Diagnostic and Therapeutic Interventions in Acute Variceal Bleeding: Trends, Mortality, and Outcomes Comparison by Timing of Procedures, NIS 2004-2019

Introduction: Acute variceal bleeding (AVB) is a life-threatening emergency with a high mortality rate. Management requires endoscopic intervention after fluid resuscitation, ideally within 12 hours of presentation. We aimed to analyze AVB hospitalizations, the timing of procedures, and outcomes such as mortality and hospital resource utilization. Methods: We extracted adult hospitalizations from Nationwide Inpatient Sample (NIS) 2004-2019yy with ICD-9 and ICD-10 Diagnosis codes of AVB (456.0,I85.01) and associated procedure codes of esophagoscopy (EGD) and esophageal variceal ligation (EVL) (42.22,42.23,42.33,42.91,44.43,45.13, 49.95,0DJ08ZZ,0W3P8ZZ,06L38CZ,06L34CZ). We divided procedure timing into early (< 24hrs) and delayed ( >24hrs). Mortality, length of stay (LOS), and mean charges (MC) were used as outcomes. These outcomes were compared between early and delayed procedure groups. Results: Over a 16-year period, AVB hospitalizations increased from 4,798 in 2004 to 8,095 in 2019, with a peak of 9,280 in 2016. Timing of procedures has not shown significant change, ranging from 76% to 80% of EGDs performed in < 24 hours across all years. There was significant male-to-female predominance (69% vs. 31% in 2004; 63% vs. 37% in 2019). The racial distribution was similar over time, except for a minor increase in Native American/Other and Asian or Pacific Islander hospitalizations and a decrease in Black patient hospitalizations. A large shift was noted in hospitalizations towards teaching institutions (39% in 2004 to 74% in 2019). Mortality of early and delayed procedure groups is demonstrated in Figure. Overall mortality was 6.4% (95% CI:6.02%-6.83%) in the early and 9.1% (95% CI: 8.18%-10.01%) in the delayed procedure group. MC has increased, by +Δ $62,527.00 for early and +Δ $105,406.00 for the delayed procedure group; Mean LOS was 5 (95% CI 5.0-5.1) and 9 days (95% CI 8.8-9.4) for early and delayed groups, respectively. Conclusion: From 2004 to 2019, hospitalizations for acute variceal bleeding, as well as associated therapeutic procedures, costs, and lengths of stay have steadily increased. There was a notable spike in hospitalizations in 2016, however, this coincided with ICD coding transition. Most EGD and EVL procedures (76-80%) were performed in < 24 hours from admission. Inpatient mortality is notably higher if interventions for AVB are delayed. Early and timely interventions should be strongly encouraged and performed.Figure 1.: Mortality of Variceal Bleeding Hospitalizations by Timing of Upper Endoscopy, NIS 2004-2019.