as minimizing aspiration risk, improving endoscopic visualization, excluding foregut source in presumed LGIB remain controversial Background

4. Purpose Early NGL improves patient outcomes in the management of acute GI bleeding ?? Performed a retrospective analysis to test whether NGL is associated with improved process measures and outcomes Length of stay Blood transfusion requirements Use of endoscopy Time to endoscopy Need for emergency Surgery Mortality rate

5. Study Design & Patients - Propensity-based retrospective study - Between January 1996 and December 2005 - University-based West Los Angeles Veterans Affairs Medical Center - Study Patients - Including criteria 1) Primary reason for admission was GI bleeding 2) Hospitalized for at least 24 hours 3) Received an inpatient GI consultation 4) Had a complete set of relevant clinical data documented in the chart - Excluding criteria 1) Not hospitalized 2) GI bleeding developed while already hospitalized 3) Discharged prematurely against medical advice A total of 633 patients admitted with GI bleeding are enrolled Methods

6. Outcomes Measurements 1) Length of hospitalization 2) Blood transfusion requirements 3) Use of endoscopy 4) Time to endoscopy 5) Performance of emergency surgery 6) All-cause mortality within 30 days of index hospitalization, including inpatient mortality Risk factors - To isolate independent effect of NGL on outcomes, we attempted to adjust for significant confounders - Prespecified patient characteristics, clinical data at the time of initial presentation, use of medical and transfusion therapies, endoscopic data. ; obtained these data by reviewing nursing records, endoscopy reports, and radiology reports. Methods

10. Results 1)Baseline Characteristics - full cohort & propensity matched cohort 2)Outcomes related to Nasogastric lavage 3)Time to Endoscopy related to Nasogastric lavage

11. Baseline characteristics for full cohort

12. Baseline characteristics of propensity-matched cohort

13. Outcomes related to Nasogastric lavage

14. Time to Endoscopy related to Nasogastric lavage

15. Performing NGL is associated with the earlier performance of endoscopy, but does not affect clinical outcomes. Performing NGL at initial triage may promote more timely process of care, but further studies will be needed to confirm these findings Conclusion