Prediction of outcome of acute GI hemorrhage: a review of risk scores and predictive models

Utilizing point-of-care lactate testing for rapid prediction of clinical outcomes in patients with acute gastrointestinal bleeding in the emergency department

Objectives

We aimed to rapidly predict the prognosis of patients who present to the emergency department (ED) with acute gastrointestinal bleeding (AGIB) using point-of-care (POC) lactate testing.

Methods

This single-center retrospective observational study included 327 patients (survival group, 287; non-survival group, 40) who presented to the ED with AGIB between March 2021 and February 2022. We compared POC-measured lactate levels with laboratory-measured lactate levels using Pearson's correlation. Multivariate logistic regression analysis was used to identify early predictors of in-hospital mortality and correlated clinical outcomes. Receiver operating characteristic (ROC) curves were used to determine the optimal cutoff for POC-measured lactate levels for predicting in-hospital mortality, and the ROC curves for POC-measured lactate levels and AIMS65 scores were compared using the DeLong test.

Results

POC-measured lactate levels strongly correlated with laboratory-measured lactate levels (R2 = 0.82). Patients in the non-survival group had higher POC-measured lactate levels than did those in the survival group (2.6 mmol/L vs. 1.4 mmol/L, p < 0.001). POC-measured lactate level, age, systolic blood pressure, heart rate, and malignancy were identified as early predictors of in-hospital mortality (adjusted odds ratio [aOR] for POC-measured lactate levels: 1.15; 95 % confidence interval [CI] 1.02-1.30). The optimal POC-measured lactate level cutoff was 3.2 mmol/L. Areas under the ROC curves for POC-measured lactate level and the AIMS65 score were 0.70 and 0.73, respectively, showing statistical compatibility. Higher POC-measured lactate levels correlated with ICU admission, blood transfusion, and mechanical ventilation (aOR: 1.16, 95 % CI 1.05-1.27; 1.16, 1.04-1.30; and 1.31, 1.13-1.53, respectively]. Further, the hyperlactatemia subgroup (POC-measured lactate level ≥3.2 mmol/L) exhibited a lower survival probability in the Kaplan-Meier survival analysis (p < 0.01).

Conclusions

Our study shows that rapidly obtainable POC-measured lactate levels are valuable for predicting critical outcomes in AGIB patients and should be considered an early prognostic indicator for in-hospital mortality in the ED.

VALIDATION OF THE ROCKALL SCORE IN UPPER GASTROINTESTINAL TRACT BLEEDING IN A COLOMBIAN TERTIARY HOSPITAL

ABSTRACT Background Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose upper gastrointestinal bleeding (UGIB). Several studies have been conducted in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. Also, there is controversy regarding the best cut-off point for the score. Moreover, no studies validating this score in Colombia have been carried out. Objective To assess the diagnostic performance of the Rockall score in predicting rebleeding and mortality in patients with non-varicose UGIB. Methods A prospective cohort study was conducted in patients requiring upper gastrointestinal endoscopy (UGIE) for non-varicose bleeding. The pre-and post-endoscopy Rockall scores were calculated and outcomes, including mortality, UGIB-associated mortality and in hospital rebleeding were determined at the 1 and 3-month time points. The association between the scores and these outcomes was assessed using the chi2 or the Fisher test, whereas the discrimination ability of the score was determined using the areas under the ROC curve (AUC). High discrimination ability was considered to exist in cases in which an AUC ≤0.7 with α=0.05 could be rejected. Results Overall, 177 patients were analyzed. In-hospital outcomes at 1 and 3 months were 12%, 17% and 23% for general mortality, 6%, 12% and 15% for UGIB mortality, and 19%, 30% and 37% for rebleeding. The post-endoscopy Rockall score was associated with the three outcomes at the three time points assessed, while the pre-endoscopy score was only associated with general mortality at the three time points, and rebleeding at 1 and 3 months. Regarding discrimination ability, although the AUC was greater than expected by randomness (0.5) in all cases, only one AUC ≤0.7 was rejected in the post-endoscopy score for in-hospital UGIB mortality (AUC=0.901; 95%CI: 0.845—0.958), at 1 month (AUC=0.836; 95%CI: 0.717—0.954) and at 3 months (AUC=0.869; 95%CI: 0.771—0.967), and for rebleeding at 1 month (AUC=0.793; 95%CI: 0.725—0.861) and at 3 months (AUC=0.806; 95%CI: 0.741—0.871). Conclusion An association was found between the Rockall score and rebleeding and mortality in patients with non-varicose UGIB. Only the post-endoscopy score had a high predictive ability for rebleeding and UGIB mortality.

Prospective cost analysis of early video capsule endoscopy versus standard of care in non-hematemesis gastrointestinal bleeding: a non-inferiority study

Background and aim: A non-inferiority cost analysis was performed to assess if the early capsule approach would incur higher costs than the standard of care approach in patients presenting with non-hematemesis gastrointestinal bleeding.Methods: A prospective non-inferiority cost analysis was performed on patients receiving either an early video capsule as the first diagnostic procedure or an endoscopic procedure as determined by gastroenterology staff that were not involved in the study. Primary outcome was total direct costs incurred in both groups.Results: Forty-five patients and 42 patients were enrolled into the early capsule and standard of care arms, respectively. There was no difference in total direct cost per inpatient case in both groups ($7,362 vs $7,148, p = 0.77 [CI = -2,285-2,315, equivalent margin = -$3,100]). Localization of a bleeding source after the first diagnostic procedure was identified more frequently in the early capsule group (69.2% vs 27.9%, p = 0.0003). If patients were discharged after their last non-diagnostic evaluation, then length of stay could be decreased by 50% in both groups (58.5 to 31.6 h, p = 0.02 in the early capsule group and 69.4 to 39.2 h in the standard of care group p = 0.001). Projections indicate the fastest a patient with non-diagnostic evaluations could be discharged is 0.88 days in the early capsule group vs 1.63 days in the standard of care group (p = 0.0005).Discussion: In patients with non-hematemesis bleeding, video capsule endoscopy may be a more efficient diagnostic approach than the standard of care approach, since it detects bleeding significantly more often without an increase in healthcare costs.

Comparison of computed tomography findings with clinical risks factors for endoscopic therapy in upper gastrointestinal bleeding cases

Several risk scoring systems exist for acute upper gastrointestinal bleeding (UGIB). The clinical Rockall score (clinical RS) and the Glasgow-Blatchford score (GBS) are major risk scores that consider only clinical data. Computed tomography (CT) findings are equivocal in non-variceal UGIB. We compared CT findings with clinical data to predict mortality, rebleeding and need for endoscopic therapy in non-variceal UGIB patients. This retrospective, single-center study included 386 patients admitted to our emergency department with diagnosis of non-variceal UGIB by urgent endoscopy between January 2009 and March 2015. Multivariable logistic regression analysis was used to investigate CT findings and risk factors derived from clinical data. CT findings could not significantly predict mortality and rebleeding in non-variceal UGIB patients. However, upper gastrointestinal hemorrhage in CT findings better predicted the need for endoscopic therapy than clinical data. The adjusted odds ratios were 10.10 (95% CI 5.01-20.40) for clinical RS and 10.70 (95% CI 5.08-22.70) for the GBS. UGI hemorrhage in CT findings could predict the need for endoscopic therapy in non-variceal UGIB patients in our emergency department. CT findings as well as risk score systems may be useful for predicting the need for endoscopic therapy.

Impact of Computed Tomography Evaluation Before Colonoscopy for the Management of Colonic Diverticular Hemorrhage

GOALS

The purpose of this study was to investigate and summarize our experience of a standardized strategy using computed tomography (CT) followed by colonoscopy for the assessment of colonic diverticular hemorrhage with focus on a comparison of CT and colonoscopy findings in patients with colonic diverticular hemorrhage.

