1. Outcome of between weekend/weekday hospital
2014 Japan Digestive Disease Week
Outcome of between weekend/weekday hospital
admissions in patients Peptic Ulcer Bleeding
after initial endoscopic hemostasis
Lung-Sheng Lu, Tsung-Chin Wu, Wei-Chen Tai, Shue-Shian Chiou
Seng-Kee Chuah, Keng-Liang Wu, Yi-Chun Chiu
Division of Hepato-gastroenterology; Kaohsiung Chang Gung Memorial Hospital
Chang Gung University, College of Medicine, Taiwan.

2. Background
Recent findings suggest that patients admitted on the weekend with upper gastrointestinal hemorrhage (UGIH), which may result in increased adverse outcomes.
Soncini M, et al J Gastroenterol. 2012
Spencer D et al., Digest Dis Sc 2010
On the other hand, there were other reports that did not observe the “weekend effect”.
V. Jairath , Am J Gastroenterol 2011
Haas JM, et al. WMJ, 2012

3. Aim
To discuss the holidays effects of endoscopy hemostasis on the outcome such as recurrent bleeding, mortality and need for surgery of the patients with bleeding peptic ulcers in Taiwan.
To analyze the independent risk factors for poor outcome

4. Patients and Methods (1)
Retrospective chart review case-controlled study
Patients enrolled:
(1) Hospital admissions in patients with peptic ulcer bleeding who received initial
endoscopic hemostasis from January 2009 to March 2011 (n=774).
(2) They were divided into two groups :
Group A: the bleeding event occurred during holiday (n=129)
Group B: the bleeding event occurred during non-holiday (n=615)
Exclusion criteria:
- Incomplete chart recording
- Malignant ulcers
- Non ulcerative bleeding, such as angiodysplasia and Mallory-Weiss tear
- Subjects who lost to follow up before 30 days except mortality
- Subjects who were not successful in initial endoscopic hemostasis

5. Patients and Methods (2)
Definitions:
(1) Rebleeding - assessement of clinical symptoms and signs including
unstable hemodynamic status
- ongoing melena passage, hematemesis, hematochezia
- decline in hemoglobin level within 24hr by the clinical
physicians evaluation
(2) Shock - tachycardia, HR> 100/min, or hypotension, SBP< 90mmHg
(3) Primary endpoints-
Poor outcome - defined by rebleeding within 30 days after endoscopic
hemostasis, need for surgery, and mortality
(4) Secondary endpoints –
Clarify relationship between clinical severity (Rockall score),
pharmacologic therapy and the occurrences of poor outcome.

6. Statistical analysis
All results were expressed as means ± standard deviations, and for continuous data and as frequencies or percentages for categorical data
Distributions of continuous variables were analyzed by the chi-square test, Fisher exact test, or independent-sample T Test.
All statistical analyses were performed with SPSS, version 18 (SPSS, Inc., Chicago, IL, USA)

7. Results 1. Comparison of the clinical characteristics and endoscopic findings between non-holiday and holiday groups
Characteristic
Non-holiday group
(n=615)
Holiday group
(n=129)
P-value
Age (yr)
64.6±14.1
66.45±14.1
0.978
Female gender, n (%)
195(32%)
48(37%)
0.226
Hb(g/dl)
9.3±2.8
9.3±2.7
0.848
Platelet(x103/μl)
190.1±99.3
205.4±120.1
0.244
Use of NSAIDs,n (%)
72(12% )
9(7%)
0.117
Use of aspirin, n (%)
93(15%)
18(14%)
0.735
Use of Plavix, n (%)
65(11%)
14(11%)
0.924
Use of wafarin, n (%)
32(5%)
5(4%)
0.528
Shock at presentation
311(51%)
76(59%)
0.084
Coexistingillness, n (%)
CKD III, IV / V
COPD
CAD DM
CVA
HTN
Cancer
Liver Cirrhosis
204 / 83 (33%/13%)
44(7%)
110(18%)
199(32%)
105(17%)
326(53%)
116(19%)
115(19%)
49 / 11(40%/9%)
11( 9%)
19(15%)
36(28%)
24(19%)
63(49%)
20(16%)
0.245
0.588
0.389
0.323
0.676
0.946
0.392
Rockall score
6.2±1.7
6.0±1.8
0.727
Time to endoscope (hrs)
16.7±19.8
12.2±15.3
0.008*
PRBC BT(u)
6.6±9.3
4.8±5.2
0.020*
High dose PPI(%)
440(71.5%)
80(62.0%)
0.032*
Ulcer size (cm)
1.1±0.7
1.2±0.8
0.434
Forrest classification
Ia/Ib/IIa/IIb/IIc/III
44 / 348 / 67 / 140 / 14 /2
8 / 62 / 20 / 33 / 6 / 0
0.260
High Stigmata, n (%)
599(97.3%)
123(95.3%)
0.212
Time to oral PPI(days)
6.9±9.1
5.3±6.1
0.05*
Hospital stay (days)
17.4±28.2
12.05±12.5
0.005*
P < 0.05 is significant*:
Abbreviations: Hb, hemoglobin; NSAIDs, non-steroid anti-inflammation drugs; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CAD, coronary artery disease; DM, diabetes mellitus; CVA, cerebral vascular accident; PRBC BT, blood transfusion of packed red blood cell.

8. Results 2. Significant clinical characteristics between non-holiday and holiday groups

9. Results 2. The clinical outcomes of non-holiday and holiday groups.

10. Limitations
This retrospective analysis is dependent on the completeness of the medical charts. If the chart report of ulcer pattern was not complete, we reviewed the image obtained by endoscopy or watching the recorded video in order to record the ulcer characteristics. Therefore, the investigation reliability might vary in this area.
The sample size is small that selection bias definitely existed among the two groups.

11. Conclusions
Less patients with peptic ulcer bleeding after endoscopic homeostasis experienced recurrent bleeding and needed to receive surgery in the holiday group although but did not attain significant statistical differences.
The mortality was comparable between the two groups.
In fact, patients admitted on the holiday needed less waiting time to receive endoscopic hemostasis, time to oral PPI, and hospital stay

12. Thanks for your attention