Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage

Cost-Effectiveness of Vaccination of Older Adults with an MF59®-Adjuvanted Quadrivalent Influenza Vaccine Compared to Standard-Dose and High-Dose Vaccines in Denmark, Norway, and Sweden

Individuals aged 65 years and above are at increased risk of complications and death from influenza compared with any other age group. Enhanced vaccines, as the MF59®-adjuvanted quadrivalent influenza vaccine (aQIV) and the high-dose quadrivalent influenza vaccine (HD-QIV), provide increased protection for older adults in comparison to the traditional standard-dose quadrivalent influenza vaccines (SD-QIV). This study aimed to assess the cost-effectiveness of aQIV compared to SD-QIV and HD-QIV in Denmark, Norway, and Sweden for adults aged ≥65 years. A static decision tree model was used to evaluate costs and outcomes of different vaccination strategies from healthcare payer and societal perspectives. This model projects that compared to SD-QIV, vaccination with aQIV could prevent a combined total of 18,772 symptomatic influenza infections, 925 hospitalizations, and 161 deaths in one influenza season across the three countries. From a healthcare payer perspective, the incremental costs per quality adjusted life year (QALY) gained with aQIV versus SD-QIV were EUR 10,170/QALY in Denmark, EUR 12,515/QALY in Norway, and EUR 9894/QALY in Sweden. The aQIV was cost saving compared with HD-QIV. This study found that introducing aQIV to the entire population aged ≥65 years may contribute to reducing the disease and economic burden associated with influenza in these countries.

When to Discharge a Patient After Endoscopy: A Narrative Review

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Management of upper gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis: a prospective, multicenter, observational study

Background

Upper gastrointestinal bleeding (UGB) is common in emergency departments (EDs) and can be caused by many eso-gastro-duodenal lesions. Most available epidemiological data and data on the management of UGB comes from specialized departments (intensive care units or gastroenterology departments), but little is known from the ED perspective.

We aimed to determine the distribution of symptoms revealing UGB in EDs and the hemorrhagic lesions identified by endoscopy. We also describe the characteristics of patients consulting for UGB, UGB management in the ED and patients outcomes.

Method

This was a prospective, observational, multicenter study covering 4 consecutive days in November 2013. Participating EDs were part of the Initiatives de Recherche aux Urgences network coordinated by the French Society of Emergency Medicine. All patients with suspected UGB in these EDs were included.

Results

In total, 110 EDs participated, including 194 patients with suspected UGB (median age 66 years [Q1-Q3: 51-81]). Overall, 104 patients (54%) had hematemesis and 75 (39%) melena. Endoscopy revealed lesions in 121 patients, mainly gastroduodenal ulcer or ulcerations (41%) or bleeding lesions due to portal hypertension (20%). The final diagnosis of UGB was reversed by endoscopy in only 3% of cases. Overall, 67 patients (35%) had at least one severity sign. Twenty-one patients died (11%); 40 (21%) were hospitalized in intensive care units and 126 (65%) in medicine departments; 28 (14%) were outpatients. Mortality was higher among patients with clinical and biological severity signs.

Conclusion

Most of the UGB cases in EDs are revealed by hematemesis. The emergency physician diagnosis of UGB is rarely challenged by the endoscopic findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0425-6) contains supplementary material, which is available to authorized users.

Comparison of Three Risk Scores to Predict Outcomes of Severe Lower Gastrointestinal Bleeding

BACKGROUND AND AIMS

Improved medical decisions by using a score at the initial patient triage level may lead to improvements in patient management, outcomes, and resource utilization. There is no validated score for management of lower gastrointestinal bleeding (LGIB) unlike for upper gastrointestinal bleeding. The aim of our study was to compare the accuracies of 3 different prognostic scores [Center for Ulcer Research and Education Hemostasis prognosis score, Charlson index, and American Society of Anesthesiologists (ASA) score] for the prediction of 30-day rebleeding, surgery, and death in severe LGIB.

METHODS

Data on consecutive patients hospitalized with severe gastrointestinal bleeding from January 2006 to October 2011 in our 2 tertiary academic referral centers were prospectively collected. Sensitivities, specificities, accuracies, and area under the receiver operator characteristic curve were computed for 3 scores for predictions of rebleeding, surgery, and mortality at 30 days.

RESULTS

Two hundred thirty-five consecutive patients with LGIB were included between 2006 and 2011. Twenty-three percent of patients rebled, 6% had surgery, and 7.7% of patients died. The accuracies of each score never reached 70% for predicting rebleeding or surgery in either. The ASA score had a highest accuracy for predicting mortality within 30 days (83.5%), whereas the Center for Ulcer Research and Education Hemostasis prognosis score and the Charlson index both had accuracies <75% for the prediction of death within 30 days.

CONCLUSIONS

ASA score could be useful to predict death within 30 days. However, a new score is still warranted to predict all 30 days outcomes (rebleeding, surgery, and death) in LGIB.

A Novel Easy-to-Use Prediction Scheme for Upper Gastrointestinal Bleeding: Cologne-WATCH (C-WATCH) Risk Score

Acute upper gastrointestinal bleeding (UGIB) is the leading indication for emergency endoscopy. Scoring schemes have been developed for immediate risk stratification. However, most of these scores include endoscopic findings and are based on data from patients with nonvariceal bleeding. The aim of our study was to design a pre-endoscopic score for acute UGIB--including variceal bleeding--in order to identify high-risk patients requiring urgent clinical management. The scoring system was developed using a data set consisting of 586 patients with acute UGIB. These patients were identified from the emergency department as well as all inpatient services at the University Hospital of Cologne within a 2-year period (01/2007-12/2008). Further data from a cohort of 322 patients who presented to our endoscopy unit with acute UGIB in 2009 served for external/temporal validation.Clinical, laboratory, and endoscopic parameters, as well as further data on medical history and medication were retrospectively collected from the electronic clinical documentation system. A multivariable logistic regression was fitted to the development set to obtain a risk score using recurrent bleeding, need for intervention (angiography, surgery), or death within 30 days as a composite endpoint. Finally, the obtained risk score was evaluated on the validation set. Only C-reactive protein, white blood cells, alanine-aminotransferase, thrombocytes, creatinine, and hemoglobin were identified as significant predictors for the composite endpoint. Based on the regression coefficients of these variables, an easy-to-use point scoring scheme (C-WATCH) was derived to estimate the risk of complications from 3% to 86% with an area under the curve (AUC) of 0.723 in the development set and 0.704 in the validation set. In the validation set, no patient in the identified low-risk group (0-1 points), but 38.7% of patients in the high-risk group (≥ 2 points) reached the composite endpoint. Our easy-to-use scoring scheme is able to distinguish high-risk patients requiring urgent endoscopy, from low-risk cases who are suitable candidates for outpatient management or in whom endoscopy may be postponed. Based on our findings, a prospective validation of the C-WATCH score in different patient populations outside the university hospital setting seems warranted.

