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Profile and Outcome of Patients with Upper Gastrointestinal Bleeding Presenting to Urban Emergency Departments of Tertiary Hospitals in Tanzania Shaffin S

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Profile and Outcome of Patients with Upper Gastrointestinal Bleeding Presenting to Urban Emergency Departments of Tertiary Hospitals in Tanzania Shaffin S Rajan et al. BMC Gastroenterology (2019) 19:212 https://doi.org/10.1186/s12876-019-1131-9 RESEARCH ARTICLE Open Access Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania Shaffin S. Rajan1, Hendry R. Sawe1,2* , Asha J. Iyullu1, Dereck A. Kaale1, Nancy A. Olambo4, Juma A. Mfinanga1,2 and Ellen J. Weber2,3 Abstract Background: Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania. Methods: This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non- traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality. Results: During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32–64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3–4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7–29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8–22.8). Conclusions: In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes. Keywords: Upper gastrointestinal bleeding, Non-traumatic patients, Emergency department, Tanzania, Sub Saharan Africa. * Correspondence: [email protected] 1Emergency Medicine Department, Muhimbili University of Health and Allied Science, P.O. Box 65001, Dar es Salaam, Tanzania 2Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Rajan et al. BMC Gastroenterology (2019) 19:212 Page 2 of 9 Background Methods Upper Gastrointestinal bleeding (UGIB) is a medico- Study design surgical emergency. Although there has been a global This was a prospective cohort study of adult patients decline in the mortality associated with UGIB, the inci- presenting to two EDs in Tanzania with upper gastro- dence and mortality associated with GI bleeding remains intestinal bleeding from July 2018 to December 2018. high in limited income countries. In the United States, UGIB accounts for 300,000 admissions per year with ap- Study setting proximately 5% mortality rate [1], whereas in several This study was conducted at the ED- MNH and ED- studies from sub-Saharan Africa, mortality ranges from MAMC, Dar es Salaam Tanzania. MNH is a public, ter- 6 to 30% [2–5]. It is not clear if the higher mortality seen tiary referral hospital which opened in 2010. It is the site in low and middle income countries (LIMC’s) is due to of the first full capacity public ED in Tanzania and the patient demographics, severity on presentation, etiology primary training site for the only Emergency Medicine or compliance with care standards. Esophageal varices (EM) residency program in the country. MAMC is a re- has been implicated as the most common cause of UGIB cently inaugurated full capacity university health facility in several African studies [2–11]. Rather than being due with a state of the art emergency medicine department, to alcoholic liver disease as in high income countries located approximately 30 km from MNH. MNH and (HIC’s), varices in sub-Saharan Africa result from MAMC both have a fully equipped endoscopy unit. Schistosoma-related portal hypertension [5, 8, 12]. This is in contrast to HIC where erosive gastritis has been commonly implicated [1, 13, 14]. Other potential con- Study participants tributors to the higher mortality may be the severity of All consenting adults (age greater than or equal to 18 disease presentation, as there is little primary care in years) presenting with UGIB unrelated to a recent these settings, and many patients seek care very late in trauma were eligible for the study. We excluded patients their disease. who had previously been enrolled in the study who pre- Another potential contributor is failure to treat pa- sented with recurrent episodes of UGIB during the tients in accordance with management guidelines. Pro- period of the study. ton pump inhibitor (PPI) for those with suspected Non- variceal UGIB (NVUGIB), somatostatin analogues such Study protocol as octreotide and antibiotics in suspected cases of vari- Research assistants were scheduled to collect data 24 h a ceal UGIB (VUGIB) and in those with clinical suspicion day, seven days a week and during that time patients of liver disease, timely blood transfusion and early use of were consecutively approached and asked for consent to endoscopy may not occur in these settings due to lack of be followed for the study. Demographics, clinical presen- appropriate specialists, lack of resources or supply chain tation, initial management, and ED outcomes were col- issues [15–17]. A knowledge gap on the current UGIB lected by the research assistant using information given management guidelines and recommendations amongst by the patient or caregiver, the treating physician, and the health care providers may also contribute to inad- data found in the electronic medical record (Wellsoft™). equate management of UGIB cases. Prior studies in A structured case report form was used to record all Tanzania studies demonstrate lack of appropriate care participants’ information. All admitted patients were offered to patients with UGIB. Nearly half of the patients followed up in a hospital ward and if discharged through in one the studies did not receive endoscopic evaluation mobile phone calls to determine their outcome from the and treatment [5] whereas 47.1% of the patients who re- EMD-MNH and EMD-MAMC, at 24-h and 7-days. quired blood transfusion, did not receive blood transfu- sion in another study [10]. There is little information on the presentation, etiology Assessment of disease severity and management of patients presenting to EDs and this Clinical severity was measured using the pre-endoscopic is particularly true for LIMCS, where emergency medi- Rockall score (Table 1) and the Glasgow-Blatchford cine is a new specialty. The presence of full capacity (Table 2). For pre-endoscopic Rockall score, scores < 3 sig- emergency departments at Muhimbili National Hospital nifies low risk, scores 3–4 signifies moderate risk and (MNH) and MUHAS Academic Medical Centre score > 4 signifies high risk for re-bleeding, mortality or (MAMC) in Dar es Salaam have provided the opportun- surgery [19]. For Glasgow-Blatchford score, a score of < 3 ity for early stabilization and management of patients is considered Low-risk, whereas a score greater than ≥ 3is presenting with UGIB. The aim of this study was to de- high risk, thus needing intervention, transfusion, endos- scribe the patient profile, clinical severity and outcomes copy or surgery. The cut-off value for GBS severity deter- of the patients who present with UGIB to the ED. mined as per the study by Ramfrez et al [20]. Rajan et al. BMC Gastroenterology (2019) 19:212 Page 3 of 9 Table 1 Clinical (Pre-Endoscopic) Rockall Score COMPONENT 0 1 2 3 AGE (yrs) < 60 60–79 > 80 HEMODYNAMICS HR < 100 HR > 100 SBP < 100 SBP > 100 SBP > 100 COMORBIDITIES NONE – IHD, CHF, ANY MAJOR COMORBIDITIES RENAL FAILURE, LIVER FAILURE, METASTASIS Source: Wang2013 Total score is calculated by addition of individual scores Emergent and early upper GI endoscopy Data analysis Emergent upper GI endoscopy was defined as endoscopy Data from the case report form was entered into Research performed within 12 h of ED presentation whereas early Electronic Data Capture (REDCap) software (version upper GI endoscopy was defined as endoscopy per- 7.2.2, Vanderbilt, Nashville, TN, USA) and transferred into formed within 24 h of ED presentation [21].
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