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Garcia-Iglesias P, Machlab S, Martinez-Bauer E, Lira A, Campo R, Marín S, Raurich-Seguí M, Calvet X, Brullet E. Diagnostic accuracy of the Oakland score versus haemoglobin for predicting outcomes in lower gastrointestinal bleeding. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:742-749. [PMID: 38341089 DOI: 10.1016/j.gastrohep.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Acute lower gastrointestinal bleeding (ALGIB) is a common cause of hospitalization. Recent guidelines recommend the use of prognostic scales for risk stratification. However, it remains unclear whether risk scores are more accurate than some simpler prognostic variables. OBJECTIVE To compare the predictive values of haemoglobin alone and the Oakland score for predicting outcomes in ALGIB patients. DESIGN Single-centre, retrospective study at a University Hospital. Data were extracted from the hospital's clinical records. The Oakland score was calculated at admission. Study outcomes were defined according to the original article describing the Oakland score: safe discharge (the primary Oakland score outcome), transfusion, rebleeding, readmission, therapeutic intervention and death. Area under the receiver operating characteristics (AUROC) curve and accuracy using haemoglobin and the Oakland score were calculated for each outcome. RESULTS Two hundred and fifty-eight patients were included. Eighty-four (32.6%) needed transfusion, 50 (19.4%) presented rebleeding, 31 (12.1%) required therapeutic intervention, 20 (7.8%) were readmitted and six (2.3%) died. There were no differences in the AUROC curve values for haemoglobin versus the Oakland score with regard to safe discharge (0.82 (0.77-0.88) vs 0.80 (0.74-0.86), respectively) or to therapeutic intervention and death. Haemoglobin was significantly better for predicting transfusion and rebleeding, and the Oakland score was significantly better for predicting readmission. CONCLUSION In our study, the Oakland score did not perform better than haemoglobin alone for predicting the outcome of patients with ALGIB. The usefulness of risk scores for predicting outcomes in clinical practice remains uncertain.
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Affiliation(s)
- Pilar Garcia-Iglesias
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Spain; Grup de Recerca Consolidat, Spain
| | - Salvador Machlab
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Spain
| | - Eva Martinez-Bauer
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Spain; Grup de Recerca Consolidat, Spain; CIBEREHD - Instituto de Salud Carlos III.(SGR01500), Spain
| | - Alba Lira
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
| | - Rafel Campo
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Spain; Grup de Recerca Consolidat, Spain; CIBEREHD - Instituto de Salud Carlos III.(SGR01500), Spain
| | - Susana Marín
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Documentació Clínica i Arxiu, Unitat de l'Organització de la Informació Assistencial, Spain
| | - Maria Raurich-Seguí
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Documentació Clínica i Arxiu, Unitat de l'Organització de la Informació Assistencial, Spain
| | - Xavier Calvet
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Spain; Grup de Recerca Consolidat, Spain; CIBEREHD - Instituto de Salud Carlos III.(SGR01500), Spain.
| | - Enric Brullet
- Hospital de Sabadell, Corporació Sanitària Universitària Parc Taulí, Sabadell, Spain
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Tominaga N, Sadashima E, Aoki T, Fujita M, Kobayashi K, Yamauchi A, Yamada A, Omori J, Ikeya T, Aoyama T, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Hikichi T, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Kaise M, Nagata N. A novel prediction tool for mortality in patients with acute lower gastrointestinal bleeding requiring emergency hospitalization: a large multicenter study. Sci Rep 2024; 14:5367. [PMID: 38438534 PMCID: PMC10912311 DOI: 10.1038/s41598-024-55889-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 02/28/2024] [Indexed: 03/06/2024] Open
Abstract
The study aimed to identify prognostic factors for patients with acute lower gastrointestinal bleeding and to develop a high-accuracy prediction tool. The analysis included 8254 cases of acute hematochezia patients who were admitted urgently based on the judgment of emergency physicians or gastroenterology consultants (from the CODE BLUE J-study). Patients were randomly assigned to a derivation cohort and a validation cohort in a 2:1 ratio using a random number table. Assuming that factors present at the time of admission are involved in mortality within 30 days of admission, and adding management factors during hospitalization to the factors at the time of admission for mortality within 1 year, prognostic factors were established. Multivariate analysis was conducted, and scores were assigned to each factor using regression coefficients, summing these to measure the score. The newly created score (CACHEXIA score) became a tool capable of measuring both mortality within 30 days (ROC-AUC 0.93) and within 1 year (C-index, 0.88). The 1-year mortality rates for patients classified as low, medium, and high risk by the CACHEXIA score were 1.0%, 13.4%, and 54.3% respectively (all P < 0.001). After discharge, patients identified as high risk using our unique predictive score require ongoing observation.