Characteristics of gastrointestinal hemorrhage associated with pancreatic cancer: A retrospective review of 246 cases

While gastrointestinal (GI) hemorrhage is common in the general population, few studies have evaluated large numbers of GI hemorrhage patients with pancreatic cancer. The clinical features and potential risk factors of GI hemorrhage with pancreatic cancer was investigated in the present study and the effect of GI hemorrhage on survival rate was examined. Patients enrolled in the present study had pathologically proven pancreatic cancer, and received treatment between August 2006 and 2012. Their medical records were retrospectively reviewed. The data for the present study were obtained from a review of 246 patients with pancreatic cancer (average age, 63.4±10.92 years; 190 male cases, 56 female cases). In addition, 73 cases had stage I-II, 173 had stage III-IV, and only 67 cases (27.2%) were candidates for curative pancreatectomy. Among them, 32 cases (13.0%) were clinically diagnosed with GI hemorrhage. A total of 24 cases were male patients and the other 8 cases were female, the cases of hemorrhage history and alcoholism were 2 and 29 cases, respectively. The major initial clinical symptoms of GI hemorrhage included 18 patients with melena or blood stool (56.25%), 9 with haematemesis (28.13%), 3 with abdominal distention (9.37%) and 2 with stomach ache (6.25%). The independent risk factor for GI hemorrhage was tumor initial stage of IV. A continuous increase in carbohydrate antigen 19-9 (CA19-9) may be a warning of GI hemorrhage, particularly when it is >1,000 U/ml. The most frequent method of hemostasis was combination therapy (n=12, 37.5%). Only 3 cases (9.3%) of these 32 GI hemorrhage patients were blood stanched and only 10 patients (31.2%) received gastroscopy. The time from GI hemorrhage to fatality is extremely short (median 30 days, range from 1 h to 65 days), and the median overall survival time of the patients with GI hemorrhage was 9.0 months (range, 2.0-16.0 months) and was significantly shorter than that of patients without GI hemorrhage [14.5 months (range, 0.5-48.0 months)]. In conclusion, although GI hemorrhage was not common in patients with pancreatic cancer, it is critical. GI hemorrhage was controlled with endoscopic hemostasis. Clinicians should fully assess the risk factors of GI hemorrhage (such as alcohol, smoking, past hemorrhage history, initial stage, tumor location and CA19-9 level at diagnosis of pancreatic cancer) when the pancreatic cancer patients were on admission, particularly for patients of the late stage, preventive measures should be investigated to reduce suffering.

Gastrointestinal Hemorrhage Severity Triage: Locally Derived Score May Outperform Existing Scoring Systems

Background

Scoring tools to predict need for intervention, re-bleeding and mortality of upper gastrointestinal hemorrhage (UGIH) have been developed. It is inconclusive whether these tools are also appropriate for UGIH severity and/or urgency triage. The objective of the study was to compare the performances of the Blatchford score, the Rockall score, and the UGIH score on UGIH severity triage.

Methods

Retrospective 3-year data of UGIH patients (2009 - 2011) were collected. Patients were assigned to each of the three scoring systems based on their clinical characteristics required for the scoring systems. The score ranges of each scoring system were transformed into the same scale from 0 to 100. The score performances were compared by diagnostic indices, graphically presented with area under receiver operating curve (AuROC), discrimination curves, and statistically tested with Chi-squared tests.

Results

When focusing on the diagnostic indices, the local UGIH had similar sensitivity to, but better specificity than the Blatchford score in detecting mild UGIH. The sensitivity was better than and the specificity was less than the Blatchford score in detecting severe UGIH. The local UGIH score was better than the pre-endoscopic Rockall in almost all diagnostic indices. Focusing overall performances, the local UGIH score classified patients non-significantly better than the Blatchford: 89.3% vs. 87.9% for mild (P = 0.243), 87.2% vs. 85.0% for severe (P = 0.092), but significantly classified better than the pre-endoscopic Rockall score: 89.3% vs. 76.4% for mild (P < 0.001), and 87.2% vs. 81.2% for severe (P < 0.001). When exploring the discrimination curves, the Blatchford score classified more patients into the mild categories, and less into the severe categories than the local UGIH score. In contrast, the pre-endoscopic Rockall score classified less patients into the mild, but more into the severe than the local UGIH score.

Conclusion

Triaging UGIH patients into three severity levels in order to decide or set for endoscopy should apply the scoring system specifically developed for that purpose. Adopting other scores developed for other purposes may result in under- and/or over-estimations. The local UGIH score classified patients into three severity levels to help indicate endoscopy more efficiently than the Blatchford score and the pre-endoscopic Rockall score which was developed for different purposes.

A national survey on the initial management of upper gastrointestinal bleeding

GOALS

To evaluate the initial management of upper gastrointestinal (GI) bleeding in the United States.

BACKGROUND

Various guidelines have addressed the initial management of upper GI bleeding, but the extent to which these guidelines are followed in clinical practice is unknown.

STUDY

We conducted a national survey of emergency physicians, internists, and gastroenterologists practicing in hospitals affiliated with an ACGME-accredited gastroenterology fellowship. Participants rated their agreement and adherence to 9 preendoscopic quality indicators for the initial management of upper GI bleeding. Awareness, use, and barriers to the use of early prognostic risk scores were also assessed.

RESULTS

A total of 1402 surveys were completed, with an estimated response rate of 11.3%. Gastroenterologists and trainees agreed with the quality indicators more than nongastroenterologists and attending physicians, respectively. There was no difference in the application of the quality indicators by specialty or clinical position. Among all physicians, 53% had ever heard of and 30% had ever used an upper GI bleeding risk score. More gastroenterologists than nongastroenterologists had heard of (82% vs. 44%, P<0.001) and used (51% vs. 23%, P<0.001) a risk score. There was no difference between attending physicians and trainees. Gastroenterologists and attending physicians more often cited lack of utility as a reason to not use risk scores, whereas nongastroenterologists and trainees more often cited lack of knowledge.

CONCLUSIONS

Among emergency physicians, internists, and gastroenterologists in the United States, agreement with upper GI bleeding initial management guidelines was high but adherence--especially pertaining to the use of risk scores--was low.

Caring for patients in a hospitalist-run clinical decision unit is associated with decreased length of stay without increasing revisit rates

BACKGROUND

Observation medicine is a growing field with increasing involvement by hospitalists. Little has been written regarding clinical outcomes in hospitalist-run clinical decision units (CDUs).

OBJECTIVE

To determine the impact of a hospitalist-run geographic CDU on length of stay (LOS) for observation patients. Secondary objectives included examining the impact on 30-day emergency department (ED) or hospital revisit rates.

DESIGN

Retrospective cohort study with pre- and post-implementation analysis.

SETTING

Urban, academic, 600-bed teaching hospital in Camden, New Jersey.

PATIENTS

Observation patients discharged from medical-surgical units before and after CDU opening and those discharged from the CDU after CDU opening.

INTERVENTION

Creation of a hospitalist-run, 20-bed geographic CDU, adjacent to the ED with order sets, protocols, and priority consults and testing.

MEASUREMENTS

Median LOS for observation patients was calculated for 7 months pre- and post-CDU implementation. ED and hospital revisits requiring an observation or inpatient stay within 30 days of discharge were measured.

RESULTS

CDU observation patients had a lower median LOS than medical-surgical observation patients during the same period (17.6 hours vs 26.1 hours, P < 0.001). CDU LOS was lower than medical-surgical observation LOS in the 7 months 1 year prior to CDU implementation (17.6 hours vs 27.1 hours, P < 0.001). CDU patients had a similar 30-day ED or hospital revisit rate compared with observation patients pre-CDU.

CONCLUSIONS

Implementing a hospitalist-run geographic CDU was associated with a 35% decrease in observation LOS for CDU patients compared with a 3.7% decrease for medical-surgical observation patients. CDU LOS decreased without increasing ED or hospital revisit rates.

Impact of ethnicity in upper gastrointestinal hemorrhage

GOALS

To examine ethnicity's role in the etiology and outcome of upper gastrointestinal hemorrhage (UGIH).

BACKGROUND

UGIH is a serious condition with considerable associated morbidity and mortality.

MATERIALS AND METHODS

We analyzed 2196 patients admitted with acute UGIH between January 2006 and February 2012. Complete clinical data were gathered prospectively and entered into our GI Bleed Registry, which captures demographic and clinical variables. Results were analyzed using the χ² analyses and the analysis of variance techniques with Tukey multiple comparisons.

RESULTS

Among 2196 patients, 620 (28%) were black, 625 (29%) white, 881 (40%) Hispanic, and 70 (3%) were members of other ethnicities. Gastroduodenal ulcers (25%), esophageal varices (25%), and esophagitis (12%) were the most frequently identified causes of UGIH. Blacks experienced a high rate of gastroduodenal ulcers (199/620), whereas Hispanics most commonly had esophageal varices. In all ethnicities, the most common cause of bleeding in patients younger than 35 or older than 65 years was gastroduodenal ulcer disease. However, among patients aged 35 to 64 years, there were differences in the etiology of UGIH. Blacks aged 50 to 64 years frequently experienced gastroduodenal ulcers, whereas Hispanics aged 35 to 49 years typically had esophageal varices. Rebleeding rates were significantly lower in whites (5.8%) than in Hispanics (9.9%) or blacks (8.7%) (P=0.02).

