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Prevalence, management, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding in the United Kingdom

Authors

  • Vipul Jairath,

    Corresponding author
    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Brennan C. Kahan,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Simon J. Stanworth,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Richard F.A. Logan,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Sarah A. Hearnshaw,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Simon P.L. Travis,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Kelvin R. Palmer,

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • Michael F. Murphy

    1. From NHS Blood & Transplant and the Translational Gastroenterology Unit, Oxford University Hospitals, Oxford; the MRC Clinical Trials Unit, London; the Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, Nottingham; the Royal Victoria Infirmary, Newcastle; and Western General Infirmary, Edinburgh, UK.
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  • VJ is a current research fellow funded by NHS Blood and Transplant and SH is a previous research fellow who was jointly funded by NHS Blood and Transplant and the British Society of Gastroenterology. Representatives from each of these groups (MM and KP) were involved in the design and reporting of the study (see contributorship statement). Participating hospitals did not receive any financial support.

  • VJ had the idea for this analysis, performed analyses, wrote the first draft of the manuscript, and has approved the final draft submitted; BCK performed analyses for the study, contributed to the writing of this manuscript, and has approved the final draft submitted; SJS contributed to the writing of this manuscript and has approved the final draft submitted; RFAL designed the original study, contributed to the writing of this manuscript, is a guarantor, and has approved the final draft submitted; SAH designed and conducted the original audit study, is guarantor for the data, and has approved the final draft submitted; SPLT was involved in the original study design, contributed to the writing of this manuscript, and has approved the final draft submitted; KP designed the audit original study, is a guarantor, reviewed this manuscript, and has approved the final draft submitted; and MFM had the idea for the original study, was involved in study design, is a guarantor, and has approved the final draft submitted.

Vipul Jairath, BSc, MBChB, MRCP, NHS Blood and Transplant and Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford OX3 9DU, UK; e-mail: vipul.jairath@nhsbt.nhs.uk.

Abstract

BACKGROUND: Coagulopathy after major hemorrhage has been found to be an independent risk factor for mortality after traumatic bleeding. It is unclear whether similar associations are present in other causes of major hemorrhage. We describe the prevalence, use of plasma, and outcomes of patients with coagulopathy after acute nonvariceal upper gastrointestinal bleeding (NVUGIB).

STUDY DESIGN AND METHODS: This study was a multicenter UK national audit. Data were collected prospectively on consecutive admissions with upper gastrointestinal bleeding over a 2-month period to 212 UK hospitals. Coagulopathy was defined as an international normalized ratio (INR) of at least 1.5. Logistic regression was used to examine the relationship between coagulopathy and patient-related outcome measures of mortality, rebleeding, and need for surgery and/or radiologic intervention.

RESULTS: A total of 4478 patients were included in the study. Coagulopathy was present in 16.4% (444/2709) of patients in whom an INR was recorded. Patients with coagulopathy were more likely to present with hemodynamic shock (45% vs. 36%), have a higher clinical Rockall score (4 vs. 2), receive red blood cell transfusion (79% vs. 48%) and have high-risk stigmata of hemorrhage at endoscopy (34% vs. 25%). After adjustment for confounders the presence of a coagulopathy was associated with a fivefold increased in the odds of mortality (odds ratio, 5.63; 95% confidence interval, 3.09-10.27; p < 0.001). Only 35% of patients with coagulopathy received fresh-frozen plasma transfusion.

CONCLUSIONS: Coagulopathy was prevalent in 16% of patients after NVUGIB and independently associated with more than a fivefold increase in the odds of in-hospital mortality. Wide variation in plasma use exists indicates clinical uncertainty regarding optimal practice.

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