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Affiliation(s)
- Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, 400 Nakabaru, Kasemachi, Saga, 840-8571, Japan.
| | - Eiji Sadashima
- Department of Medical Research Institute, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Chikushi Hospital, Fukuoka University, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
- Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
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Omori J, Kaise M, Nagata N, Aoki T, Kobayashi K, Yamauchi A, Yamada A, Ikeya T, Aoyama T, Tominaga N, Sato Y, Kishino T, Ishii N, Sawada T, Murata M, Takao A, Mizukami K, Kinjo K, Fujimori S, Uotani T, Fujita M, Sato H, Suzuki S, Narasaka T, Hayasaka J, Funabiki T, Kinjo Y, Mizuki A, Kiyotoki S, Mikami T, Gushima R, Fujii H, Fuyuno Y, Hikichi T, Toya Y, Narimatsu K, Manabe N, Nagaike K, Kinjo T, Sumida Y, Funakoshi S, Kobayashi K, Matsuhashi T, Komaki Y, Miki K, Watanabe K, Iwakiri K. Characteristics, outcomes, and risk factors of surgery for acute lower gastrointestinal bleeding: nationwide cohort study of 10,342 hematochezia cases. J Gastroenterol 2024; 59:24-33. [PMID: 38006444 DOI: 10.1007/s00535-023-02057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/23/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Current evidence on the surgical rate, indication, procedure, risk factors, mortality, and postoperative rebleeding for acute lower gastrointestinal bleeding (ALGIB) is limited. METHODS We constructed a retrospective cohort of 10,342 patients admitted for acute hematochezia at 49 hospitals (CODE BLUE J-Study) and evaluated clinical data on the surgeries performed. RESULTS Surgery was performed in 1.3% (136/10342) of the cohort with high rates of colonoscopy (87.7%) and endoscopic hemostasis (26.7%). Indications for surgery included colonic diverticular bleeding (24%), colorectal cancer (22%), and small bowel bleeding (16%). Sixty-four percent of surgeries were for hemostasis for severe refractory bleeding. Postoperative rebleeding rates were 22% in patients with presumptive or obscure preoperative identification of the bleeding source and 12% in those with definitive identification. Thirty-day mortality rates were 1.5% and 0.8% in patients with and without surgery, respectively. Multivariate analysis showed that surgery-related risk factors were transfusion need ≥ 6 units (P < 0.001), in-hospital rebleeding (P < 0.001), small bowel bleeding (P < 0.001), colorectal cancer (P < 0.001), and hemorrhoids (P < 0.001). Endoscopic hemostasis was negatively associated with surgery (P = 0.003). For small bowel bleeding, the surgery rate was significantly lower in patients with endoscopic hemostasis as 2% compared to 12% without endoscopic hemostasis. CONCLUSIONS Our cohort study elucidated the outcomes and risks of the surgery. Extensive exploration including the small bowel to identify the source of bleeding and endoscopic hemostasis may reduce unnecessary surgery and improve the management of ALGIB.
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Affiliation(s)
- Jun Omori
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Mitsuru Kaise
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Naoyoshi Nagata
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan.