CONCLUSIONS

By examining a diverse population, we conclude that UGIH may follow trends. Hispanics were likely to have esophageal varices and higher rebleeding rates, whereas blacks were likely to have ulcers and the highest mortality. Whites were equally likely to have ulcers or varices, but a lower rate of rebleeding.

Management of GI emergencies: peptic ulcer acute bleeding

Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.

Upper Gastrointestinal Hemorrhage: Validation of the Severity Score

Background

A simple scoring system was developed earlier to classify patients presenting with upper gastrointestinal hemorrhage into mild, moderates and severe. To validate the derived simple UGIH severity scoring system to another set of data obtained from consecutive patients.

Methods

The score was developed earlier from data of patients with UGIH in 2009 - 2010. The same scoring system was assigned to another set of data from patients of the following year. Classification of patients into 3 urgency levels reflecting their severity was compared. Performance similarity of the score in the two sets of data was tested with a chi-squared test for homogeneity. The ability of the score to discriminate mild patients from moderate/severe, and to discriminate severe patients from mild/moderate was identified and compared with analysis of area under the receiver operating characteristic curve (AuROC).

Results

Patients from the validation data were similar to those from the development data in overall aspects. The severity of UGIH and the score distribution in the two sets were similar. The score successfully classified patients in the validation data into 3 severity levels similar to the development data (P = 0.381, chi-squared for homogeneity), and similarly discriminated mild patients from moderate/severe patients (P = 0.360, AuROC analysis), and similarly discriminated severe patients from mild/moderate patients (P = 0.589, AuROC analysis)

Conclusion

The simple scoring scheme developed earlier to classify UGIH patients into 3 severity/urgency levels performed similarly in the validation data obtained from patients in the following year. Advantages of the scoring scheme should be tested when applied to patient care to assure clinical adoption into routine practice.

The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage

BACKGROUND & AIMS

Risk scoring systems are used increasingly to assess patients with upper gastrointestinal hemorrhage (UGIH). There have been comparative studies to identify the best system, but most have been retrospective and included small sample sizes, few patients with severe bleeding and with low mortality. We aimed to identify the optimal scoring system.

METHODS

We performed a prospective study to compare the accuracy of the Glasgow Blatchford score (GBS), an age-extended GBS (EGBS), the Rockall score, the Baylor bleeding score, and the Cedars-Sinai Medical Center predictive index in predicting patients' (1) need for hospital-based intervention or 30-day mortality, (2) suitability for early discharge, (3) likelihood of rebleeding, and (4) mortality. We analyzed the area under receiver operating characteristic (AUROC) curve, sensitivity, specificity, and positive and negative predictive values for each system. The study included 831 consecutive patients admitted with UGIH during a 2-year period.

RESULTS

The GBS and EGBS better predicted patients' need for hospital-based intervention or 30-day mortality than the other systems (AUROC, 0.93; P < .001) and were also better in identifying low-risk patients (sensitivity values, 0.27-0.38; specificity values, 0.099-1). The EGBS identified a significantly higher proportion of low-risk patients than the GBS (P = .006). None of the systems accurately predicted which patients would have rebleeding or patients' 30-day mortality, on the basis of low AUROC and specificity values.

CONCLUSIONS

The GBS accurately identifies patients with UGIH most likely to need hospital-based intervention and also those best suited for outpatient care. The EGBS seems promising but must be validated externally. No scoring system seems to accurately predict patients' 30-day mortality or rebleeding. ClinicalTrials.gov number, NCT01589250.

Update on risk scoring systems for patients with upper gastrointestinal haemorrhage

Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.

The management of low-risk primary upper gastrointestinal haemorrhage in the community: a 5-year observational study

BACKGROUND

Acute upper gastrointestinal haemorrhage is a common medical emergency, initially managed with inpatient care. Bleeding stops spontaneously in over 80% of cases, indicating that patients with low-risk upper gastrointestinal haemorrhage may be more optimally managed in the community, without the need for admission to hospital.

AIM

To assess the safety of managing patients with low-risk upper gastrointestinal haemorrhage without admission to hospital.

METHODS

Prospective/retrospective study of all patients presenting to a UK teaching hospital with low-risk upper gastrointestinal haemorrhage who were managed without admission to hospital over 5 years. Low risk was defined as Glasgow Blatchford Score of 2 or less, age below 70 years, no other active medical problems, not taking warfarin and suspected nonvariceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death.

RESULTS

One hundred and forty-two patients fulfilled the inclusion criteria, and were managed without admission to hospital. No patients required endoscopic intervention, blood transfusion or surgery. The 28-day mortality was nil. Forty-one patients had normal endoscopic examination and 11 had significant endoscopic findings (peptic ulceration=10, oozing Mallory-Weiss tear=1) but did not require intervention.

CONCLUSION

Patients presenting with a primary upper gastrointestinal haemorrhage aged below 70 years with a Glasgow Blatchford Score of 2 or less are at a low risk, and can be safely managed in the community.

Upper gastrointestinal bleeding: what's the score?

Upper gastrointestinal haemorrhage (UGIH) is a common medical emergency. Recent publications have emphasised the need for early risk assessment of patients with this condition to help direct management. Several risk scores have been developed for UGIH and are variably used in clinical practice. In this article, we discuss the various risk scoring systems for this condition and summarise the available evidence for their use.

Gastrointestinal bleeding

Gastrointestinal bleeding is a common complaint encountered in the emergency department and frequent cause of hospitalization. Important diagnostic factors that increase morbidity and mortality include advanced age, serious comorbid conditions, hemodynamic instability, esophageal varices, significant hematemesis or melena, and marked anemia. Because gastrointestinal bleeding carries a 10% overall mortality rate, emergency physicians must perform timely diagnosis, aggressive resuscitation, risk stratification, and early consultation for these patients.

Prospective evaluation of a clinical guideline recommending early patients discharge in bleeding peptic ulcer

BACKGROUND AND AIM

To validate an early discharge policy in patients admitted with upper gastrointestinal bleeding (UGIB) due to ulcers.

METHODS

Patients with gastroduodenal ulcer or erosive gastritis/duodenitis were included in a previous study aiming to develop a practice guideline for early discharge of patients with UGIB. Variables associated with unfavorable evolution were analyzed in order to identify patients with low-risk of re-bleeding. After that, a one-year prospective analysis of all UGIB episodes was carried out.

RESULTS

A total of 341 patients were identified in the retrospective study. Variables associated with unfavorable evolution were: systolic blood pressure < or = 100 mmHg, heart rate > or = 100 bpm, and a Forrest endoscopic classification of severe. 10% of patients were immediately discharged; however, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 34% of patients. A total of 77 patients were included in the prospective analysis. Although only 19.5% of patients were immediately discharged without complications, 29 patients (37.7%) were theoretically suitable for early discharge.

CONCLUSIONS

Patients with UGIB who have clean-based ulcers and are stable on admission can be safely discharged immediately after endoscopy. Implementation of the clinical practice guideline safely reduced hospital admission for those patients.

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

BACKGROUND

There is conflicting evidence regarding the clinical efficacy of proton pump inhibitors (PPI) initiated before endoscopy for upper gastrointestinal bleeding.

OBJECTIVES

To systematically review evidence from randomised controlled trials (RCTs) of PPI treatment initiated before endoscopy for upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL databases and major conference proceedings to September 2005, using the Cochrane Upper Gastrointestinal and Pancreatic Diseases model. Searches were re-run in February 2006 and October 2008.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs), of hospitalised participants with unselected upper gastrointestinal bleeding, undergoing active treatment with a proton pump inhibitor PPI (oral or intravenous) and control treatment with either placebo, histamine-2 receptor antagonist (H2RA) or no treatment prior to endoscopy. Outcomes were assessed at 30 days and included mortality, rebleeding and surgery. Also assessed were stigmata of recent haemorrhage (SRH; active bleeding, non bleeding visible vessel or adherent clot) at index endoscopy, length of hospital stay, blood transfusion requirements and requirement for endoscopic therapy at index endoscopy.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed eligibility criteria and extracted data regarding outcomes and factors affecting methodological quality.