BACKGROUND

Colonic diverticular hemorrhage is usually diagnosed by colonoscopy, but it is difficult to identify the responsible bleeding point among many diverticula.

STUDY

We retrospectively included 257 consecutive patients with colonic diverticular hemorrhage. All patients underwent a CT examination before colonoscopy. All-cause mortality and rebleeding-free rate after discharge were analyzed by Kaplan-Meier analysis and compared using the log-rank test.

RESULTS

In CT examinations, 184 patients (71.6%) had definite diverticular hemorrhage with 31.9% showing intraluminal high-density fluid on plain CT, 39.7% showing extravasation, and 31.1% showing arteriovenous increase of extravasation on enhanced CT. In colonoscopy, 130 patients (50.6%) showed endoscopic stigmata of bleeding with 12.1% showing active bleeding, 17.1% showing a nonbleeding visible vessel, and 21.4% showing an adherent clot. A comparison of the locations of bleeding in CT and colonoscopy showed that the agreement rate was 67.3%, and the disagreement rate was 0.8% when the lesion was identified by both modalities patients with definite diverticular hemorrhage identified by CT had a longer hospital stay, higher incidences of hemodynamic instability and rebleeding events than did patients with presumptive diverticular hemorrhage.

CONCLUSION

CT evaluation before colonoscopy can be a good option for managing patients with colonic diverticular hemorrhage.

Lower Endoscopic Diagnostic Yields Observed in Non-hematemesis Gastrointestinal Bleeding Patients

BACKGROUND

Location of bleeding can present a diagnostic challenge in patients without hematemesis more so than those with hematemesis.

AIM

To describe endoscopic diagnostic yields in both hematemesis and non-hematemesis gastrointestinal bleeding patient populations.

METHODS

A retrospective analysis on a cohort of 343 consecutively identified gastrointestinal bleeding patients admitted to a tertiary care center emergency department with hematemesis and non-hematemesis over a 12-month period. Data obtained included presenting symptoms, diagnostic lesions, procedure types with diagnostic yields, and hours to diagnosis.

RESULTS

The hematemesis group (n = 105) took on average 15.6 h to reach a diagnosis versus 30.0 h in the non-hematemesis group (n = 231), (p = 0.005). In the non-hematemesis group, the first procedure was diagnostic only 53% of the time versus 71% in the hematemesis group (p = 0.02). 25% of patients in the non-hematemesis group required multiple procedures versus 10% in the hematemesis group (p = 0.004). Diagnostic yield for a primary esophagogastroduodenoscopy was 71% for the hematemesis group versus 50% for the non-hematemesis group (p = 0.01). Primary colonoscopies were diagnostic in 54% of patients and 12.5% as a secondary procedure in the non-hematemesis group. A primary video capsule endoscopy yielded a diagnosis in 79% of non-hematemesis patients (n = 14) and had a 70% overall diagnostic rate (n = 33).

CONCLUSION

Non-hematemesis gastrointestinal bleeding patients undergo multiple non-diagnostic tests and have longer times to diagnosis and then compared those with hematemesis. The high yield of video capsule endoscopy in the non-hematemesis group suggests a role for this device in this context and warrants further investigation.

Lower Gastrointestinal Bleeding

Lower gastrointestinal bleeding entails a range of severity and a multitude of options for localization and control of bleeding. With experience in trauma, critical care, endoscopy, and definitive surgical interventions, general surgeons are equipped to manage this condition in various clinical settings. This article examines traditional and emerging options for bleeding localization and control available to general surgeons.

Elevated lactate level predicts intensive care unit admissions, endoscopies and transfusions in patients with acute gastrointestinal bleeding

Background and aims

Initial clinical management decision in patients with acute gastrointestinal bleeding (GIB) is often based on identifying high- and low-risk patients. Little is known about the role of lactate measurement in the triage of patients with acute GIB. We intended to assess if lactate on presentation is predictive of need for intervention in patients with acute GIB.

Patients and methods

We performed a single-center, retrospective, cross-sectional study including patients ≥18 years old presenting to emergency with acute GIB between January 2014 and December 2014. Intensive care unit (ICU) admission, inpatient endoscopy (upper endoscopy and/or colonoscopy), and packed red blood cell (PRBC) transfusion were assessed as outcomes. Analyses included univariate and multivariate logistic regression analyses.

Results

Of 1,237 patients with acute GIB, 468 (37.8%) had venous lactate on presentation. Of these patients, 165 (35.2%) had an elevated lactate level (>2.0 mmol/L). Patients with an elevated lactate level were more likely to be admitted to ICU than patients with a normal lactate level (adjusted odds ratio [AOR] 2.96, 95% confidence interval [CI] 1.74–5.01; p<0.001). Patients with an elevated lactate level were more likely to receive PRBC transfusion (AOR 3.65, 95% CI 1.76–7.55; p<0.001) and endoscopy (AOR 1.64, 95% CI 1.02–2.65; p=0.04) than patients with a normal lactate level.

Conclusion

Elevated lactate level predicts the need for ICU admissions, transfusions, and endoscopies in patients with acute GIB. Lactate measurement may be a useful adjunctive test in the triage of patients with acute GIB.

Predictors of in-hospital mortality in a cohort of elderly Egyptian patients with acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (UGIB) affects large number of elderly with high rates of morbidity and mortality. Early identification and management of the factors predicting in-hospital mortality might decrease mortality. This study was conducted to identify the causes of acute UGIB and the predictors of in-hospital mortality in elderly Egyptian patients.286 elderly patients with acute UGIB were divided into: bleeding variceal group (161 patients) and bleeding nonvariceal group (125 patients). Patients' monitoring was done during hospitalization to identify the risk factors that might predict in-hospital mortality in elderly.Variceal bleeding was the most common cause of acute UGIB in elderly Egyptian patients. In-hospital mortality rate was 8.74%. Increasing age, hemodynamic instability at presentation, co-morbidities (especially liver cirrhosis associated with other co-morbidity) and failure to control bleeding were the predictors of in-hospital mortality.Increasing age, hemodynamic instability at presentation, co-morbidities (especially liver cirrhosis associated with other co-morbidity) and failure to control bleeding should be considered when triaging those patients for immediate resuscitation, close observation, and early treatment.

Weekend effect in upper gastrointestinal bleeding: a systematic review and meta-analysis

Aim

To perform a systematic review and meta-analysis of the weekend effect on the mortality of patients with upper gastrointestinal bleeding(UGIB).

Methods

The review protocol has been registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42017073313) and was written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a search of the PUBMED, COCHRANE, EMBASE and CINAHL databases from inception to August 2017. All observational studies comparing mortality between UGIB patients with weekend versus weekday admissions were included. Articles that were published only in abstract form or not published in a peer-reviewed journal were excluded. The quality of articles was assessed using the Newcastle-Ottawa Scale. We pooled results from the articles using random-effect models. Heterogeneity was evaluated by the chi-square-based Q-test and I²test. To address heterogeneity, we performed sensitivity and subgroup analyses. Potential publication bias was assessed via funnel plot.

Results

Eighteen observational cohort studies involving 1,232,083 study patients were included. Weekend admission was associated with significantly higher 30-day or in-hospital mortality in all studies (OR = 1.12, 95% CI [1.07–1.17], P < 0.00001). Increased in-hospital mortality was also associated with weekend admission (OR = 1.12, 95% CI [1.08–1.17], P < 0.00001). No significant difference in in-hospital mortality was observed between patients admitted with variceal bleeding during the weekend or on weekdays (OR = 0.99, 95% CI [0.91–1.08], P = 0.82); however, weekend admission was associated with a 15% increase in in-hospital mortality for patients with non-variceal bleeding (OR = 1.15, 95% CI [1.09–1.21], P < 0.00001). The time to endoscopy for weekday admission was significantly less than that obtained for weekend admission (MD = −2.50, 95% CI [−4.08–−0.92], P = 0.002).