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsumasa Kobayashi
- Department of Gastroenterology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Atsushi Yamauchi
- Department of Gastroenterology and Hepatology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke's International University, Tokyo, Japan
| | - Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Hiroshima, Japan
| | - Naoyuki Tominaga
- Department of Gastroenterology, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Yoshinori Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | - Takaaki Kishino
- Department of Gastroenterology and Hepatology, Center for Digestive and Liver Diseases, Nara City Hospital, Nara, Japan
| | - Naoki Ishii
- Department of Gastroenterology, Tokyo Shinagawa Hospital, Tokyo, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akinari Takao
- Department of Gastroenterology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Ken Kinjo
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Shunji Fujimori
- Department of Gastroenterology, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan
| | - Takahiro Uotani
- Department of Gastroenterology, Japanese Red Cross Shizuoka Hospital, Shizuoka, Japan
| | - Minoru Fujita
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School General Medical Center, Okayama, Japan
| | - Hiroki Sato
- Division of Gastroenterology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Sho Suzuki
- Department of Gastroenterology and Hepatology, Center for Digestive Disease and Division of Endoscopy, University of Miyazaki Hospital, Miyazaki, Japan
| | - Toshiaki Narasaka
- Department of Gastroenterology, University of Tsukuba, Ibaraki, Japan
- Division of Endoscopic Center, University of Tsukuba Hospital, Ibaraki, Japan
| | | | - Tomohiro Funabiki
- Emergency and Critical Care Center, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
| | - Yuzuru Kinjo
- Department of Gastroenterology, Naha City Hospital, Okinawa, Japan
| | - Akira Mizuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Shu Kiyotoki
- Department of Gastroenterology, Shuto General Hospital, Yamaguchi, Japan
| | - Tatsuya Mikami
- Division of Endoscopy, Hirosaki University Hospital, Aomori, Japan
| | - Ryosuke Gushima
- Department of Gastroenterology and Hepatology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroyuki Fujii
- Department of Gastroenterology and Hepatology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuta Fuyuno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takuto Hikichi
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Yosuke Toya
- Division of Gastroenterology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Kazuyuki Narimatsu
- Department of Internal Medicine, National Defense Medical College, Saitama, Japan
| | - Noriaki Manabe
- Division of Endoscopy and Ultrasonography, Department of Clinical Pathology and Laboratory Medicine, Kawasaki Medical School, Okayama, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, University of the Ryukyus Hospital, Okinawa, Japan
| | - Yorinobu Sumida
- Department of Gastroenterology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Sadahiro Funakoshi
- Department of Gastroenterological Endoscopy, Fukuoka University Hospital, Fukuoka, Japan
| | - Kiyonori Kobayashi
- Department of Gastroenterology, School of Medicine, Kitasato University, Kanagawa, Japan
| | - Tamotsu Matsuhashi
- Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yuga Komaki
- Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
- Hygiene and Health Promotion Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Kuniko Miki
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Katsuhiko Iwakiri
- Department of Gastroenterology, Nippon Medical School, Graduate School of Medicine, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Fermann GJ, Cash BD, Coelho‐Prabhu N, Maegele M, Bingisser R, Sehgal V, Cohen AT, Golden AH, Russo J, Price M, Mangel A, Koch B, Christoph MJ, Milling TJ. Definition of factor Xa inhibitor-related, life-threatening gastrointestinal bleeding and guidance on when to use reversal therapy: A Delphi panel. J Am Coll Emerg Physicians Open 2023; 4:e13043. [PMID: 37794950 PMCID: PMC10545659 DOI: 10.1002/emp2.13043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/11/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023] Open
Abstract
Objective To define and contextualize life-threatening gastrointestinal (GI) bleeding in the setting of factor Xa (FXa) inhibitor therapy and to derive a consensus-based, clinically oriented approach to the administration of FXa inhibitor reversal therapy. Methods We convened an expert panel of clinicians representing specialties in emergency medicine, gastroenterology, vascular medicine, and trauma surgery. Consensus was reached among the clinician panelists using the Delphi technique, which consisted of 2 survey questionnaires followed by virtual, real-time consensus-building exercises. Results Hypovolemia and hemodynamic instability were considered the most important clinical signs of FXa inhibitor-related, life-threatening GI bleeds. Clinician panelists agreed that potentially life-threatening GI bleeding should be determined on the basis of hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. Last, the panel agreed that all patients with life-threatening, FXa inhibitor-associated GI bleeding should be considered for FXa inhibitor reversal therapy; the decision to reverse FXa inhibition should be individualized, weighing the risks and benefits of reversal; and when reversal is elected, therapy should be administered within 1 h after initial emergency department evaluation, when possible. Conclusions Consensus-based definitions of life-threatening GI bleeding and approaches to FXa inhibitor reversal centered on hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. The results from this Delphi panel may inform clinical decision-making for the treatment of patients experiencing GI bleeding associated with FXa inhibitor use in the emergency department setting.