MAIN RESULTS

Six RCTs comprising 2223 participants were included. There was no statistical heterogeneity among trials for dichotomous outcomes. There were no statistically significant differences in mortality, rebleeding or surgery between PPI and control treatment. Unweighted pooled mortality rates were 6.1% and 5.5% respectively (odds ratio (OR)1.12; 95% CI 0.72 to 1.73). Unweighted pooled rebleeding rates were 13.9% and 16.6% respectively (OR 0.81; 95%CI 0.61 to 1.09). Pooled rates for surgery were 9.9% and 10.2% respectively (OR 0.96 95% CI 0.68 to 1.35). PPI treatment compared to control significantly reduced the proportion of participants with SRH at index endoscopy; unweighted pooled rates were 37.2% and 46.5% respectively (OR 0.67; 95% CI 0.54 to 0.84). However, this result was not robust to sensitivity analysis. PPI treatment compared to control significantly reduced endoscopic therapy at index endoscopy; unweighted pooled rates were 8.6% and 11.7% respectively (OR 0.68; 95% CI 0.50 to 0.93). For continuous outcomes (length of hospital stay and blood transfusion requirements), quantitative analysis could not be performed.

AUTHORS' CONCLUSIONS

PPI treatment initiated before endoscopy for upper gastrointestinal bleeding might reduce the proportion of participants with SRH at index endoscopy and significantly reduces requirement for endoscopic therapy during index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.

The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage

BACKGROUND

Upper gastrointestinal (UGI) haemorrhage is a frequent cause of hospital admission. Scoring systems have been devised to identify those at risk of adverse outcomes. We evaluated the Glasgow Blatchford score's (GBS) ability to identify the need for clinical and endoscopic intervention in patients with UGI haemorrhage.

METHODS

A retrospective observational study was performed in all patients who attended the A&E department with UGI haemorrhage during a 12-month period. Patients were separated into low and high risk categories. High risk encompassed patients who required blood transfusions, operative or endoscopic interventions, management on high dependency or intensive care units, and those who re-bled, represented with further bleeding, or who died.

RESULTS

A total of 174 patients were seen with UGI bleeding. Eight of them self-discharged and were excluded. Of the remaining 166, 94 had a 'low risk' bleed, and 72 'high risk'. The GBS was significantly higher in the high risk (median = 10) than in the low risk group (median 1, p < 0.001). To assess the validity of the GBS at separating low and high risk groups, receiver-operator characteristic (ROC) curves were plotted. The GBS had an area under ROC curve of 0.96 (95% CI 0.95-1.00). When a cut-off value of > or = 3 was used, sensitivity and specificity of GBS for identifying high risk bleeds was 100% and 68%. Thus at a cut-off value of < or = 2 the GBS is useful for distinguishing those patients with a low risk UGI bleed.

CONCLUSIONS

The GBS accurately identifies low risk patients who could be managed safely as outpatients.

Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score

BACKGROUND

The Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death.

AIMS

To identify the GBS that predicts lack of intervention or death and to apply this to clinical practice by managing low-risk patients in the community.

METHODS

GBSs prospectively calculated on 232 patients with upper gastrointestinal haemorrhage to identify low-risk score. Patients with low-risk of requiring intervention (GBS <or=2, age <70 years) from a further 304 patients were considered for management in the community.

RESULTS

Fifty-two of 232 patients in the first cohort had a GBS <or=2 and were aged less than 70 years: none of these required intervention or died. In the second cohort 104 of 304 (34.2%) patients had a GBS <or=2 and were aged less than 70 years, none of whom died or required endoscopic therapy, blood transfusion, surgery or died. Thrity-two of 104 (10.5% of total cohort) were safely managed in the community.

CONCLUSION

Using the criteria of a GBS <or=2, aged less than 70 years to define patients at 'low risk' allows 10.5% of patients with primary upper gastrointestinal haemorrhage to be safely managed in the community.

Acetylsalicylic acid use in patients with acute myocardial infarction and peptic ulcer bleeding

BACKGROUND

Acetylsalicylic acid (ASA) is used in the treatment of acute myocardial infarction (AMI) but is also a risk factor for peptic ulcer disease (PUD) bleeding.

OBJECTIVE

To determine the factors associated with continued ASA use in patients with AMI who develop PUD bleeding.

METHODS

AMI patients who developed PUD bleeding during the same hospitalization at two tertiary care hospitals in Edmonton, Alberta, between January 1999 and December 2006, were evaluated retrospectively. Multivariate analysis was used to determine predictors of the primary outcome of continued ASA use during PUD bleeding.

RESULTS

A total of 102 patients were analyzed. Thirty-eight patients (37%) were continued on ASA, while 64 (63%) had ASA discontinued during their hospitalization. On multivariate regression analysis, significant predictors of continued ASA use included lowrisk ulcer stigmata on endoscopy (OR 3.7; 95% CI 1.4 to 10.2; P=0.01) and AMI requiring coronary intervention (OR 8.2; 95% CI 2.1 to 32.1; P=0.002). The mean (+/- SD) blood transfusion requirement was 3.9+/-3.6 units. The 30-day rebleeding and mortality rates were 14% and 14%, respectively.

CONCLUSIONS

The continued use of ASA during AMI and PUD bleeding was variable. However, patients with low-risk ulcers and those who received coronary intervention were more likely to have ASA continued during PUD bleeding. Further studies evaluating the gastrointestinal risk of immediate ASA use in AMI with acute PUD bleeding are required.

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.

Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation

BACKGROUND

Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.

METHODS

Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.

FINDINGS

Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).

INTERPRETATION

The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries

BACKGROUND & AIMS

Outpatient management of selected patients with nonvariceal upper gastrointestinal hemorrhage (UGIH) has been proposed as a mechanism to decrease resource utilization and expenditures. However, the true prevalence and outcomes of this practice have not been well evaluated in population-based studies.

METHODS

We identified a cohort of 9123 episodes of UGIH in 2004 Medicare claims data, including 3506 (38.4%) managed as outpatients. Clinical characteristics, treatment, and outcomes were compared between inpatient and outpatient groups. In order to adjust for potential selection bias in outpatient treatment, propensity score analysis was used to divide patients into quartiles of likelihood for inpatient treatment.

RESULTS

Inpatients tended to be older, with higher comorbidity scores, and were more likely to have a bleeding ulcer or tear. Inpatients were also more likely to undergo endoscopy, including early endoscopy and therapeutics, and require surgery. The overall 30-day mortality rate was 8.0% in the inpatient group and 6.3% in the outpatient group (P< .001), and in the quartile of patients most likely to be managed as inpatients, the 30-day mortality rate was higher in outpatients than in inpatients.

CONCLUSIONS

The prevalence of outpatient management of UGIH in the Medicare population was almost 40%, and although patients were likely selected for outpatient management based on clinical criteria, the overall mortality rate in outpatients was considerable. Any potential financial benefit should be balanced against significant mortality rates, at least some of which could possibly be avoided with hospitalization. More optimal selection of candidates for outpatient therapy is likely needed.

[Upper gastrointestinal bleeding--five-year experience from one centre]

INTRODUCTION

Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologists.

OBJECTIVE

To assess the frequency of erosive gastropathy and duodenal ulcer as a cause of upper gastrointestinal (GI) bleeding as well as its relation to age, gender and known risk factors.

METHOD

We conducted retrospective observational analysis of emergency endoscopy reports from the records of the Emergency Department of Clinic for Gastroenterology and Hepatology, Clinical Centre of Serbia, during the period from 2000 to 2005. Data consisted of patients'demographics, endoscopic findings and potential risk factors.

