The clinical benefit of fresh frozen plasma ( #FFP ) transfusion prior to endoscopy in patients with acute upper gastrointestinal bleeding (AUGIB) and mild coagulopathy remains uncertain. We evaluated the association between pre-endoscopic FFP transfusion and clinical outcomes in patients with AUGIB and an international normalized ratio (INR) of 1.5-2.5. We conducted a retrospective two-center cohort study including adult patients admitted with AUGIB and INR 1.5-2.5 at two tertiary referral hospitals in Thailand between 2016 and 2020. Patients were categorized according to receipt of pre-endoscopic FFP transfusion. Multivariable logistic regression analyses were performed using baseline covariates and bleeding severity scores. An exploratory composite in-hospital major adverse event endpoint was evaluated to improve model stability. Among 244 patients (158 received FFP; 86 did not), those receiving pre-endoscopic FFP had higher crude rates of 30-day all-cause mortality (23.4% vs. 11.6%), in-hospital mortality (24.1% vs. 7.0%), pulmonary edema (23.4% vs. 4.7%), and the composite in-hospital major adverse event endpoint (40.5% vs. 10.5%) (all p < 0.01). After multivariable adjustment, pre-endoscopic FFP transfusion remained associated with the composite endpoint (adjusted odds ratio [aOR] 5.28; 95% confidence interval [CI], 2.17-12.82), in-hospital mortality (aOR 5.36; 95% CI, 1.87-15.37), pulmonary edema (aOR 3.85; 95% CI, 1.21-12.26), and 30-day mortality (aOR 2.69; 95% CI, 1.09-6.66). In subgroup analyses, these associations were more consistent among patients with variceal bleeding. In patients with AUGIB and mildly elevated INR, pre-endoscopic FFP transfusion was associated with higher mortality and pulmonary complications, particularly in those with variceal bleeding. Given the retrospective design and potential for residual confounding, these findings should be interpreted with caution. Nevertheless, these findings support consideration of a more selective, context-based approach to plasma transfusion and highlight the need for prospective studies to inform evidence-based transfusion strategies.
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