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Affiliation(s)
- Gregory J. Fermann
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Brooks D. Cash
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Texas Health Science Center at Houston‐McGovern Medical SchoolHoustonTexasUSA
| | | | - Marc Maegele
- Department of Trauma and Orthopedic SurgeryCologne‐Merheim Medical CenterInstitute of Research in Operative MedicineUniversity Witten‐HerdeckeCologneGermany
| | - Roland Bingisser
- Department of Emergency MedicineUniversitätsspital BaselBaselSwitzerland
| | - Vinay Sehgal
- Department of GastroenterologyUniversity College Hospital LondonLondonUK
| | - Alexander T. Cohen
- Department of Haematological MedicineGuy's and St. Thomas’ HospitalLondonUK
| | | | - Jon Russo
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Mark Price
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Allen Mangel
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Bruce Koch
- AstraZenecaMedical AffairsWilmingtonDelawareUSA
| | | | - Truman J. Milling
- Departments of Neurology and of Surgery and Perioperative CareDell Medical SchoolAustinTexasUSA
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Sharma S, Sallout D, Acharya A, Adler DG. Early Colonoscopy Does Not Affect 30-Day Readmission After Lower GI Bleeding: Insights from a Nationwide Analysis. Dig Dis Sci 2022; 67:3948-3954. [PMID: 34519910 DOI: 10.1007/s10620-021-07243-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/25/2021] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Lower gastrointestinal bleeding (LGIB) is one of the most common indications for hospital admission. The current standard of care for patients admitted with LGIB includes colonoscopy. The aims of this study are to define the rate of readmission in patients with LGIB and to determine whether early colonoscopy within the first 24 h after admission impacts the rate of readmission in these patients. METHODS We performed a retrospective cohort study on data obtained from the Nationwide Readmission Database and identified patients admitted with lower GI bleed using ICD-10 codes. The primary outcome was 30-day all-cause readmission, and one of our secondary outcomes was the impact of early colonoscopy on 30-day readmission. RESULTS We analyzed data from 35,790,513 patients who were admitted for LGIB in 2017. A total of 16.4% of these patients were readmitted within 30 days of discharge, with diverticular bleeding most common diagnosis for readmission. Overall, in-hospital mortality was 1.18% for index admission and 4.44% for readmission. Early colonoscopy did not impact the rate of readmission within 30 days of discharge. CONCLUSION LGIB remains a commonly encountered in clinical practice with a high readmission rate. Mortality is significantly higher during readmission compared to index admission. Early colonoscopy did not impact the 30-day readmission rate.
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Affiliation(s)
- Sachit Sharma
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, OH, USA
| | - Deema Sallout
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ashu Acharya
- Department of Internal Medicine, The University of Toledo Medical Center, Toledo, OH, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy, Centura Health, Denver, CO, USA.
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Lee HS, Moon HS, Kwon IS, Jeong HY, Lee BS, Kim SH, Lee ES, Sung JK, Kang SH. Validation and modification of existing mortality prediction models for lower gastrointestinal bleeding: a retrospective study. BMC Gastroenterol 2021; 21:450. [PMID: 34844565 PMCID: PMC8628414 DOI: 10.1186/s12876-021-02037-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 11/18/2021] [Indexed: 11/10/2022] Open
Abstract
Background Lower gastrointestinal bleeding (LGIB) often subsides without medical intervention; however, in some cases, the bleeding does not stop and the patient’s condition worsens. Therefore, predicting severe LGIB in advance can aid treatment. This study aimed to evaluate variables related to mortality from LGIB and propose a scoring system. Methods In this retrospective study, we reviewed the medical records of patients who visited the emergency room with hematochezia between January 2016 and December 2020. Through regression analysis of comorbidities, medications, vital signs, laboratory investigations, and duration of hospital stay, variables related to LGIB-related mortality were evaluated. A scoring system was developed and the appropriateness with an area under the receiver operating characteristics curve (AUROC) was evaluated and compared with other existing models. Results A total of 932 patients were hospitalized for LGIB. Variables associated with LGIB-related mortality were the presence of cancer, heart rate > 100 beats/min, blood urea nitrogen level ≥ 30 mg/dL, an international normalized ratio > 1.50, and albumin level ≤ 3.0 g/dL. The AUROCs of the models CNUH-4 and CNUH-5 were 0.890 (p < 0.001; cutoff, 2.5; 95% confidence interval, 0.0851–0.929) and 0.901 (p < 0.001; cutoff, 3.5; 95% confidence interval, 0.869–0.933), respectively. Conclusions The model developed for predicting the risk of LGIB-related mortality is simple and easy to apply clinically. The AUROC of the model was better than that of the existing models.