Conclusions

The weekend effect is associated with increased mortality of UGIB patients, particularly in non-variceal bleeding. The timing of endoscopic intervention might be a factor that influences mortality of UGIB patients.

Digital Rectal Examination Reduces Hospital Admissions, Endoscopies, and Medical Therapy in Patients with Acute Gastrointestinal Bleeding

BACKGROUND

Although digital rectal examination is an established part of physical examinations in patients with acute gastrointestinal bleeding, clinicians are reluctant to perform a rectal examination. We intended to assess whether rectal examination affects the clinical management decision in these patients.

METHODS

We performed a single-center, retrospective, cross-sectional study using data from electronic health records of patients aged ≥18 years presenting to the emergency department with acute gastrointestinal bleeding. Hospital admissions, intensive care unit admissions, gastroenterology consultation, initiation of medical therapy (proton pump inhibitor or octreotide), and inpatient endoscopy (upper endoscopy or colonoscopy) were assessed as outcomes. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Of 1237 patients with acute gastrointestinal bleeding, 549 (44.4%) did not have a rectal examination. Patients who had a rectal examination were less likely to be admitted than patients who did not have a rectal examination (adjusted odds ratio [AOR], 0.49; 95% confidence interval [CI], 0.30-0.79; P = .004). Patients who had a rectal examination were less likely to be started on medical therapy (AOR, 0.64; 95% CI, 0.41-0.98; P = .04) and to have endoscopy (AOR, 0.64; 95% CI, 0.44-0.94; P = .02) than patients who did not have a rectal examination.

CONCLUSIONS

Rectal examination in patients with acute gastrointestinal bleeding can assist clinicians with clinical management decision and reduce admissions, endoscopies, and medical therapy in these patients.

Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding

Background

Acute upper gastrointestinal bleeding (UGIB) is a common gastrointestinal disease emergency and a cause of morbidity and mortality.

Objectives

To assess the clinical outcomes and explore predictive factors for mortality of elderly patients with acute UGIB.

Methods

During the study period from January 2010 to September 2011, we prospectively enrolled 981 patients presenting with UGIB from 11 hospitals (mean age ± standard deviation (SD), 59.4 ± 14.9 years; range, 17–94 years; including 661 men). Of these 981 patients, 499 (50.9%) were elderly. Basic demographic data and clinical findings, and Rockall scores were collected and calculated.

Results

We studied 499 elderly patients. Their mean age ± SD was 71.63 ± 7.65 years. The 30-day mortality rate was 9% and rebleeding was just 1%. Regression analysis showed a pulse rate >100 beats per min at first visit, red blood in a nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL were independent predictive factors of 30-day mortality.

Conclusions

Peptic ulcer bleeding is a major cause of acute UGBI in the elderly. We recommend patients with predictive factors of mortality, pulse rate >100 beats per min at first visit, red blood in nasogastric aspiration, comorbidity with coronary artery disease, and creatinine >1.5 mg/dL be closely monitored and treated promptly. Reducing mortality from peptic ulcer bleeding should focus on preventing peptic ulcer occurrence as a result of ulcerogenic medications.

Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding

OBJECTIVE

Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients.

METHODS

The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB.

RESULTS

Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17).

CONCLUSION

Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.

Accurate triage of lower gastrointestinal bleed (LGIB) - A cohort study

INTRODUCTION

Acute lower gastrointestinal bleeding (LGIB) is a common acute presenting complaint to hospital. Unlike upper gastrointestinal bleeding, the diagnostic and therapeutic approach is not well-standardised. Intensive monitoring and urgent interventions are essential for patients with severe LGIB. The aim of this study is to investigate factors that predict severe LGIB and develop a clinical predictor tool to accurately triage LGIB in the emergency department of a busy metropolitan teaching hospital.

METHODS

We retrospectively identified all adult patients who presented to Middlemore Hospital Emergency Department with LGIB over a one year period. We recorded demographic variables, Charlson Co-morbidities Index, use of anticoagulation, examination findings, vital signs on arrival, laboratory test results, treatment plans and further investigations results. We then identified a subgroup of patients who suffered severe LGIB.

RESULTS

A total of 668 patients presented with an initial triage diagnosis of LGIB. 83 of these patients (20%) developed severe LGIB. Binary logistic regression analysis identified four independent risk factors for severe LGIB: use of aspirin, history of collapse, haemoglobin on presentation of less than 100 mg/dl and albumin of less than 38 g/l.

CONCLUSIONS

We have developed a clinical prediction tool for severe LGIB in our population with a negative predictive value (NPV) of 88% and a positive predictive value (PPV) of 44% respectively. We aim to validate the clinical prediction tool in a further cohort to ensure stability of the multivariate model.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

Increased mortality with peptic ulcer bleeding in patients with both compensated and decompensated cirrhosis

BACKGROUND

Cirrhosis is associated with worse outcomes in peptic ulcer bleeding (PUB). There are no population-based studies from the United States on the impact of cirrhosis on PUB outcomes.

OBJECTIVE

To investigate the impact of cirrhosis on outcomes of patients with PUB.

DESIGN

Cross-sectional study.

SETTING

Nationwide Inpatient Sample 2009.

PATIENTS

International Classification of Diseases, the 9th revision, codes were used to identify patients with PUB and cirrhosis. The control group was patients with PUB without cirrhosis.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality, length of stay, and hospitalization costs.

RESULTS

A total of 96,887 discharges with PUB as a diagnosis were identified-3574 with PUB and cirrhosis and 93,313 with PUB alone without cirrhosis. Mortality of PUB with concomitant cirrhosis was higher than in the control group without cirrhosis (5.5% vs 2%; P = .01); decompensated cirrhosis had higher mortality than did compensated cirrhosis (6.6% vs 3.9%; P = .01). In multivariate analysis, the presence of cirrhosis independently increased mortality (adjusted odds ratio (aOR) 3.3; 95% confidence interval [CI], 2.2-4.9). Stratified analysis showed that decompensated cirrhosis (aOR 4.4; 95% CI, 2.6-7.3) had higher mortality than compensated cirrhosis (aOR 1.9; 95% CI, 1.04-3.6). There was no difference in the proportion of patients who underwent endoscopy within 24 hours (51.9% vs 51.1%; P = .68) between those with cirrhosis and controls. Patients with cirrhosis received less surgical intervention (aOR 0.8; 95% CI, 0.6-0.9) compared with controls. Hospitalization costs also were increased in patients with decompensated cirrhosis.

LIMITATIONS

Administrative data set.

CONCLUSION

Both decompensated and compensated cirrhosis are associated with increased mortality in patients with PUB.

Timing of colonoscopy and outcomes in patients with lower GI bleeding: a nationwide population-based study

BACKGROUND

The role of urgent colonoscopy in lower GI bleeding (LGIB) remains controversial. Population-based studies on LGIB outcomes are lacking.

OBJECTIVE

To investigate the impact of the timing of colonoscopy on outcomes of patients with LGIB.

DESIGN

Cross-sectional study.

SETTING

Nationwide Inpatient Sample 2010.

PATIENTS

International Classification of Diseases, Ninth Revision, Clinical Modification codes identified patients with LGIB who underwent colonoscopy.