RESULTS

During the period 2000-2005, three thousand nine hundred and fifty four emergency upper endoscopies were performed for acute bleeding. In one quarter of cases, acute gastric erosions were the actual cause of bleeding. One half of them were associated with excessive consumption of salicylates and NSAIDs. In most of the examined cases, bleeding stopped spontaneously, while 7.6% of the cases required endoscopic intervention. Duodenal ulcer was detected as a source of bleeding in 1320 (33.4%) patients and was significantly associated with a male gender (71.8%) and salicylate or NSAID abuse (59.1%) (chi2-test; p = 0.007).

CONCLUSION

Erosive gastropathy and duodenal ulcer represent a significant cause of upper gastrointestinal bleeding accounting for up to 60% of all cases that required emergency endoscopy during the 5-year period. Consumption of NSAIDs and salicylates was associated more frequently with bleeding from a duodenal ulcer than with erosive gastropathy leading to a conclusion that we must explore other causes of erosive gastropathy more thoroughly.

Prognostic factors in gastrointestinal bleeding due to peptic ulcer: construction of a predictive model

OBJECTIVES

The identification of prognostic factors of easy application in clinical practice can improve the diagnostic and therapeutic decision making process in upper gastrointestinal bleeding (UGB). The present study estimates the capacity to predict an unfavorable clinical course (mortality, unstable bleeding, and/or interventional therapy) on the basis of the preendoscopic and endoscopic clinical analytical findings in patients with UGB owing to peptic ulcer.

METHOD

A retrospective cohort study was made of 473 adult patients seen in the Emergency Service of a District Hospital, and diagnosed with UGB secondary to gastroduodenal ulcer. Logistic regression analysis was used to construct different models, with the evaluation of their predictive capacity based on calculation of the area under the receiver operating curve (ROC). The final model was used to calculate the probabilities of an unfavorable clinical course for different profiles, with the purpose of constructing an algorithm of help in the decision making process applied to patients initially considered to be at low risk (Forrest classification IIb and III).

RESULTS

The model with the Forrest variable showed a high predictive capacity: ROCa=0.81 (95% confidence interval, 0.76-0.85). Incorporation to the model of clinical and preendoscopic factors (type of UGB, hematocrit, kidney failure, and liver disease) significantly increased its predictive capacity: ROCa=0.87 (95% confidence interval, 0.83-0.91). This model allows the differentiation of different complication risk levels in patients initially at low risk according to the Forrest classification (IIb and III).

CONCLUSIONS

The Forrest classification is the principal predictive factor for an unfavorable course in patients with gastrointestinal bleeding owing to peptic ulcer, though clinical factors are also important and should complement the decision taking process.

Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding

BACKGROUND & AIMS

Randomized trials suggest high-dose proton-pump inhibitors (PPIs) administered before gastroscopy in suspected upper gastrointestinal bleeding downstage bleeding ulcer stigmata. We assessed the cost-effectiveness of this approach.

METHODS

A decision model compared high-dose IVPPI initiated while awaiting endoscopy with IVPPI administration on the basis of endoscopic findings. IVPPIs were given to all patients undergoing endoscopic hemostasis for 72 hours thereafter. Once the IV regimen was completed or for patients with low-risk endoscopic lesions, an oral daily PPI was given for the remainder of the time horizon (30 days after endoscopy). The unit of effectiveness was the proportion of patients without rebleeding, representing the denominator of the cost-effectiveness ratio (cost per no rebleeding). Probabilities and costs were derived from the literature and national databases.

RESULTS

IVPPIs before endoscopy were both slightly more costly and effective than after gastroscopy in the U.S. and Canadian settings, with cost-effectiveness ratios of US$5048 versus $4933 and CAN$6064 versus $6025 and incremental costs of US$45,673 and CAN$19,832 to prevent one additional rebleeding episode, respectively. Sensitivity analyses showed robust results in the US In Canada, intravenous proton-pump inhibitors (IVPPIs) before endoscopy became more effective and less costly (dominant strategy) when the uncomplicated stay for high-risk patients increased above 6 days or that of low-risk patients decreased below 3 days.

CONCLUSIONS

With conservative estimates and high-quality data, IVPPIs given before endoscopy are slightly more effective and costly than no administration. In Canada, this approach becomes dominant as the duration of hospitalization for high-risk ulcer patients increases or that of low-risk ulcer patients decreases.

Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

BACKGROUND

Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB.

METHODS

International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients.

RESULTS

The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score (P < .0001) or with the complete Rockall score (P < .0001). In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion.

CONCLUSIONS

The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.

An economic model of long-term use of celecoxib in patients with osteoarthritis

Background

Previous evaluations of the cost-effectiveness of the cyclooxygenase-2 selective inhibitor celecoxib (Celebrex, Pfizer Inc, USA) have produced conflicting results. The recent controversy over the cardiovascular (CV) risks of rofecoxib and other coxibs has renewed interest in the economic profile of celecoxib, the only coxib now available in the United States. The objective of our study was to evaluate the long-term cost-effectiveness of celecoxib compared with nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) in a population of 60-year-old osteoarthritis (OA) patients with average risks of upper gastrointestinal (UGI) complications who require chronic daily NSAID therapy.

Methods

We used decision analysis based on data from the literature to evaluate cost-effectiveness from a modified societal perspective over patients' lifetimes, with outcomes expressed as incremental costs per quality-adjusted life-year (QALY) gained. Sensitivity tests were performed to evaluate the impacts of advancing age, CV thromboembolic event risk, different analytic horizons and alternate treatment strategies after UGI adverse events.

Results

Our main findings were: 1) the base model incremental cost-effectiveness ratio (ICER) for celecoxib versus nsNSAIDs was $31,097 per QALY; 2) the ICER per QALY was $19,309 for a model in which UGI ulcer and ulcer complication event risks increased with advancing age; 3) the ICER per QALY was $17,120 in sensitivity analyses combining serious CV thromboembolic event (myocardial infarction, stroke, CV death) risks with base model assumptions.

Conclusion

Our model suggests that chronic celecoxib is cost-effective versus nsNSAIDs in a population of 60-year-old OA patients with average risks of UGI events.

Risk stratification in upper gastrointestinal bleeding

Acute upper gastrointestinal (UGI) bleeding is a common clinical problem that accounts for a large number of hospitalizations and results in substantial health care expenditures. Risk stratification after UGI hemorrhage involves the use of clinical and endoscopic parameters to predict the likelihood of rebleeding and death. This information can guide management decisions, such as the necessity of hospital admission, the application of endoscopic hemostatic therapy, and the length of inpatient stay. This concise review examines the current literature on risk stratification in UGI hemorrhage and attempts to integrate evidence-based data into the clinical decision-making process.

Acute upper gastrointestinal bleeding

Aims: Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologist. Our aim was to assess the frequency of erosive gastropathy as a cause of upper GI bleeding as well as its relation to age, gender and known risk factors. Material and methods: We conducted retrospective observational analysis of emergency endoscopy reports from the files of Emergency Department of Clinic of Gastroenterology and Hepatology, Clinical Center of Serbia, during the period from 2000-2005. Data consisted of patients? demographics, endoscopic findings and potential risk factors. Results: During the period 2000-2005. Three thousandnine hundred and fifty four emergency upper endoscopies were performed for acute bleeding. In one quarter of cases acute gastric erosions were the actual cause of bleeding. One half of them were associated with excessive consumption of salicilates and NSAIDs. In most of the examined cases bleeding stopped spontaneously, while in 7.6% of the cases required endoscopic intervention. Conclusion: Erosive gastropathy represents significant cause of upper gastrointestinal bleeding count up to one quarter of all cases required emergency endoscopy during the 5- year period. Consumption of NSAIDs and salicilates was associated with erosive gastropathy in almost one half of cases (46%) leading us with a conclusion that we must explore other causes of erosive gastropathy more thoroughly.

Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting

AIM: To validate the Rockall scoring system for predicting outcomes of rebleeding, and the need for a surgical procedure and death.