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Affiliation(s)
- Hyun Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea.
| | - In Sun Kwon
- Clinical Trials Center, Chungnam National University, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Byung Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Seok Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Eaum-Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, 282, Munhwa-ro, Juong-gu, Daejeon, 35015, Republic of Korea
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Identifying Bleeding Etiologies by Endoscopy Affected Outcomes in 10,342 Cases With Hematochezia: CODE BLUE-J Study. Am J Gastroenterol 2021; 116:2222-2234. [PMID: 34388140 PMCID: PMC8560163 DOI: 10.14309/ajg.0000000000001413] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The bleeding source of hematochezia is unknown without performing colonoscopy. We sought to identify whether colonoscopy is a risk-stratifying tool to identify etiology and predict outcomes and whether presenting symptoms can differentiate the etiologies in patients with hematochezia. METHODS This multicenter retrospective cohort study conducted at 49 hospitals across Japan analyzed 10,342 patients admitted for outpatient-onset acute hematochezia. RESULTS Patients were mostly elderly population, and 29.5% had hemodynamic instability. Computed tomography was performed in 69.1% and colonoscopy in 87.7%. Diagnostic yield of colonoscopy reached 94.9%, most frequently diverticular bleeding. Thirty-day rebleeding rates were significantly higher with diverticulosis and small bowel bleeding than with other etiologies. In-hospital mortality was significantly higher with angioectasia, malignancy, rectal ulcer, and upper gastrointestinal bleeding. Colonoscopic treatment rates were significantly higher with diverticulosis, radiation colitis, angioectasia, rectal ulcer, and postendoscopy bleeding. More interventional radiology procedures were needed for diverticulosis and small bowel bleeding. Etiologies with favorable outcomes and low procedure rates were ischemic colitis and infectious colitis. Higher rates of painless hematochezia at presentation were significantly associated with multiple diseases, such as rectal ulcer, hemorrhoids, angioectasia, radiation colitis, and diverticulosis. The same was true in cases of hematochezia with diarrhea, fever, and hemodynamic instability. DISCUSSION This nationwide data set of acute hematochezia highlights the importance of colonoscopy in accurately detecting bleeding etiologies that stratify patients at high or low risk of adverse outcomes and those who will likely require more procedures. Predicting different bleeding etiologies based on initial presentation would be challenging.
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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese. Dig Dis Sci 2021; 66:823-831. [PMID: 32285322 DOI: 10.1007/s10620-020-06253-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese. METHODS Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis. RESULTS There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 103/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively). CONCLUSIONS The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese.
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Abstract
Massive gastrointestinal hemorrhage is a life-threatening condition that can result from numerous causes and requires skilled resuscitation to decrease patient morbidity and mortality. Successful resuscitation begins with placement of large-bore intravenous or intraosseous access; early blood product administration; and early consultation with a gastroenterologist, interventional radiologist, and/or surgeon. Activate a massive transfusion protocol when initial red blood cell transfusion does not restore effective perfusion or the patient's shock index is greater than 1.0. Promptly reverse coagulopathies secondary to oral anticoagulant or antiplatelet use. Use thromboelastography or rotational thromboelastometry to guide further transfusions. Secure a definitive airway and minimize aspiration.
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Affiliation(s)
- Katrina D'Amore
- Department of Emergency Medicine, Good Samaritan Hospital Medical Center, 1000 Montauk Highway, West Islip, NY 11795, USA.
| | - Anand Swaminathan
- St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, USA
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Ramaekers R, Perry J, Leafloor C, Thiruganasambandamoorthy V. Prediction Model for 30-day Outcomes Among Emergency Department Patients with Lower Gastrointestinal Bleeding. West J Emerg Med 2020; 21:343-347. [PMID: 32191192 PMCID: PMC7081856 DOI: 10.5811/westjem.2020.1.45420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/20/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION There are currently no robust tools available for risk stratification of emergency department (ED) patients with lower gastrointestinal bleed (LGIB). Our aim was to identify risk factors and develop a preliminary model to predict 30-day serious adverse events among ED LGIB patients. METHODS We conducted a health records review including adult ED patients with acute LGIB. We used a composite outcome of 30-day all-cause death, recurrent LGIB, need for intervention to control the bleeding, and severe adverse events resulting in intensive care unit admission. One researcher collected data for variables and a second researcher independently collected 10% of the variables for inter-observer reliability. We used backward multivariable logistic regression analysis and SELECTION=SCORE option to create a preliminary risk-stratification tool. We assessed the diagnostic accuracy of the final model. RESULTS Of 372 patients, 48 experienced an adverse outcome. We found that age ≥75 years, hemoglobin ≤100 g/L, international normalized ratio ≥2.0, ongoing bleed in the ED, and a medical history of colorectal polyps were statistically significant predictors in the multivariable regression analysis. The area under the curve (AUC) for the model was 0.83 (95% confidence interval, 0.77-0.89). We developed a scoring system based on the logistic regression model and found a sensitivity 0.96 (0.90-1.00) and specificity 0.53 (0.48-0.59) for a cut-off score of 1. CONCLUSION This model showed good ability to differentiate patients with and without serious outcomes as evidenced by the high AUC and sensitivity. The results of this study could be used in the prospective derivation of a clinical decision tool.