MAIN OUTCOME MEASUREMENTS

In-hospital mortality, length of stay, and hospitalization costs in patients who underwent early (≤24 hours) or delayed (>24 hours) colonoscopy.

RESULTS

A total of 58,296 discharges with LGIB were identified; 22,720 had a colonoscopy performed during the hospitalization. A total of 9156 patients had colonoscopy performed within 24 hours (early colonoscopy), and 13,564 had colonoscopy performed after 24 hours (delayed colonoscopy). There was no difference in mortality in patients with LGIB who had early versus delayed colonoscopy (0.3% vs 0.4%, P = .24). However, patients who underwent early colonoscopy had a shorter length of hospital stay (2.9 vs 4.6 days, P < .001), decreased need for blood transfusion (44.6% vs 53.8%, P < .001), and lower hospitalization costs ($22,142 vs $28,749, P < .001). On multivariate analysis, timing of colonoscopy did not affect mortality (adjusted odds ratio 1.5; 95% confidence interval, 0.7-2.7). On multivariate analysis, delayed colonoscopy was associated with an increase in the length of hospital stay by 1.6 days and an increase in hospitalization costs of $7187.

LIMITATIONS

Administrative dataset.

CONCLUSIONS

Early colonoscopy within 24 hours is associated with decreased length of hospital stay and hospitalization costs in patients with LGIB.

Nonvariceal upper gastrointestinal tract bleeding - risk factors and the value of emergency endoscopy

INTRODUCTION

Upper gastrointestinal tract bleeding (UGIB) remains a valid issue of modern medicine. The mortality and recurrence rates remain high and have not decreased as expected over the past decades.

AIM OF THE STUDY

to assess the treatment outcomes of nonvariceal UGIB depending on the timing of endoscopy (urgent vs. elective) and to perform an analysis of risk factors for death in patients with nonvariceal UGIB.

MATERIAL AND METHODS

Comparative evaluation of treatment outcomes in two groups of patients. Group A consisted of patients undergoing elective endoscopy (n = 187). Group B consisted of patients undergoing emergency endoscopy (n = 295). Moreover, the influence of selected factors on the risk of death and bleeding recurrence was analyzed in the combined population of the two groups. This was done by constructing a logistic regression model and testing dependence hypotheses.

RESULTS

In group A the mortality rate was 9.1%, and the recurrence rate was 18.2%. In group B the values were 6.8% and 12.2%, respectively. No statistically significant difference was found (p = NS). In group B the number of surgical interventions, blood transfusions and intensive care admissions was significantly lower (p < 0.05). An analysis of the combined material showed that the factors which correlated with an elevated risk of death included: old age, hemodynamic state (shock), elevated Charlson Comorbidity Index score, hemoglobin concentration, bleeding from a malignant lesion, recurrent bleeding and the need for surgery (p < 0.05).

CONCLUSIONS

The use of emergency endoscopy improves the treatment outcomes in patients with UGIB, although no statistically significant decrease in the mortality and recurrence rates could be observed.

Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management

Acute upper gastrointestinal bleeding (UGIB) is the most common reason that the 'on-call' gastroenterologist is consulted. Despite the diagnostic and therapeutic capabilities of upper endoscopy, there is still significant associated morbidity and mortality in patients experiencing acute UGIB, thus this is a true GI emergency. Acute UGIB is divided into non-variceal and variceal causes. The most common type of acute UGIB is 'non-variceal' and includes diagnoses such as peptic ulcer (gastric and duodenal), gastroduodenal erosions, Mallory-Weiss tears, erosive oesophagitis, arterio-venous malformations, Dieulafoy's lesion, and upper GI tract tumours and malignancies. This article focuses exclusively on initial management strategies for acute upper GI bleeding. We discuss up to date and evidence-based strategies for patient risk stratification, initial patient management prior to endoscopy, potential causes of UGIB, role of proton pump inhibitors, prokinetic agents, prophylactic antibiotics, vasoactive pharmacotherapies, and timing of endoscopy.

End-stage renal disease is associated with worse outcomes in hospitalized patients with peptic ulcer bleeding

BACKGROUND

Patients with end-stage renal disease (ESRD) are at increased risk of peptic ulcer bleeding (PUB). To our knowledge, there are no population-based studies of the impact of ESRD on PUB.

OBJECTIVE

To determine nationwide impact of ESRD on outcomes of hospitalized patients with PUB.

DESIGN

Cross-sectional study.

SETTING

Hospitals from a 2008 Nationwide Inpatient Sample.

PATIENTS

We used the International Classification of Diseases, the 9th Revision, Clinical Modification codes to identify patients who had a primary discharge diagnosis of PUB.

MAIN OUTCOME MEASUREMENT

In-hospital mortality, length of stay, and hospitalization charges.

INTERVENTIONS

Comparison of PUB outcomes in patients with and without ESRD.

RESULTS

Of a total of 102,525 discharged patients with PUB, 3272 had a diagnosis of both PUB and ESRD, whereas 99,253 had a diagnosis of PUB alone without ESRD. The mortality of ESRD patients with PUB was significantly higher than that of the control group without ESRD (4.8% vs 1.9%, P < .0001). On multivariate analysis, patients with PUB and ESRD had greater mortality than patients admitted to the hospital with PUB alone (adjusted odds ratio [aOR] 2.1; 95% confidence interval [CI], 1.3-3.4), were more likely to undergo surgery (aOR 1.4; 95% CI, 1.2-1.7), and had a longer hospital stay (aOR 2.1; 95% CI, 1.2-2.9). These patients also incurred higher hospitalization charges ($54,668 vs $32,869, P < .01) compared with patients with PUB alone.

LIMITATIONS

Administrative data set.

CONCLUSIONS

ESRD is associated with a significant health care burden in hospitalized patients with PUB. The presence of ESRD contributes to a higher mortality rate, longer hospital stay, and increased need for surgery.

Urgent endoscopy in elderly patients with non-variceal upper gastrointestinal bleeding

INTRODUCTION

Age of the patient is an important prognostic factor in patients with non-variceal upper gastrointestinal bleeding (UGIB). Despite that fact, current treatment algorithms do not differentiate UGIB management according to the patient's age.

AIM

To compare treatment outcomes in patients below and above 75 years of age, treated for UGIB with urgent endoscopy.

MATERIAL AND METHODS

Prospective analysis of treatment outcomes in 295 patients with non-variceal UGIB divided into two age groups (group A < 75 years of age, group B > 75 years of age). Urgent endoscopy (up to 3 h since admission) was performed in 292 patients. The groups were compared in regards to the duration of symptoms, previous UGIB, presence of factors predisposing to UGIB (NSAIDs, peptic ulcer disease, liver cirrhosis, and previous gastrointestinal surgery), haemodynamic state and haemoglobin (Hb) levels on admission. We analysed the causes of UGIB, severity of UGIB on the Forrest scale, type of endoscopic bleeding control method, and co-morbidities with use of the Charlson Co-morbidity Index (CCI). Treatment outcomes were assessed in regard of mortality rate, UGIB-recurrence rate, duration of hospital stay, amount of transfused blood products and the requirement of intensive therapy unit (ITU) or other departments' admissions. Patients were followed until their discharge home.

RESULTS

Mortality rate was 6.8% (group A vs. B: 3.5% vs. 18.7%; p = 0.001). Upper gastrointestinal bleeding recurrence was noted in 12.2% of patients (group A vs. B: 12.5% vs. 10.9%; p = 0.73). 2.4% of patients required surgery for UGIB (group A vs. B: 1.7% vs. 4.7%; p = 0.16). Patients in group B required ITU admission more frequently (group A vs. B: 1% vs. 4.7%; p < 0.01). The mean hospital stay (4.3 days) and the mean number of transfused packed red blood cells (PRBCs) (2.35 Units) did not differ between the groups. Patients in group B used NSAIDS much more frequently, more often had hypovolaemic shock and had a higher CCI score.

