Background: Esophageal varices with bleeding (EVB) are one of the most common causes of deaths in cirrhotic patients in the United States. Over the course of years, studies have reported an increase in the incidence of EVB and is associated with a high risk for morbidity and mortality. Data is lacking with regards to recent incidence patterns, associated risk predictors, and outcomes of cirrhotic patients admitted with EVG in the United States. We aim to determine the hospitalization trend, predictors and outcomes of EVB in patients with cirrhosis using the largest population database available in the US.
Methods: National Inpatient Sample (NIS) for years 2007-2018 was utilized to identify hospitalizations due to EVB among adult cirrhotic patients using International Classification of Diseases (9th/10th Edition) Clinical Modification Procedural codes (ICD-9/10-CM) diagnosis codes which have been previously validated. Diagnosis of interests and other co-morbidities were identified by ICD-9/10-CM codes and Elixhauser comorbidity software. Multi-variable survey logistic regression was performed to analyze the temporal trends, predictors and outcomes using SAS 9.4 analytical software.
Results: Out of a total 9,804,819 hospitalizations among cirrhotic patients during 2007-2018, 462,723 (4.6%) were due to EVB. Trend of EVB decreased from 6.8% in 2007 to 4.4% in 2018 (ptrend<0.001). Cirrhotic patients who were admitted due to EVB were younger (56 vs 59; p< 0.001) and predominantly male (68% vs. 32%, p< 0.001). Furthermore, in multi-variable regression analysis, males (OR 1.3; 95% CI 1.3-1.4; p< 0.0001), Hispanics (OR 1.7; 95% CI 1.6-1.7; p< 0.001), Asians (OR 1.5; 95% CI 1.6-1.7; p< 0.001), Caucasians (OR 1.3; 95% CI 1.3-1.4; p< 0.001), lower socio-economic status (OR 1.1; 95% CI 1.1-1.1; p: 0.001), West Region (OR 1.3; 95% CI 1.2-1.4; p< 0.0001), H. Pylori infection (OR 1.5; 95% CI 1.4-1.5; p< 0.001), Alcoholism (OR 1.8; 95% CI 1.8-1.9; p< 0.001), and NSAIDS (OR 2.5; 95% CI 2.5-2.8; p< 0.001) were associated with higher odds of EVB. Moreover older age and African-American ethnicity were associated with lower odds of hospitalization due to EVB. In-hospital mortality rate (10% vs 7%, p:<0.001) was higher during hospitalization due to EVB as compared to non-EVB causes among cirrhotic patients. Of those admitted due to EVB, 14% were discharged to facility and mean length of stay of hospitalization was 6-days.
Conclusions: In this study we demonstrated decreasing trends of hospitalizations due to EVB among cirrhotic patients however it is still associated with significant in-hospital mortality and morbidity. Our study also identified risk factors associated with EVB some which are modifiable. More in-depth studies are required to better risk stratification and develop preventive strategies among these high-risk cirrhotic patients to improve overall outcomes.