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Affiliation(s)
- Rosa Ramaekers
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario.,University of Ottawa, School of Epidemiology, Epidemiology and Public Health, Ottawa, Ontario.,University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario
| | - Jeffrey Perry
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario.,University of Ottawa, School of Epidemiology, Epidemiology and Public Health, Ottawa, Ontario.,University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario
| | - Cameron Leafloor
- University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario
| | - Venkatesh Thiruganasambandamoorthy
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario.,University of Ottawa, School of Epidemiology, Epidemiology and Public Health, Ottawa, Ontario.,University of Ottawa, Department of Emergency Medicine, Ottawa, Ontario
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A multicentre development and validation study of a novel lower gastrointestinal bleeding score-The Birmingham Score. Int J Colorectal Dis 2020; 35:285-293. [PMID: 31845024 DOI: 10.1007/s00384-019-03459-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Lower gastrointestinal bleeding (LGIB) is common and risk stratification scores can guide clinical decision-making. There is no robust risk stratification tool specific for LGIB, with existing tools not routinely adopted. We aimed to develop and validate a risk stratification tool for LGIB. METHODS Retrospective review of LGIB admissions to three centres between 2010 and 2018 formed the derivation cohort. Using regressional analysis within a machine learning technique, risk factors for adverse outcomes were identified, forming a simple risk stratification score-The Birmingham Score. Retrospective review of an additional centre, not included in the derivation cohort, was performed to validate the score. RESULTS Data from 469 patients were included in the derivation cohort and 180 in the validation cohort. Admission haemoglobin OR 1.07(95% CI 1.06-1.08) and male gender OR 2.29(95% CI 1.40-3.77) predicted adverse outcomes in the derivation cohort AUC 0.86(95% CI 0.82-0.90) which outperformed the Blatchford 0.81(95% CI 0.77-0.85), Rockall 0.60(95% CI 0.55-0.65) and AIM65 0.55(0.50-0.60) scores and in the validation cohort AUC 0.80(95% CI 0.73-0.87) which outperformed the Blatchford 0.77(95% CI 0.70-0.85), Rockall 0.67(95% CI 0.59-0.75) and AIM 65 scores 0.61(95% CI 0.53-0.69). The Birmingham Score also performs well at predicting adverse outcomes from diverticular bleeding AUC 0.87 (95% CI 0.75-0.98). A score of 7 predicts a 94% probability of adverse outcome. CONCLUSION The Birmingham Score represents a simple risk stratification score that can be used promptly on patients admitted with LGIB.
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13
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Tung Chen Y, Blancas Gómez-Casero R, Quintana Díaz M, Villén Villegas T, Cobo Mora J, Carballo Cardona C. Results of a Prospective Study to Evaluate the Impact of Point-of-Care Ultrasound in the Enhancement of Gastrointestinal Bleeding Risk Scores. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:279-287. [PMID: 31379015 DOI: 10.1002/jum.15101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/08/2019] [Accepted: 07/07/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. METHODS Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. RESULTS In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). CONCLUSIONS The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.
