SCURVY IS PREVALENT IN PATIENTS PRESENTING WITH UPPER GASTROINTESTINAL BLEEDING AND PREDICTS INCREASED MORTALITY AND ADVERSE CLINICAL OUTCOMES: A PROSPECTIVE AUSTRALIAN COHORT STUDY

ABSTRACT

Background: Upper gastrointestinal bleeding (UGIB) remains the most common gastrointestinal emergency associated with high morbidity and mortality. Established risk factors for UGIB include Helicobacter pylori infection and non steroidal anti inflammatory use. While thought to be rare in developed countries, Vitamin C deficiency (VCD) is well described in patients with pneumonia, sepsis and more recently Coronavirus disease 2019. No previous studies have investigated the impact of VCD in UGIB. Aims: To investigate the prevalence of VCD in patients presenting with UGIB and the association between VCD and clinical outcomes. Methods: Patients presenting with UGIB to 2 Australian tertiary centers were prospectively recruited over a 10-month period. Fasting Vitamin C levels were obtained on admission. All patients were risk stratified using the AIMS65 score. The primary outcome was the prevalence of VCD (Vitamin C level <23mcmol/L) and severe deficiency (<11mcmol/L). Secondary outcomes included a composite endpoint of adverse events (AE), comprising inpatient death, intensive care unit (ICU) admission, rebleeding, surgery, angioembolization or massive transfusion ($4 units blood). Subgroup analyses were performed in variceal and non-variceal UGIB and outcomes stratified by AIMS65 score. Results: 157 patients were included. Median age was 64 years (IQR 53-77), 65% were male and median AIMS65 was 1 (IQR 1-2). Mean Vitamin C level was 39.5 ± 25mcmol/L. The etiology of UGIB was variceal bleeding (21.6%), peptic ulcer disease (45.2%) and other (33.1%). Inpatient mortality was 5.7% and mean length of stay (LOS) was 7.7 days. VCD was identified in 53 patients (33.8%) with severe deficiency in 21 (13.3%). VCD was associated with significantly higher mortality (13.2% vs. 1.9%, p<0.01) and AEs (composite endpoint 47.2% vs. 28.8%, p=0.02). Inpatient rebleeding was higher in the VCD group (13.2% vs. 7.7%, p=0.27);this did not reach significance, most likely due to Type 2 error. No differences in ICU admission, transfusion requirements, LOS or AIMS65 score were noted. In non-variceal UGIB (n=123), VCD was associated with higher mortality (5.6% vs. 0%, p=0.03) and AEs (composite endpoint 41.7% vs. 24.1%, p=0.05). VCD was most prevalent in patients with variceal UGIB (50% vs. 29%, p=0.02) and associated with a trend towards higher mortality (29.4% vs. 11.7%, p=0.21). In the low-risk UGIB cohort (AIMS65 score 0-2), VCD was associated with increased mortality (10% vs. 0%, p<0.01) and AEs (composite endpoint 36.7% vs. 17.1%, p=0.03);in the high-risk UGIB cohort (AIMS65 35), VCD was associated with a trend towards higher mortality (17.4% vs. 6.1%, p=0.18). Conclusion: VCD is prevalent in patients with UGIB and associated with significantly higher mortality and AEs. Further studies are required to determine the impact of early Vitamin C supplementation following UGIB.