METHODS: We used data extracted from the Registry of Upper Gastrointestinal Bleeding and Endoscopy including information of 1869 patients with non-variceal upper gastrointestinal bleeding treated in Canadian hospitals. Risk scores were calculated and used to classify patients based on outcomes. For each outcome, we used χ² goodness-of-fit tests to assess the degree of calibration, and built receiver operating characteristic curves and calculated the area under the curve (AUC) to evaluate the discriminative ability of the scoring system.

RESULTS: For rebleeding, the χ² goodness-of-fit test indicated an acceptable fit for the model [χ² (8) = 12.83, P = 0.12]. For surgical procedures [χ² (8) = 5.3, P = 0.73] and death [χ² (8) = 3.78, P = 0.88], the tests showed solid correspondence between observed proportions and predicted probabilities. The AUC was 0.59 (95% CI: 0.55-0.62) for the outcome of rebleeding and 0.60 (95% CI: 0.54-0.67) for surgical procedures, representing a poor discriminative ability of the scoring system. For the outcome of death, the AUC was 0.73 (95% CI: 0.69-0.78), indicating an acceptable discriminative ability.

CONCLUSION: The Rockall scoring system provides an acceptable tool to predict death, but performs poorly for endpoints of rebleeding and surgical procedures.

Predicting outcome of acute non-variceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score

BACKGROUND

The Rockall risk scoring system uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage. A clinical Rockall score obtained using only the clinical criteria may be able to predict outcome without endoscopy.

AIM

To validate the clinical Rockall Score in predicting outcome after acute non-variceal upper gastrointestinal haemorrhage.

METHODS

A retrospective observational study of consecutive patients who were admitted with non-variceal acute upper gastrointestinal haemorrhage was undertaken. Medical records were abstracted using a standardised form.

RESULTS

102 cases were identified (51 men and 51 women; mean age 59 years). 38 (37%) patients considered to be at low risk of adverse outcomes (clinical Rockall Score 0) had no adverse outcomes and did not require transfusion. Patients with a clinical Rockall Score of 1-3 had no adverse outcomes, although 13 of 45 (29%) patients required blood transfusions. Clinical Rockall Scores >3 (n = 19) were associated with adverse outcomes (rebleeding in 4 (21%), surgery in 1 (5%) and death in 2 (10%)).

CONCLUSIONS

The clinical Rockall Score without endoscopy may be a useful prognostic indicator in this cohort of patients with acute non-variceal upper gastrointestinal haemorrhage. This score may reduce the need for urgent endoscopy in low-risk patients, which can instead be carried out on a more elective outpatient basis.

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

BACKGROUND

There is conflicting evidence regarding the clinical efficacy of proton pump inhibitors (PPI) initiated prior to endoscopy in patients with upper gastrointestinal bleeding.

OBJECTIVES

We aimed to systematically review evidence from randomised controlled trials (RCTs) that studied PPI treatment initiated before endoscopy in patients with upper gastrointestinal bleeding.

SEARCH STRATEGY

A search was undertaken according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases model using CENTRAL, (The Cochrane Library), MEDLINE, EMBASE and CINAHL databases and major conference proceedings up to September 2005. The literature search was re-run in February 2006.

SELECTION CRITERIA

Types of studies: Randomised controlled trials (RCTs).

TYPES OF PARTICIPANTS

Hospitalised patients with unselected upper gastrointestinal bleeding. Types of interventions: Active treatment with a PPI (oral or intravenous) and control treatment with either placebo or an histamine-(2) receptor antagonist (H(2)RA). Types of outcome measures: Assessed at 30 days: mortality, rebleeding and surgery. Also assessed were stigmata of recent haemorrhage at index endoscopy, length of hospital stay and blood transfusion requirements.

DATA COLLECTION AND ANALYSIS

At least two reviewers assessed the eligibility criteria of each study and extracted data regarding outcomes and factors affecting methodological quality.

MAIN RESULTS

Five RCTs were included for review. No further RCTS were identified in an updated literature search. Four trials comprising a total of 1512 patients in total reported data for all randomised patients. There was no statistical heterogeneity among trials for the outcomes of mortality, rebleeding and surgery. There were no statistically significant differences in rates of mortality, rebleeding or surgery between PPI and control treatment. Pooled mortality rates were 6.1% and 5.5% respectively (odds ratio (OR)1.12; 95% CI 0.72 to 1.73). Pooled rebleeding rates were 13.9% and 16.6% respectively (OR 0.81; 95%CI 0.61 to 1.09). Pooled rates for surgery were 9.9% and 10.2% respectively (OR 0.96 95% CI 0.68 to 1.35). PPI treatment compared to control significantly reduced the proportion of patients with stigmata of recent haemorrhage at index endoscopy; pooled rates were 37.2% and 46.5% respectively (OR 0.67; 95% CI 0.54 to 0.84). For the continuous outcomes, namely length of hospital stay and blood transfusion requirements, quantitative analysis could not be performed.

AUTHORS' CONCLUSIONS

PPI treatment initiated prior to endoscopy in patients with upper gastrointestinal bleeding significantly reduces the proportion of patients with stigmata of recent haemorrhage at index endoscopy. However, there is no evidence that PPI treatment affects clinically important outcomes, namely mortality, rebleeding or need for surgery.

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.

Mesure de l’hémoglobine capillaire par un lecteur d’hémoglobine portable

INTRODUCTION

Monitoring of hemoglobin is necessary in patients with gastrointestinal haemorrhage. Take blood sample and analysis at laboratory with automatum is the gold standard. A fast determination of hemoglobin at the bedside is possible with a portable haemoglobinometer Hemocue.

AIMS AND METHODS

To assess correlation of capillary hemoglobin by Hemocue at the bedside, with venous hemoglobin by Coulter STKS in laboratory, for the monitoring of patients with a gastrointestinal haemorrhage hospitalized at november 2001 to july 2002. Statistical analysis used t test student apparied, and the determination of correlation coefficient r.

RESULTS

Fourteen males and 8 females 61+/-17 aged had taking 204 venous blood samples and 204 capillaries blood simultaneously. Gastrointestinal haemorrhage was related with variceal bleeding (n=11), a duodenal ulcer (n =6), an esophagitis peptic ulcer (n =1), a diverticulous colitis (n =2), a gastric cancer (n =1), and an ischemic colitis (n =1). Initial hemoglobin was at 7.6+/-2,4 g/dL. Transfusion of 3+/-3 blood unit were realised in 17 patients. Means of hemoglobin were 9.15+/-1,62 g/dL on venous blood analyzed in laboratory, and 9.43 +/- 1,72 g/dL on blood capillary by Hemocue at the bedside. Correlation coefficient r was 0.87 (p <0.001). Variceal or others bleeding, fluid infusion for hypovolaemia, red cell transfusion and widespread of low level hemoglobin do not disturbed the validity of results.

CONCLUSION

In acute period of a gastrointestinal hemorrhage, monitoring of hemoglobin by Hemocue with capillary blood at the bedside is a reliable method.

Risk assessment and outpatient management in bleeding peptic ulcer

AIMS

1) To review clinical and endoscopic variables in patients hospitalized for upper gastrointestinal bleeding (UGIB) due to peptic gastroduodenal lesions over a period of 3 years; 2) to identify factors associated with unfavorable evolution; and 3) to evaluate characteristics of patients discharged immediately after endoscopy.

METHODS

A 3-year retrospective analysis of all UGIB episodes was performed. Patients with gastroduodenal ulcer or erosive gastritis/duodenitis at endoscopy were included. The prognostic value of several clinical, endoscopic, and analytical variables was assessed. Persistence or recurrence of bleeding, surgery, and mortality were considered as outcome variables (evolution was classified as "unfavorable" when any of these was observed).

