title: Delayed endoscopy increases re-bleeding and mortality in patients with hematemesis and active esophageal variceal bleeding: a cohort study.
abstract: OBJECTIVE
  Active bleeding is a poor prognostic indicator in patients with acute esophageal variceal bleeding. This study aimed at determining indicators of 6-week re-bleeding and mortality in patients with "active" esophageal variceal bleeding, particularly emphasizing the presenting symptoms and timing of endoscopy to define the treatment strategy.
  
  
  METHODS
  From July 2005 to December 2009, cirrhotic patients with endoscopy-proven active esophageal variceal bleeding were evaluated. Cox proportional hazards regression analysis was used to determine the indicators of 6-week re-bleeding and mortality. Outcome comparisons were performed by Kaplan-Meier method and log rank test.
  
  
  RESULTS
  In 101 patients, the overall 6-week and 3-month re-bleeding rates were 25.7% (n=26) and 29.7% (n=30), respectively. The overall 6-week and 3-month mortality was 31.7% (n=32) and 38.6% (n=39), respectively. Door-to-endoscopy time (hr), MELD score, and portal vein thrombosis were indicators of 6-week re-bleeding, while hematemesis upon arrival, MELD score, and hepatocellular carcinoma were indicators of 6-week mortality. Overall mortality was poorer in hematemesis than in non-hematemesis patients (39.7% vs. 10.7%, p=0.007). In hematemesis patients, 6-week re-bleeding rate (18.9% vs. 38.9%, p=0.028) and mortality (27% vs. 52.8%, p=0.031) were lower in those with early (≤ 12 h) than delayed (>12h) endoscopy. In non-hematemesis patients, early and delayed endoscopy had no difference on 6-week re-bleeding rate (17.6% vs. 18.2%, p=0.944) and mortality (11.8% vs. 9.1%, p=0.861).
  
  
  CONCLUSIONS
  It is likely that early endoscopy (≤ 12 h) is associated with a better outcome in hematemesis patients, but a randomized trial with larger case numbers is required before making a firm conclusion.
authors.affiliation: Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Ping-Hsien
authors.initials: PH
authors.lastname: Chen
authors.forename: Wen-Chi
authors.initials: WC
authors.lastname: Chen
authors.forename: Ming-Chih
authors.initials: MC
authors.lastname: Hou
authors.forename: Tsu-Te
authors.initials: TT
authors.lastname: Liu
authors.forename: Chen-Jung
authors.initials: CJ
authors.lastname: Chang
authors.forename: Wei-Chih
authors.initials: WC
authors.lastname: Liao
authors.forename: Chien-Wei
authors.initials: CW
authors.lastname: Su
authors.forename: Huay-Min
authors.initials: HM
authors.lastname: Wang
authors.forename: Han-Chieh
authors.initials: HC
authors.lastname: Lin
authors.forename: Fa-Yauh
authors.initials: FY
authors.lastname: Lee
authors.forename: Shou-Dong
authors.initials: SD
authors.lastname: Lee
mesh_terms: D000368:Aged; D015331:Cohort Studies; D016099:Endoscopy, Gastrointestinal; D004932:Esophageal and Gastric Varices / Q000401:mortality*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000401:mortality*; D006396:Hematemesis / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D012008:Recurrence; D012720:Severity of Illness Index