HONOLULU – Obese patients who develop an upper GI bleed receive more treatment, are more likely to develop hemorrhagic shock, and are more likely to require admission to an intensive care unit than those who are not obese, but they do not have higher in-hospital mortality, according to analysis of a large national database that was presented at the annual meeting of the American College of Gastroenterology.
The significantly greater odds ratio of most major complications from upper GI bleeds in patients with obesity relative to those who are not obese was expected but so was an increased rate of in-hospital mortality, according to the first author of the study, Dr. Marwan S. Abou Gergi of Catalyst Medical Consulting, Baltimore.
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“In this study, patients with obesity received more frequent endoscopic interventions, which could explain why mortality rates were not significantly higher,” Dr. Abou Gergi reported.
In the analysis, characterized as the first study to evaluate the impact of obesity on outcomes in upper GI hemorrhage, data were drawn from the 2012 Nationwide Inpatient Sample database, which is considered to provide a representative sample of U.S. hospital experience. Drawn from more than 7 million hospitalizations, the study focused on patients 18 or over with a primary ICD-9 code for upper GI hemorrhage. The primary outcome was mortality. Secondary outcomes included interventions, ICU admissions, and length of stay.
Of the 132,545 discharges with upper GI hemorrhage, 11,220 (8.5%) were identified as obese. The in-hospital mortality overall was 1.97%, but the proportion of those who died was slightly lower among patients identified as obese, producing a nonsignificant adjusted odds ratio (OR) of 0.87 (P greater than .1). Yet the rates of hemorrhage shock (OR 1.31; P = .02) and admission to the ICU (OR 1.35; P less than .02) were greater in the obese. The median length of stay of 0.35 days for obese patients was also significantly longer.
One reason for the lower rate of mortality may be more aggressive treatment. In particular, repeat endoscopy therapy was more common in those who were obese (P less than .01), suggesting, “Our treatments are working,” Dr. Abou Gergi said.
The proportion of patients with a score of 3 or greater on the Charlson comorbidity index was higher in the obese than in those not identified as obese (49% vs. 39%; P less than .01). This along with previously published evidence that obese patients take more anticoagulants, take more antiplatelets, and may face delays in endoscopy due to greater difficulty in administering sedation, were among considerations predicting a higher mortality, according to Dr. Abou Gergi.
However, there are several potential explanations for these unexpected findings. One is that mortality rates overall were low, making it difficult to show differences on this outcome. In addition, ICD-9 codes may be effective for isolating a group with obesity but not in identifying a control group without obesity.
“It is likely that not all patients who are obese received this code, so we may be seeing a population of obese patients be compared to another population that includes at least some patients who also have obesity,” explained Dr. John R. Saltzman, director of endoscopy, Brigham and Women’s Hospital, Boston. A coauthor of this study, Dr. Saltzman noted that despite a comparable rate of in-hospital mortality, most of the findings in the study argued that patients who develop upper GI bleeding have a more difficult course. He noted that this is reflected in the cost of care, which was significantly higher in those who were obese.
Although he acknowledged that he was surprised that this was “essentially a negative study,” he believes that mortality may have been “too tough” as a primary endpoint for demonstrating a difference. However, he also believes that it may be appropriate to give credit for effective treatments.
“I think that may be the key. We are just getting better at taking care of these patients,” Dr. Saltzman said.
Dr. Abou Gergi reported he has no relevant financial relationships.