RESULTS

A total of 341 patients were identified, with a mean age of 62 years. Melena was the most frequent UGIB presentation (70%). Forty-five percent had associated diseases, and 45% were taking gastroerosive drugs. Duodenal ulcer was the most frequent cause of UGIB (48%), followed by gastric ulcer (32%). The evolution of UGIB was unfavorable in 7% of cases. Variables associated with unfavorable evolution in the multivariate analysis were: systolic blood pressure < or = 100 mm Hg, heart rate > or = 100 bpm, and a Forrest endoscopic classification of severe. Only 10% of patients were immediately discharged, with no subsequent complications. However, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 115 patients (34%) without subsequent complications.

CONCLUSIONS

A number of clinical and endoscopic variables (blood pressure, heart rate, and endoscopic stigmata of bleeding) with prognostic value have been identified. These are easy to obtain and apply in clinical practice and allow an accurate estimation of the evolution of UGIB. This diagnostic strategy identifies a relatively high proportion of UGIB patients who can be managed on an outpatient basis.

Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis

BACKGROUND & AIMS

The optimal management of bleeding peptic ulcer with adherent clot is controversial and may include endoscopic therapy or medical therapy.

METHODS

We searched MEDLINE, BIOSIS, EMBASE, and the Cochrane Library to identify all randomized controlled trials comparing the 2 interventions. Outcomes evaluated in the meta-analysis were recurrent bleeding, need for surgical intervention, length of hospitalization, transfusion requirement, and mortality.

RESULTS

Six studies were identified that included 240 patients from the United States, Hong Kong, South Korea, and Spain. Patients in the endoscopic therapy group underwent endoscopic clot removal and treatment of the underlying lesion with thermal energy, electrocoagulation, and/or injection of sclerosants. Rebleeding occurred in 5 of 61 (8.2%) patients in the endoscopic therapy group, compared with 21 of 85 (24.7%) in the medical therapy group (P = .01), for a pooled relative risk of 0.35 (95% confidence interval, 0.14-0.83; number needed to treat, 6.3). There was no difference between endoscopic therapy and medical therapy in length of hospital stay (mean, 6.8 vs 5.6 days; P = .27), transfusion requirement (mean, 3.0 vs 2.8 units of packed red blood cells; P = .75), or mortality (9.8% vs 7%; P = .54). Patients in the endoscopic therapy group were less likely to undergo surgery (pooled relative risk, 0.43; 95% confidence interval, 0.19-0.98; number needed to treat, 13.3); however, this outcome became nonsignificant when only peer-reviewed studies were considered.

CONCLUSIONS

Endoscopic therapy is superior to medical therapy for preventing recurrent hemorrhage in patients with bleeding peptic ulcers and adherent clots. The interventions are comparable with respect to the need for surgical intervention, length of hospital stay, transfusion requirement, and mortality.

Endoscopic Treatment of Upper Gastrointestinal Bleeding

Endoscopic therapy for nonvariceal bleeding should only be used if major stigmata of hemorrhage such as active bleeding and nonbleeding visible vessel are present. Treatment of peptic ulcers with adherent clots is currently controversial. Combination of epinephrine injection and coaptive coagulation is most effective in achieving endoscopic hemostasis. Hemoclips may be preferable for very deep ulcers and large visible blood vessels if coaptive coagulation is anticipated to have a high risk of perforation or bleeding. Adrenaline injection or hemoclip application should be used in bleeding Mallory-Weiss tears, as the safety of thermal methods is not well established. Argon plasma coagulation is the mainstay of endoscopic treatment for superficial lesions such as angiodysplasia and gastric antral vascular ectasia. Both sclerotherapy and band ligation are effective in acute hemostasis of bleeding esophageal varices. Variceal band ligation is preferred due to its superior safety profile and shorter procedure time. Due to the early recurrence of varices after banding ligation, there may be a role for metachronous combination therapy of ligation followed by sclerotherapy. Histoacryl glue is the preferred method of endoscopic hemostasis in gastric varices.

Proposed risk stratification in upper gastrointestinal haemorrhage: is hospitalisation essential?

AIMS

Patients with upper gastrointestinal haemorrhage (UGIH) are usually admitted to hospital regardless of the severity of the bleed. The aim of this study was to identify patients who could be safely managed without hospitalisation and immediate inpatient endoscopy.

METHODS

Based on a literature review, a protocol was devised using clinical and laboratory data regarded as being of prognostic value. A retrospective observational study of consecutive patients who attended the emergency department (ED) with UGIH was conducted during one calendar month.

RESULTS

Fifty four patients were identified of whom 44 (81%) were admitted. Twelve suffered an adverse event. One of the 10 patients (10%) initially discharged from the ED was later admitted. Strict implementation of the protocol would have resulted in safe discharge of a further 15 patients, (34% of those admitted), and a saving of an estimated 37 bed days per month.

CONCLUSIONS

Patients at low risk from UGIH may be identified in the ED. If validated, this protocol may improve patient management and resource utilisation.

Risk factors for mortality in severe upper gastrointestinal bleeding

BACKGROUND AND AIMS

Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre.

PATIENTS/METHODS

Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared.

RESULTS/FINDINGS

The mean Rockall score was 6.6+/-1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality.

INTERPRETATION/CONCLUSION

In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.

The cost-effectiveness of high-dose oral proton pump inhibition after endoscopy in the acute treatment of peptic ulcer bleeding

BACKGROUND

Recent data suggest a role for high-dose oral proton pump inhibition in ulcer bleeding.

AIM

To compare the cost-effectiveness of oral high-dose proton pump inhibition to both high-dose intravenous proton pump inhibition and placebo administration.

METHODS

The model adopted a 30-day time horizon, and focused on patients with ulcer haemorrhage initially treated endoscopically for high-risk stigmata. Re-bleeding rates were set a priori based on non-head-to-head data from the literature, and charges and lengths of stay from a national American database. Sensitivity analyses were carried across a broad range of clinically relevant assumptions.

RESULTS

Re-bleeding rates for patients receiving intravenous, oral, or placebo therapies were 5.9%, 11.8%, and 27%, respectively. The mean lengths of stay and costs for admitted patients with and without re-bleeding were 4.7 and 3 days; $11,802, and $7993, respectively. High-dose intravenous proton pump inhibition was more effective and less costly (dominant) than high-dose oral proton pump inhibition with incremental savings of $136.40 per patient treated. The oral high-dose strategy in turn dominated placebo administration. Results remained robust according to one- and two-way sensitivity analyses.

CONCLUSION

In patients undergoing endoscopic haemostasis, subsequent high-dose intravenous proton pump inhibition is more cost-effective than high-dose oral proton pump inhibition, which in turn dominates placebo. The results from this exploratory-type cost analysis require confirmation by head-to-head prospective trials performed in Western populations.

A randomized study of the safety of outpatient care for patients with bleeding peptic ulcer treated by endoscopic injection

BACKGROUND

Outpatient management is safe for patients with non-variceal upper-GI bleeding who are at low risk of recurrent bleeding and death. However, outpatient care cannot be offered to many patients because of the presence of risk factors (severe comorbid disorders, major endoscopic stigmata of bleeding, significant hemorrhage). The present study assessed the safety of outpatient management for selected high-risk patients with bleeding peptic ulcer.

METHODS

Patients hospitalized with upper-GI bleeding because of peptic ulcer with a non-bleeding vessel were eligible for inclusion in the study. Inclusion criteria were the following: ulcer size less than 15 mm, absence of hypovolemia, no associated severe disease, and appropriate family support. After endoscopic therapy (injection of epinephrine and polidocanol), patients were randomized to outpatient or hospital care. Patients remained in the emergency ward for a minimum of 6 hours before discharge, during which time omeprazole was administered intravenously. Outpatients were contacted by telephone daily during the first 3 days; a 24-hour telephone hotline was provided for any queries. For both groups, outpatient visits were scheduled at 7 to 10 and 30 days after discharge.

RESULTS

A total of 82 patients were included: 40 were randomized to outpatient care and 42 to hospital care. Clinical and endoscopic variables were similar in both groups. The rate of recurrent bleeding was similar in both groups (4.8% outpatient, 5% hospital). There was no morbidity or mortality in either group at 30 days. Seven patients (17%) randomized to outpatient care received blood transfusion compared with 14 (38%) in the hospital care group (p=0.06). Mean cost of care per patient was significantly lower for the outpatient vs. the hospital group (970 US dollars vs. 1595 US dollars; p < 0.001).

