THE IMPACT OF ADHERENCE TO CLINICAL MANAGEMENT GUIDELINES ON THE OUTCOMES OF THE PATIENTS PRESENTING WITH ACUTE UPPER GASTROINTESTINAL VARICEAL BLEED: A UNIVERSITY HOSPITAL EXPERIENCE

Kesavan, Saumiya; Desai, Rajeev; Abbasi, Abdullah; Muller, Sara

Abstract

Background Upper gastrointestinal bleeding (UGIB) caused by gastro-oesophageal varices remains a common complication of cirrhosis with 10% mortality despite improvements in care. University Hospitals of North Midlands (UHNM) was identified by the previous two Dr Foster reports as having higher than expected mortality for patients with liver disease. We undertook an audit to assess the management of patients presenting to UHNM with an UGIB. We examined the impact of the adherence to management guidelines on the patient outcomes.

Three audit standards were used terlipressin administration, antibiotic prophylaxis administration and performing endoscopy within 24 hours of admission. Data were collected for patients presenting with UGIB between 24/03/2019 and 21/03/2021. T-tests and chi-square test, as appropriate, were used to assess the association between age, gender, liver disease severity (Child-Pugh (CP) category, MELD-NA score) and presentation out of hours and receipt of guideline adherent treatment. Kaplan-Meier curves and log-rank tests were used to assess differences in survival over 28 (D28) and 90 (D90) days between those who did and did not receive guideline-adherent treatment.

Results A total of 149 patients were included. Mean age 57.06 years (14.6 SD); 82 (55%) males. The mean MELD-Na score was 19.14 (SD 7.91), commonest CP class was B (44%). Eighty-seven (58%) patients presented outside working hours. 121 (81%) and 108 (72%) were alive at D28 and D90 respectively. 135 (91.22%) received terlipressin and 140 (93.94%) antibiotics. There was no significant differences in age, gender, MELD-Na score in those receiving any or all guideline adherent treatments. There were significantly more CP class A patients in the group managed without terlipressin (6/13 (46.15%) versus15/135 (11.11%), p=0.002) and without antibiotics (5/9 (55.56%) versus 17/140 (12.14%), p=0.002). Eighty seven (59.18%) patients underwent endoscopy within 24 hours of admission. Of the patients presenting out-of-hours, a significantly higher proportion received endoscopy within 24 hours of admission than those presenting in working hours (44/60 (73.33%) versus41/87 (47.12%), p=0.032). Kaplan Meier survival estimates and log-rank tests showed no significant difference in survival at D28 or D90 between the patients receiving any or all guideline adherent treatments.

Discussion Lower clinical suspicion of varices as the cause of UGIB in patients with CP class A appears to reduce the likelihood of appropriate pharmacological therapy. Guideline adherent treatment was not associated with survival at D28 or D90. Further understanding of the local case mix, relative to other similar trusts, may help to understand higher relative mortality.

Citation

Kesavan, S., Desai, R., Abbasi, A., & Muller, S. (2022, September). THE IMPACT OF ADHERENCE TO CLINICAL MANAGEMENT GUIDELINES ON THE OUTCOMES OF THE PATIENTS PRESENTING WITH ACUTE UPPER GASTROINTESTINAL VARICEAL BLEED: A UNIVERSITY HOSPITAL EXPERIENCE. Poster presented at British Association for the Study of the Liver Annual Meeting

• Presentation Conference Type: Poster
• Conference Name: British Association for the Study of the Liver Annual Meeting
• Start Date: Sep 20, 2022
• End Date: Sep 23, 2022
• Deposit Date: Jun 28, 2023
• Publisher: BMJ Publishing Group
• DOI: https://doi.org/10.1136/gutjnl-2022-BASL.34