CONCLUSIONS

Urgent endoscopy is an important and broadly accepted method of treatment of UGIB. Despite strict adherence to the modern UGIB-treatment algorithms, mortality remains high in the elderly. Thus, these patients need particular attention. The presented study indicates that the standard management might not be sufficient in elderly patients.

Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding

AIM

The BLEED criterion is a triaging model for lower gastrointestinal bleeding (LGIB), which was developed and validated in the USA. We assessed the BLEED criteria in a UK population and aimed to elucidate factors that can be implemented for early risk stratification.

METHOD

Patients were identified from a prospectively maintained surgical admission database at a central London teaching hospital. Data were collected on 26 clinical factors available on initial presentation. The primary-outcome end-points included severe bleeding (persistent bleeding within the first 24 h, blood transfusion, a decrease in haematocrit of ≥ 20% or recurrent bleeding after ≥ 24 hours of stability) and adverse outcome (emergency surgery to control bleeding, intensive care unit [ITU] admission or death).

RESULTS

One hundred and eighty-four clinical episodes were identified, representing 3% of all surgical referrals. Twelve patients with upper gastrointestinal bleeding were excluded. Severe bleeding occurred in 110 (64%) patients. An adverse outcome was recorded in 20 (11.6%) patients, and 10 (5.4%) patients died during admission. The commonest aetiologies were diverticular disease, haemorrhoids and malignancy. Four prognosticators of adverse outcome were identified, these being: creatinine > 150 μm (P = 0.002); age > 60 years (P = 0.001); abnormal haemodynamic parameters on presentation (P = 0.05); persistent bleeding within the first 24 h (P = 0.05); and area under the receiver-operating characteristics curve (AUC) = 0.79. The BLEED criteria were shown to be nonpredictive (AUC = 0.60).

CONCLUSION

The BLEED criterion was not shown to have any predictive value in this patient cohort. Our study has determined an independent set of prognostic factors that could be incorporated into initial triaging of patients presenting with LGIB. This may facilitate the early identification of patients requiring more aggressive resuscitation, admission to a monitored bed and consideration for early radiological or surgical intervention.

Live view video capsule endoscopy enables risk stratification of patients with acute upper GI bleeding in the emergency room: a pilot study

BACKGROUND

Risk stratification of patients with acute upper GI bleeding (UGIB) in the emergency room (ER) enables appropriate triage to urgent endoscopy and therapeutic intervention.

AIM

The aim of this study was to evaluate the ability of Live View Video Capsule Endoscopy (VCE) with Pillcam Eso(®) to accurately identify high and low risk patients with UGIB.

METHODS

Twenty-four patients with a history of UGIB within 48 h of admission to the ER were randomized to VCE versus standard clinical assessment. VCE was read real-time at the bedside and later reviewed after download. Positive VCE findings included coffee grounds, blood clot, red blood, or a bleeding lesion. VCE positive patients underwent EGD within 6 h. Control patients and VCE negative patients underwent EGD within 24 h.

RESULTS

Seven of 12 patients were VCE positive. All seven had confirmatory stigmata at EGD. Of the five VCE negative patients, four had no stigmata at EGD and one was not endoscoped due to comorbidities. The actual lesion was visualized at VCE in four of 12 patients during live view and in an additional two patients after download (6/12). Time to endoscopy in the VCE positive group was significantly shorter than control patients (2.5 vs. 8.9 h, P = 0.029). There was no mortality. Blood transfusion requirement and length of stay were not significantly different in the two groups.

CONCLUSIONS

Live view VCE accurately identifies high and low risk ER patients with UGIB. Use of VCE to risk stratify these patients significantly reduced time to emergent EGD and therapeutic intervention.

Analysis of risk scoring for the outpatient management of acute upper gastrointestinal bleeding

OBJECTIVE

To determine whether the Glasgow-Blatchford bleeding score (GBS) or pre-endoscopy Rockall score was better at accurately identifying patients with acute upper gastrointestinal bleeding (AUGIB) who were at low risk of the need for clinical intervention and death and therefore suitable for outpatient management.

DESIGN

Retrospective database and case note review of all patients admitted to the emergency departments with AUGIB from 1 January 2008 to 31 December 2009.

SETTING

Two tertiary centre teaching hospitals.

PATIENTS

432 patients met the inclusion criteria.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Clinical interventions (blood transfusion, endoscopic therapy and surgery) and death.

RESULTS

Of 432 patients, 40 (9.3%) had a GBS of 0 and none required intervention or died. In contrast, 13/104 patients (12.5%) who had a pre-endoscopy Rockall score of 0 and 23/125 patients (18.4%) who had a complete Rockall score <3, required clinical intervention. The performance of the scores at these cut-offs were: GBS (sensitivity 100%, specificity 16.1%, positive predictive value (PPV) 37.8%, negative predictive value (NPV) 100%, accuracy 82.3%), pre-endoscopy Rockall (sensitivity 91.2%, specificity 32.0%, PPV 41.2%, NPV 87.5%, accuracy 70.9%) and complete Rockall (sensitivity 84.5%, specificity 50.7%, PPV 55.8%, NPV 81.6%, accuracy 76.2%). For prediction of the need for intervention or death, the accuracy of the GBS (0.82; 95% CI 0.78 to 0.86) was superior to the pre-endoscopy Rockall score (0.71; 95% CI 0.67 to 0.76).

CONCLUSION

The GBS but not the pre-endoscopy Rockall score identifies patients with upper gastrointestinal bleeding who may be suitable for outpatient management, therefore potentially allowing for more efficient use of hospital resources.

Predictors of rebleeding and mortality in patients with high-risk bleeding peptic ulcers

BACKGROUND AND AIM

Patients with bleeding ulcers can have recurrent bleeding and mortality after endoscopic therapy. Risk stratification is important in the management of the initial patient triage. The aim of this study is to identify the clinical and laboratory risk factors for recurrent bleeding and mortality.

METHODS

A prospective study was conducted in 390 consecutive patients with bleeding peptic ulcers and high-risk endoscopic stigmata, e.g., active bleeding, a non-bleeding visible vessel, adherent blood clot, and hemorrhagic dot. We tested 13 available variables for association with recurrent bleeding and 15 were tested for association with mortality. A logistic regression model was used to identify individual correlates associated with these adverse outcomes.

RESULTS

Bleeding recurred in 46 patients (11.8%) within 3 days and 21 patients (5.4%) had in-hospital mortality. In the full-factor analysis model, the incidence of recurrent bleeding was significantly higher in five of the 13 investigated variables and mortality was significantly higher in two of the 15 variables. In the final analysis model, significant risk factors for recurrent bleeding within 3 days, with adjusted odds ratios (OR), were in-hospital bleeding (OR 3.3), initial hemoglobin level<10 g/dl (OR 3.3) and ulcer>or=2 cm (OR 2.0). In-hospital bleeding was the only independent risk factor for mortality (OR 8.3).

CONCLUSION

The study emphasizes the role of ulcer size, anemia and in-hospital bleeding as the determining high-risk predictors for adverse outcomes for bleeding peptic ulcers.

Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score

OBJECTIVES

We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death.

METHODS

We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the chi2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models.

RESULTS

Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54-5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72-0.90) vs. 0.66 (0.60-0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05.

CONCLUSIONS

The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.

Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study

The authors aimed to compare the clinical utility of five scoring systems for the prediction of rebleeding and death in patients with nonvariceal upper gastrointestinal bleeding (UGIB). A total of 239 consecutive patients who had undergone endoscopy due to nonvariceal UGIB were prospectively investigated on the basis of five scoring systems (Forrest classification, Rockall scoring system, Cedars-Sinai Medical Centre Predict Index, Blatchford scoring system, and Baylor college scoring system). Thirty-five patients (14.6%) experienced rebleeding and 20 patients (8.4%) died. Comparison of the high-risk categories of the four predictive systems showed that the Forrest classification was superior to the others in predicting rebleeding and death. The Cedars-Sinai Medical Centre Predict Index and the Rockall scoring system showed high positive predictive values for predicting rebleeding and death, respectively. We concluded that the Forrest classification was the most useful scoring system for the prediction of rebleeding and death in patients with nonvariceal UGIB.

Higher hospital volume is associated with lower mortality in acute nonvariceal upper-GI hemorrhage

BACKGROUND

Acute nonvariceal upper-GI hemorrhage (NVUGIH) is associated with significant morbidity and mortality.

OBJECTIVE

To examine the relationship between hospital volume and outcomes of NVUGIH.

DESIGN

A cross-sectional study.

SETTING

Participating hospitals from the Nationwide Inpatient Sample 2004.

PATIENTS

All discharged patients with a primary discharge diagnosis of NVUGIH based on the International Classification of Diseases, Clinical Modification, ninth edition codes.

INTERVENTIONS

Patients were divided into 3 groups based on discharge from hospitals with annual discharge volumes of 1 to 125 (low), 126 to 250 (medium), and >250 (high).

MAIN OUTCOME MEASUREMENTS

In-hospital mortality, length of stay, and hospitalization charges.

RESULTS

The study included a total of 135,366, 132,746, and 123,007 discharges with NVUGIH occurred from low-volume, medium-volume, and high-volume hospitals, respectively. On multivariate analysis, when adjusting for age, comorbidity, and the presence of complications, patients at high-volume hospitals had significantly lower in-hospital mortality (odds ratio [OR] 0.85 [95% CI, 0.74-0.98]) than patients at low-volume hospitals. Patients at high-volume hospitals were also more likely to undergo upper-GI endoscopy (OR 1.52 [95% CI, 1.36-1.69]) or early endoscopy within 1 day of hospitalization compared with low-volume hospitals (60.5% vs 53.8%, adjusted OR 1.28 [95% CI, 1.02-1.61]). Undergoing endoscopy within day 1 was associated with shorter hospital stays (-1.08 days [95% CI, -1.24 to -0.92 days]) and lower hospitalization charges (-$1958 [95% CI, -$3227 to -$688]).

LIMITATIONS

The study was based on an administrative data set.

CONCLUSIONS

Higher hospital volume is associated with lower mortality and with higher rates of endoscopy and endoscopic intervention in patients with NVUGIH.

Endoscopy for upper gastrointestinal bleeding: how urgent is it?

Early endoscopy has been advocated for the management of upper gastrointestinal bleeding, but the optimal timing for early endoscopy is still uncertain. The aim of this Review is to evaluate the optimal timing of early endoscopy by examining the findings of randomized clinical trials and retrospective cohort studies that used comparable outcome measures and have been reported in the literature. Outcome measurements included recurrent bleeding, surgery, mortality, length of hospital stay, and blood transfusion. Studies were categorized into those in which endoscopy was performed within 2-3 h, 6-8 h, 12 h or 24 h of the patient's presentation to hospital. We conclude that early endoscopy aids risk stratification of patients and reduces the need for hospitalization. However, it may also expose additional cases of active bleeding and hence increase the use of therapeutic endoscopy. No evidence exists that very early endoscopy (within a few hours of presentation) can reduce the risk of rebleeding or improve survival.

Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy

BACKGROUND & AIMS

Despite advances in management of patients with bleeding peptic ulcers, mortality is still 10%. This study aimed to identify predictive factors and to develop a prediction model for mortality among patients with bleeding peptic ulcers.

METHODS

Consecutive patients with endoscopic stigmata of active bleeding, visible vessels, or adherent clots were recruited, and risk factors for mortality were identified in this deprivation cohort by using multiple stepwise logistic regression. A prediction model was then built on the basis of these factors and validated in the evaluation cohort.

RESULTS

From 1993 to 2003, 3220 patients with bleeding peptic ulcers were treated. Two hundred eighty-four of the patients developed rebleeding (8.8%); emergency surgery was performed on 47 of these patients, whereas others were managed with endoscopic retreatment. Two hundred twenty-nine of these sustained in-hospital death (7.1%). In patients older than 70 years, presence of comorbidity, more than 1 listed comorbidity, hematemesis on presentation, systolic blood pressure below 100 mm Hg, in-hospital bleeding, rebleeding, and need for surgery were significant predictors for mortality. Helicobacter pylori-related ulcers had lower risk of mortality. The receiver operating characteristic curve comparing the prediction of mortality with actual mortality showed an area under the curve of 0.842. From 2004 to 2006, data were collected prospectively from a second cohort of patients with bleeding peptic ulcers, and mortality was predicted by using the model developed. The receiver operating characteristic curve showed an area under the curve of 0.729.

CONCLUSIONS

Among patients with bleeding peptic ulcers after endoscopic hemostasis, advanced age, presence of listed comorbidity, multiple comorbidities, hypovolemic shock, in-hospital bleeding, rebleeding, and need for surgery successfully predicted in-hospital mortality.

Non-variceal upper GI bleeding in patients already hospitalized for another condition

OBJECTIVES

To compare outpatients (OPs) presenting with non-variceal upper gastrointestinal bleeding (NVUGIB) to those who started hemorrhaging while in a hospital (inpatients, IPs) in a contemporary setting and to better identify predictors of outcome.

METHODS

Retrospective data from the Canadian Registry of Patients With Upper Gastrointestinal Bleeding Undergoing Endoscopy (RUGBE). Descriptive, inferential, and multivariate logistic regression models were carried out in 469 IPs (68.5+/-14 years, 36% women) and 1,395 OPs (65.5+/-18 years, 39% women) in 18 Canadian community and tertiary care centers.

RESULTS

Main outcomes were rebleeding, mortality, and their predictors. IPs differed from OPs in disease acuity (P=0.02) and comorbidities (3.1+/-1.7 vs. 2.3+/-1.5, P<0.001), and were admitted longer (7.2+/-7.4 vs. 5+/-5.4 days, P<0.001) and more often to intensive care unit (ICU; 40.5% vs. 16%, P<0.001). Ulcers or erosions predominated (83% vs. 85%, P=0.28), treated by endotherapy (38% vs. 36%, P=0.46). More IPs received proton pump inhibitors (PPIs; 88% vs. 83%, P=0.009). Mortality was greater for IPs (11% vs. 3.5%, P<0.001), but rebleeding (15.7% vs. 13.4%, P=0.23) and surgery (6.9% vs. 6.4%, P=0.72) were not. Among IPs, comorbidity (odds ratio, OR=1.15; 95% confidence interval, CI: 1.01-1.32) and endoscopic high-risk stigmata increased (OR=3.86, 95% CI:2.05-7.26), whereas PPI decreased (OR=0.20, 95% CI:0.10-0.42) rebleeding; high-risk stigmata (OR=3.13, 95% CI:1.23-7.99) and rebleeding (OR=4.19, 95% CI:2.06-8.55) increased mortality, whereas low disease acuity was protective (OR=0.20; 95% CI:0.46-0.90).

CONCLUSIONS

IPs are sicker than OPs. Endoscopic hemostasis and PPI therapy favorably affect rebleeding in IPs, whereas patient characteristics principally determine the threefold greater IPs mortality.