CONCLUSIONS

Selected patients with bleeding peptic ulcer can be safely managed as outpatients after endoscopic therapy. This policy conserves health care resources without compromising standards of care.

Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage

BACKGROUND

Risk scores for triage of patients with acute upper-GI hemorrhage that incorporate endoscopic variables (e.g., the complete Rockall Score) may have better test characteristics for identification of "low-risk" bleeding episodes than those (e.g., Blatchford Score, clinical Rockall Score) that rely solely on clinical variables. An endoscopy-based risk score was compared with two clinically based risk scores in a large cohort of patients hospitalized for treatment of acute upper-GI hemorrhage to quantify the incremental value of endoscopy in the identification of low-risk bleeding.

METHODS

ICD-9-CMcodes for discharge diagnosis were used to identify a cohort of patients (n=175) hospitalized at a university medical center with acute non-variceal upper-GI hemorrhage. Medical record data were abstracted by two data abstractors blinded to the study intent by using a standardized data collection instrument. Blatchford and Rockall Scores were generated for each case. Low risk was defined as a Blatchford Score of 0, a clinical Rockall Score of 0, or complete Rockall Score of 2 or less.

RESULTS

The Blatchford Score risk stratified only 14 of 175 (8%) patients with acute, non-variceal upper-GI hemorrhage as "low risk," while the clinical Rockall Score identified 12%. However, the complete Rockall Score identified the greatest number of low-risk cases, 53/175 (30%) (p < 0.0001), when compared with either the Blatchford or clinical Rockall Score.

CONCLUSIONS

The complete Rockall Score identified significantly more low-risk patients with acute upper-GI hemorrhage than either the clinical Rockall Score or the Blatchford Score. Identification of additional low-risk patients via this endoscopy-based score could lead to decreases in the use of hospital-based services, iatrogenic complications, and time lost from work or usual activity, while improving quality of care. Use of the clinical and complete Rockall Scores sequentially, with consideration of outpatient care for patients at identified as low risk, is recommended.

Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study

BACKGROUND

Urgent endoscopy in patients with acute upper-GI bleeding identifies many patients who may be safely treated without hospitalization. The aim of this multicenter trial was to determine whether urgent endoscopy effectively decreases health care resource utilization in a real-life setting where primary care providers determine the course of care.

METHODS

Ninety-three outpatients with acute upper-GI bleeding were randomized to either urgent endoscopy (before hospitalization) or elective endoscopy after admission. The results of urgent endoscopy and a recommendation regarding patient disposition were provided to the attending physician. Medical outcomes and resource utilization were measured.

RESULTS

The timing of endoscopy did not affect resource utilization or patient outcomes. Length of stay was similar (urgent endoscopy, OR 3.98 days: 95% CI[2.84, 5.11] vs. elective endoscopy, OR 3.26 days: 95% CI[2.32, 4.21], p=0.45). The mean number of days in an intensive care unit was the same (1.2 days). The urgent endoscopy group had more high-risk endoscopic lesions (15 vs. 9; p=0.031). Outpatient care was recommended for 19 patients (40%). Only 4 patients were discharged.

CONCLUSIONS

Urgent endoscopy did not reduce hospitalization or resource utilization because the results of early endoscopy did not impact the decision by attending physicians regarding admission. For early (triage) endoscopy to impact resource utilization, the results of endoscopy must change subsequent patient care.

A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management

BACKGROUND

The aim of this study was to develop a risk score system for identification of patients with upper-GI hemorrhage who are suitable for outpatient management.

METHODS

From a prospective cohort of 983 consecutive patients with upper-GI hemorrhage not associated with portal hypertension, 581 cases that did not meet pre-established criteria for admission were selected, and a logistic regression analysis was performed to identify factors associated with two adverse outcomes: recurrent bleeding and/or the need for emergency surgery. The risk score system was developed by using the beta coefficients of the logistic model, and its performance was evaluated. The results of this model were combined with pre-established criteria for admission to build a simplified scoring system for identification of patients who can be managed safely on an outpatient basis.

RESULTS

Chronic alcoholism, active malignancy, prior upper digestive tract surgery, wasting syndrome, hemodynamic compromise, duodenal ulcer as the cause of upper-GI hemorrhage, and hemorrhage of unknown cause were independently associated with a greater risk of unfavorable outcomes in the group that did not meet pre-established criteria for admission. The logistic model showed a high capacity for discrimination (C statistic: 0.87) and good calibration (p value for Hosmer-Lemeshow goodness-of-fit test, 0.62), with a sensitivity of 100% and specificity of 64%. The simplified score had a sensitivity of 100% and specificity of 29% for adverse outcomes, and sensitivity of 78% and specificity of 38% for mortality.

CONCLUSIONS

The score system developed in this study may be helpful in deciding between hospitalization and outpatient management for patients with upper-GI hemorrhage, but it remains to be validated in patient groups other than those used for its development.

Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study

BACKGROUND & AIMS

Unlike in upper tract bleeding, prognostic factors for ongoing or recurrent bleeding from the lower gastrointestinal tract have not been well-defined. The aim of this study was to identify risk factors for severe lower gastrointestinal bleeding and for significant adverse outcomes.

METHODS

All patients seeking attention at a university emergency department for gastrointestinal bleeding were prospectively identified during a 3-year period. Ninety-four of 448 (21%) admitted patients had lower gastrointestinal bleeding. Clinical predictors available in the first hour of evaluation were recorded. The primary outcome, severe lower gastrointestinal bleeding, was defined as gross blood per rectum after leaving the emergency department associated with either abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) or more than a 2-unit blood transfusion during the hospitalization. Significant adverse outcomes, including death, were tabulated.

RESULTS

Thirty-seven patients (39%) had severe lower gastrointestinal bleeding. Independent risk factors for severe lower gastrointestinal bleeding were initial hematocrit </=35% (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.2-16.7); presence of abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) 1 hour after initial medical evaluation (OR, 4.3; 95% CI, 1.4-12.5); and gross blood on initial rectal examination (OR, 3.9; 95% CI, 1.2-13.2). Nineteen patients (20%) experienced a significant adverse outcome, including 3 deaths. The main independent predictor of adverse outcomes was severe lower gastrointestinal bleeding (OR, 5.3; 95% CI, 1.7-16.5).

CONCLUSIONS

Risk factors are available in the first hour of evaluation in the emergency department to identify patients at risk for severe lower gastrointestinal bleeding. Severe lower gastrointestinal bleeding is a significant risk factor for global adverse outcomes.

Comparison of three different risk scoring systems in non-variceal upper gastrointestinal bleeding

BACKGROUND AND AIMS

To prospectively validate in patients with non-variceal upper gastrointestinal bleeding three risk scoring systems (the Baylor College scoring system, the Rockall's risk scoring system and the Cedars-Sinai Medical Centre predictive index) previously proposed to be predictive of rebleeding/death after upper gastrointestinal bleeding.

PATIENTS AND METHODS

We calculated values of the scores for 343 patients, who underwent endoscopy after non-variceal upper gastrointestinal haemorrhage during the years 1997-1999. We compared the observed outcomes with the ones expected upon the original series contributed by the authors. Discriminative ability was evaluated by calculating the area under the receiver operating characteristic curve.

RESULTS AND CONCLUSIONS

Rockall's score accurately predicted rebleeding in low- and intermediate-risk categories (< 6), but not in high-risk patients. The rates of rebleeding were significantly higher than the ones predicted by the low-risk categories of either Cedars-Sinai index (< or = 2) or Baylor score (< or = 6). The predicted and the observed mortality was not significantly different throughout all the categories of Rockall's score, except for patients with a score of 4. All the scores had better discriminative ability for mortality than for rebleeding. The Rockall's score identifies a low-risk group of patients (Rockall's score < or = 2) for rebleeding and mortality.