Acute Variceal Hemorrhage in Germany-A Nationwide Study of 65,357 Hospitalized Cases: Variceal Hemorrhage in Germany

Abstract

Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.

Keywords: AVH; EST; EVL; TIPS; adverse events; in-hospital mortality; incidence, endoscopic therapy; outcome; variceal bleeding.

Figure 1

Study population: (a) sex distribution and (b) age distribution.

Figure 2

Study population, underlying etiology for liver disease.

Figure 3

Study population, alcohol-related acute variceal hemorrhage; total number of cases per year between 2010 and 2019 (solid line), right y-axis. Cases are as percentages per year between 2010 and 2019 (bars), on the left y-axis and the x-axis: year.

Figure 4

Total number of acute variceal hemorrhage cases per year between 2010 and 2019 (solid line), right y-axis. Mortality per year between 2010 and 2019 (bars), left y-axis; x-axis: year.

Figure 5

Distribution of acute variceal hemorrhage cases (total number, inside pie chart) concerning the volume of the centers (cases per hospital/year, label below the graph) and mortality in each group (as a percentage, next to the hospital icons).

Figure 6

Incidence of AVH in Germany. (a) Incidence of AVH per 100,000 residents per year and federal state; left top corner: nationwide incidence between 2010 and 2019 (8.9). (b) Incidence of AVH in the New Federal States without Berlin (right, deep blue) and in the Old Federal States including Berlin (left, pale blue); left top corner: nationwide incidence between 2010 and 2019. BB: Brandenburg, BE: Berlin, BW: Baden-Württemberg, BA: Bavaria, HE: Hesse, BR: Bremen, HA: Hamburg, MW: Mecklenburg–Western Pomerania, LS: Lower Saxony, NW: North Rhine–Westphalia, RP: Rhineland-Palatinate, SH: Schleswig-Holstein, SL: Saarland, SA: Saxony, ST: Saxony-Anhalt, and TH: Thuringia.