Does blood urea nitrogen level predict severity and high-risk endoscopic lesions in patients with nonvariceal upper gastrointestinal bleeding?

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (UGIB) is a serious medical condition requiring prompt resuscitation and early endoscopic therapy in those with high-risk endoscopic lesions (HRLs). There are little or no data correlating sole blood urea nitrogen (BUN) level with the severity of nonvariceal UGIB or the presence of HRLs in the adult population.

OBJECTIVES

To determine if the BUN level on presentation correlates with parameters of severity of UGIB (need for blood transfusion or intensive care unit [ICU] admission) or to the subsequent finding of HRL, and in so doing identify patients who will require early endoscopic intervention.

METHODS

The Canadian Registry of patients with Upper Gastrointestinal Bleeding undergoing Endoscopy was used to identify patients enrolled from the McGill University Health Centre (Montreal, Quebec) who presented with or developed acute nonvariceal UGIB while admitted. All comparisons were performed using Student's t test or Wilcoxon's signed rank test, as appropriate. Logistic regression modelling using a stepwise method was performed to identify independent predictors of severe nonvariceal UGIB and HRL.

RESULTS

Two hundred nine patients were enrolled in the study. The mean age was 67+/-18 years and 59.8% were male. The mean BUN level was 13.4+/-9.4 mmol/L. Univariate analysis demonstrated that the BUN level was a significant predictor of ICU admission (BUN 14.7+/-10.4 mmol/L versus 12.0+/-8.0 mmol/L, P=0.035). However, when adjusted for systolic blood pressure, BUN level became a weaker predictor of ICU admission, just failing to achieve statistical significance (OR 1.03, 95% CI 1.00 to 1.06; P=0.08). Univariate analysis also demonstrated that BUN level was not a statistically significant predictor of blood transfusion requirement (BUN 14.1+/-10.6 mmol/L versus 13.6+/-8.6 mmol/L, P=0.508), nor of HRL (BUN 14.2+/-10.7 mmol/L versus 12.9+/-8.6 mmol/L, P=0.605).

CONCLUSION

In patients with nonvariceal UGIB, the BUN level at initial presentation is a weak predictor of the severity of UGIB as defined by ICU admission, but is not helpful in identifying patients with a HRL.

Predictive factors of mortality from nonvariceal upper gastrointestinal hemorrhage: a multicenter study

OBJECTIVES

From an Italian Registry of patients with upper gastrointestinal hemorrhage (UGIH), we assessed the clinical outcomes and explored the roles of clinical, endoscopic, and therapeutic factors on 30-day mortality in a real life setting.

METHODS

Prospective analysis of consecutive patients endoscoped for UGIH at 23 community and tertiary care institutions from 2003 to 2004. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression analysis identified predictors of mortality.

RESULTS

One thousand and twenty patients were included. A total of 46 patients died for an overall 4.5% mortality rate. In all, 85% of deaths were associated with one or more major comorbidity. Sixteen of 46 patients (35%) died within the first 24 h of the onset of bleeding. Of these, eight had been categorized as ASA class 1 or 2 and none of them was operated upon, despite a failure of endoscopic intention to treatment in four. Regression analysis showed advanced age, presence of severe comorbidity, low hemoglobin levels at presentation, and worsening health status as the only independent predictors of 30-day mortality (P < 0.001). The acute use of a PPI exerted a protective effect (OR 0.23, 95% CI 0.09-0.73). Recurrent bleeding was low (3.2%). Rebleeders accounted for only 11% of the total patients deceased (OR 3.27, 95% CI 1.5-11.2).

CONCLUSIONS

These results indicate that 30-day mortality for nonvariceal bleeding is low. Deaths occurred predominantly in elderly patients with severe comorbidities or those with failure of endoscopic intention to treatment.

Artificial Neural Networks for Early Prediction of Mortality in Patients with Non Variceal Upper GI Bleeding (UGIB)

BACKGROUND

Mortality for non variceal upper gastrointestinal bleeding (UGIB) is clinically relevant in the first 12-24 hours of the onset of haemorrhage and therefore identification of clinical factors predictive of the risk of death before endoscopic examination may allow for early corrective therapeutic intervention.

AIM

1) Identify simple and early clinical variables predictive of the risk of death in patients with non variceal UGIB; 2) assess previsional gain of a predictive model developed with conventional statistics vs. that developed with artificial neural networks (ANNs).

METHODS AND RESULTS

Analysis was performed on 807 patients with nonvariceal UGIB (527 males, 280 females), as a part of a multicentre Italian study. The mortality was considered "bleeding-related" if occurred within 30 days from the index bleeding episode. A total of 50 independent variables were analysed, 49 of which clinico-anamnestic, all collected prior to endoscopic examination plus the haemoglobin value measured on admission in the emergency department. Death occurred in 42 (5.2%). Conventional statistical techniques (linear discriminant analysis) were compared with ANNs (Twist® system-Semeion) adopting the same result validation protocol with random allocation of the sample in training and testing subsets and subsequent cross-over. ANNs resulted to be significantly more accurate than LDA with an overall accuracy rate near to 90%.

CONCLUSION

Artificial neural networks technology is highly promising in the development of accurate diagnostic tools designed to recognize patients at high risk of death for UGIB.

Artificial neural network as a predictive instrument in patients with acute nonvariceal upper gastrointestinal hemorrhage

BACKGROUND & AIMS

Triage of patients with acute upper gastrointestinal hemorrhage (UGIH) has traditionally required urgent upper endoscopy. The aim of this study is to evaluate the use of artificial neural network for nonendoscopic triage.

METHODS

A cohort of 387 patients was used to train (n = 194) and internally validate (n = 193) the neural network, which was then externally validated in 200 patients and compared with the clinical and complete Rockall score. Two outcome variables were assessed: major stigmata of recent hemorrhage and need for endoscopic therapy. Patient cohort data from 2 independent tertiary-care medical centers were prospectively collected. Adult patients hospitalized at both sites during the same time period with a primary diagnosis of acute nonvariceal UGIH.

RESULTS

In predicting the 2 measured outcomes, sensitivity of neural network was >80%, with high negative predictive values (92-96%) in both cohorts but with lower specificity in the external cohort. Both Rockall scores had adequate sensitivity (>80%) but poor specificity (<40%) at outcome prediction. Comparing areas under receiver operating characteristic curves, the clinical Rockall score was significantly inferior to neural network in both cohorts (</=0.65 vs. >/= 0.78), while in the external cohort, neural network performed similarly to the complete Rockall score (>/= 0.78).

CONCLUSIONS

In acute nonvariceal UGIH, artificial neural network (nonendoscopic triage) performed as well as the complete Rockall score (endoscopic triage) at predicting stigmata of recent hemorrhage and need for endoscopic therapy, even when tested in an external patient population.

A decision support system to facilitate management of patients with acute gastrointestinal bleeding

OBJECTIVE

To develop a model to predict the bleeding source and identify the cohort amongst patients with acute gastrointestinal bleeding (GIB) who require urgent intervention, including endoscopy. Patients with acute GIB, an unpredictable event, are most commonly evaluated and managed by non-gastroenterologists. Rapid and consistently reliable risk stratification of patients with acute GIB for urgent endoscopy may potentially improve outcomes amongst such patients by targeting scarce healthcare resources to those who need it the most.

