Short summary

Peptic ulcer bleeding (PUB) is common with 1000-2000 annual admissions in Denmark. In 10-15% PUB patients rebleeding occurs which is associated with a significant increase in mortality. Blood pressur and pulse are deeply integrated in evaluation and observation of patients circulation during haemorrhage. Thus PUB patients have their blood pressure and pulse examined requently during admission.

To our knowledge, no one have examined the evolution of blood pressure and pulse in the hours up to rebleeding. Because of peptic ulcerations localization, blood pressure and pulse might change before symptoms of rebleeding occurs.

Rationale

Several studies indicate a decline in incidence from end of 20th century to present explained by the increase in eradication of H. Pylori. However, mortality rates continue to be a prevalent outcome with rates ranging from 6,2%-14% in northern European countries. Another feared complication is rebleeding, which occurs in 10%-15% of PUB patients and is associated with a 3-5 fold increase in mortality (6,8-11).

Studies have tried to predict which patient characteristics that are associated with a high risk of rebleeding and found that active bleeding, ulcus localized to duodenum or lesser gastric curvature and hemodynamic instability at admission are associated with higher risk of bleeding. Furthermore, scoring systems such as Glasgow-Blatchford Score (GBS), Rockall Score (RS), AIMS65 and Baylor bleeding Score (BBS) have been examined for the purpose of predicting need of intervention, rebleeding and mortality, where GBS is shown to be superior but still not sufficient in the prediction of rebleeding.

Blood pressure and pulse is an easy and valid vital parameter regarding evaluation of blood circulation and is deeply implemented in the observation of most admitted patients. Blood loss is associated with a decrease in blood pressure and a compensated tachycardia. Because ulcus in the internal organs is difficult to localize, the discovery of rebleeding might be with some delay.

We want to examine if blood pressure and pulse can indicate rebleeding before symptoms occurs, and graphically demonstrate any potential delay in time from changes in blood pressure and pulse to recognition of rebleeding. It might change how closely patients should be monitored regarding vital parameters and cut off important time to intervene and hopefully improve outcome.

Method:

The Department of Gastroenterology at Odense University Hospital (OUH) has a proud tradition and experience regarding treatment of PUB and the complications - including rebleeding. This retrospective study will be provided with information of diagnosis and rebleeding from a database of all patients admitted with PUB- Further patient characteristics will include age, sex. time at admission and time from admission to rebleeding, endoscopic diagnosis and therapy, comorbidity, medication, ASA score, blood pressure and pulse in the last 6 hours to rebleeding. Time at admission and time to rebleed is included to reduce the diurnal blood pressure cycle effect.

The characteristics will be provided from the electronic patient journal (EPJ) and every rebleeding patient is compared to a non-rebleeding patient with same above-mentioned variables.

Approximately 30-40 patients rebleed every year at OUH. We will include rebleeding patients from September 2014 to September 2019 and therefore include 150-200 rebleeding patients and match them with 300-400 non-rebleeding patients in the same time period.

Description of the cohort

Adult men and women above 18 admitted with a chronic peptic ulceration Forrest classification 1a, 1b, 2a, 2b, 2c and/or 3.

Data and biological material

Register data from electronic patient journals

Collaborating researchers and departments

Department of Medical Gastrointestinal Diseases, Odense University Hospital

• Post.doc., Stig Borbjerg Laursen, PhD
• Medical Student, Nikolaj Vestergaard Carlsen