DESIGN AND METHODS

Using ICD-9 codes for acute GIB, 189 patients with acute GIB and all available data variables required to develop and test models were identified from a hospital medical records database. Data on 122 patients was utilized for development of the model and on 67 patients utilized to perform comparative analysis of the models. Clinical data such as presenting signs and symptoms, demographic data, presence of co-morbidities, laboratory data and corresponding endoscopic diagnosis and outcomes were collected. Clinical data and endoscopic diagnosis collected for each patient was utilized to retrospectively ascertain optimal management for each patient. Clinical presentations and corresponding treatment was utilized as training examples. Eight mathematical models including artificial neural network (ANN), support vector machine (SVM), k-nearest neighbor, linear discriminant analysis (LDA), shrunken centroid (SC), random forest (RF), logistic regression, and boosting were trained and tested. The performance of these models was compared using standard statistical analysis and ROC curves.

RESULTS

Overall the random forest model best predicted the source, need for resuscitation, and disposition with accuracies of approximately 80% or higher (accuracy for endoscopy was greater than 75%). The area under ROC curve for RF was greater than 0.85, indicating excellent performance by the random forest model.

CONCLUSION

While most mathematical models are effective as a decision support system for evaluation and management of patients with acute GIB, in our testing, the RF model consistently demonstrated the best performance. Amongst patients presenting with acute GIB, mathematical models may facilitate the identification of the source of GIB, need for intervention and allow optimization of care and healthcare resource allocation; these however require further validation.

Prediction of outcome in acute lower gastrointestinal hemorrhage: role of artificial neural network

Acute lower gastrointestinal hemorrhage (LGIH) has traditionally been defined as bleeding that occurs distal to the ligament of Treitz. More recently, however, it has been subdivided into mid-intestinal (small bowel) hemorrhage and bleeding that originates from the colon. Acute LGIH has diverse etiologies, is a frequent cause of hospital admission, and is associated with significant patient morbidity and mortality, as well as substantial economic cost. In contrast to hemorrhage from the upper gastrointestinal tract (UGIH), the management of acute LGIH is less well defined; furthermore, there is a paucity of published studies that evaluate predictive models in this disorder. Nonetheless, extrapolating from what is known in UGIH, the development of reliable predictive models in LGIH may lead to improved patient care and outcome, by enhancing clinical triage, and by the more cost-effective use of limited healthcare resources. In this review, we discuss the technical development and potential use of artificial neural network in patients presenting with acute LGIH.

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.

The importance of process issues as predictors of time to endoscopy in patients with acute upper-GI bleeding using the RUGBE data

BACKGROUND

Early endoscopy has been shown to improve outcomes and optimize cost-effectiveness in nonvariceal upper-GI bleeding (NVUGIB). However, there is little information regarding clinical and process determinants that affect the time from onset of bleeding to performance of the endoscopy.

OBJECTIVE

The aim of this study was to identify factors that predict time to endoscopy in patients with new onset NVUGIB.

DESIGN

Linear regression models were constructed with time between triage (outpatients) or onset of bleeding (inpatients) and the performance of endoscopy.

SETTING

The RUGBE is a nationwide, multicenter database collected for the purpose of obtaining descriptive data on patients with NVUGIB.

PATIENTS

The study population consisted of 1500 patients (89.6%) who underwent gastroscopy within 48 hours.

RESULTS

Median time to endoscopy was 12 hours (95% CI 11.0, 13.0). Endoscopy after working hours (regression coefficient [beta] -3.52; 95% CI -5.47, -1.58), availability of an endoscopy nurse on-call for the procedure (beta -2.48; 95% CI -3.83, -1.14), and admission to a hospital unit were associated with a shorter interval to endoscopy. In contrast, the presence of chest pain (beta 3.65; 95% CI 1.64, 5.67) or dyspnea (beta 2.79; 95% CI 1.10, 4.48), absence of gross blood on rectal examination (beta 2.20; 95% CI 0.69, 3.71), and inpatient status at onset of bleeding (beta 14.6; 95% CI 8.70, 20.4) were independent predictors of a delayed endoscopy. Subgroup analysis showed that actual time intervals as well as independent predictors of time until endoscopy differed between inpatients and outpatients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

The timing of endoscopy in patients with NVUGIB is dependent on both clinical and process parameters, which differ between inpatient and outpatient settings. They bear implications with regards to shaping practice and deciding on resource allocation in order to facilitate an early endoscopy, which is currently recommended for improved patient outcomes.

Outcome of non-variceal acute upper gastrointestinal bleeding in relation to the time of endoscopy and the experience of the endoscopist: a two-year survey

AIM

To prospectively assess the impact of time of endoscopy and endoscopist's experience on the outcome of non-variceal acute upper gastrointestinal (GI) bleeding patients in a large teaching hospital.

METHODS

All patients admitted for non-variceal acute upper GI bleeding for over a 2-year period were potentially eligible for this study. They were managed by a team of seven endoscopists on 24-h call whose experience was categorized into two levels (high and low) according to the number of endoscopic hemostatic procedures undertaken before the study. Endoscopic treatment was standardized according to Forrest classification of lesions as well as the subsequent medical therapy. Time of endoscopy was subdivided into two time periods: routine (8 a.m.-5 p.m.) and on-call (5 p.m.-8 a.m.). For each category of experience and time periods rebleeding rate, transfusion requirement, need for surgery, length of hospital stay and mortality we compared. Multivariate analysis was used to discriminate the impact of different variables on the outcomes that were considered.

RESULTS

Study population consisted of 272 patients (mean age 67.3 years) with endoscopic stigmata of hemorrhage. The patients were equally distributed among the endoscopists, whereas only 19% of procedures were done out of working hours. Rockall score and Forrest classification at admission did not differ between time periods and degree of experience. Univariate analysis showed that higher endoscopist's experience was associated with significant reduction in rebleeding rate (14% vs 37%), transfusion requirements (1.8+/-0.6 vs 3.0+/-1.7 units) as well as surgery (4% vs 10%), but not associated with the length of hospital stay nor mortality. By contrast, outcomes did not significantly differ between the two time periods of endoscopy. On multivariate analysis, endoscopist's experience was independently associated with rebleeding rate and transfusion requirements. Odds ratios for low experienced endoscopist were 4.47 for rebleeding and 6.90 for need of transfusion after the endoscopy.

CONCLUSION

Endoscopist's experience is an important independent prognostic factor for non-variceal acute upper GI bleeding. Urgent endoscopy should be undertaken preferentially by a skilled endoscopist as less expert staff tends to underestimate some risk lesions with a negative influence on hemostasis.

Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis

Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.

Nonvariceal upper gastrointestinal bleeding: standard and new treatment

Nonvariceal upper gastrointestinal bleeding remains a challenging problem with a significant morbidity and mortality. In recent years endoscopic techniques have evolved, resulting in improved primary hemostasis and a reduction in the risk of rebleeding. Combination endoscopic therapy followed by high-dose proton pump inhibitor shows improved outcomes. Innovative endoscopic therapies hold promise but are as yet unproved. An aging population with significant medical comorbidities has a major influence on the overall outcome from upper gastrointestinal bleeding.

Patients admitted to the emergency room with upper gastrointestinal bleeding: factors influencing recurrence or death

The aim of this study was to determine the clinical, laboratory, and endoscopic findings that might be related to poor prognoses, such as rebleeding or death, in patients admitted to the emergency room with upper gastrointestinal (UGI) bleeding. A prospective evaluation was conducted in 99 patients with UGI bleeding who were admitted to the emergency room of Hacettepe University Medical School between May and December 2001. Twenty-four patients were considered to have a poor prognosis. In multivariate analyses, presence of diabetes mellitus or of visible vessel at endoscopy, treatment with proton pump inhibitors, and decrease in mean blood pressure were found to be independent predictors for poor prognoses in this population. Several factors, such as comorbidities, type of treatment, or clinical and endoscopic findings, were found to be related to rebleeding or death in patients admitted to the emergency room with UGI bleeding necessitating intensive care.