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Affiliation(s)
- Yale Tung Chen
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Alfonso X. El Sabio, Madrid, Spain
| | - Rafael Blancas Gómez-Casero
- Department of Medicine, Universidad Alfonso X. El Sabio, Madrid, Spain
- Department of Critical Care, Hospital Universitario del Tajo, Aranjuez, Spain
| | | | - Tomás Villén Villegas
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
- Department of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Julio Cobo Mora
- Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain
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Khalifa A, Rockey DC. Lower Gastrointestinal Bleeding in Patients With Cirrhosis-Etiology and Outcomes. Am J Med Sci 2020; 359:206-211. [PMID: 32087941 DOI: 10.1016/j.amjms.2020.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/06/2019] [Accepted: 01/10/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Lower gastrointestinal bleeding (LGIB) is a common clinical problem, and may be more prevalent among patients with cirrhosis, especially in the setting of portal hypertension and coagulopathy. However, there is extremely little data available on the subject of LGIB in patients with cirrhosis. Therefore, the primary objective of this study was to better understand the etiology and outcomes of cirrhotic patients hospitalized with LGIB. MATERIALS AND METHODS We analyzed 3,735 cirrhotic patients admitted to the Medical University of South Carolina between January 2011 and September 2018, and identified patients admitted with a primary diagnosis of hematochezia or bright red blood per rectum. RESULTS Thirty patients with cirrhosis and LGIB were included in the cohort. The mean age was 56 ± 13 years, with 30% women. The mean model of end stage liver disease score was 22, and Child-Pugh (CP) scores were C: 41%, B: 33% and A: 26%. The mean Charlson Comorbidity Index was 5.6. Twenty-four (80%) patients had a clinical decompensating event (hepatic encephalopathy, ascites, esophageal varices); the mean hepatic venous pressure gradient was 14.1 mm Hg (n = 8). In 33% of patients, LGIB was considered significant bleeding that necessitated blood transfusion. The most common cause of LGIB was hemorrhoids (11 patients, 37%), followed by portal hypertensive enteropathy or colopathy (7 patients, 23%). Hemoglobin levels on admission were lower in patients with CP B/C cirrhosis than in those with CP A (P < 0.001). The length of stay was 9 ± 10 days, and 5 patients died (mortality, 17%). CONCLUSIONS Despite being uncommon, LGIB in cirrhotic patients is associated with a high mortality rate.
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Affiliation(s)
- Ali Khalifa
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Don C Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina.
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The impact of a multidisciplinary algorithmic approach to acute lower gastrointestinal bleeding. Am J Emerg Med 2019; 37:1751-1753. [DOI: 10.1016/j.ajem.2019.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 11/19/2022] Open
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Machine Learning to Predict Outcomes in Patients with Acute Gastrointestinal Bleeding: A Systematic Review. Dig Dis Sci 2019; 64:2078-2087. [PMID: 31055722 DOI: 10.1007/s10620-019-05645-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/25/2019] [Indexed: 12/13/2022]
Abstract
Risk stratification of patients with gastrointestinal bleeding (GIB) is recommended, but current risk assessment tools have variable performance. Machine learning (ML) has promise to improve risk assessment. We performed a systematic review to evaluate studies utilizing ML techniques for GIB. Bibliographic databases and conference abstracts were searched for studies with a population of overt GIB that used an ML algorithm with outcomes of mortality, rebleeding, hemostatic intervention, and/or hospital stay. Two independent reviewers screened titles and abstracts, reviewed full-text studies, and extracted data from included studies. Risk of bias was assessed with an adapted Quality in Prognosis Studies tool. Area under receiver operating characteristic curves (AUCs) were the primary assessment of performance with AUC ≥ 0.80 predefined as an acceptable threshold of good performance. Fourteen studies with 30 assessments of ML models met inclusion criteria. No study had low risk of bias. Median AUC reported in validation datasets for predefined outcomes of mortality, intervention, or rebleeding was 0.84 (range 0.40-0.98). AUCs were higher with artificial neural networks (median 0.93, range 0.78-0.98) than other ML models (0.81, range 0.40-0.92). ML performed better than clinical risk scores (Glasgow-Blatchford, Rockall, Child-Pugh, MELD) for mortality in upper GIB. Limitations include heterogeneity of ML models, inconsistent comparisons of ML models with clinical risk scores, and high risk of bias. ML generally provided good-excellent prognostic performance in patients with GIB, and artificial neural networks tended to outperform other ML models. ML was better than clinical risk scores for mortality in upper GIB.
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Donohoe CL, Rockall TA. Is there still a role for the surgeon in the management of gastrointestinal bleeding ? Best Pract Res Clin Gastroenterol 2019; 42-43:101622. [PMID: 31785734 DOI: 10.1016/j.bpg.2019.101622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/04/2019] [Accepted: 06/07/2019] [Indexed: 01/31/2023]
Abstract
Modern investigation of gastrointestinal bleeds allows for reliable source identification in most cases. Current treatment algorithms utilise therapeutic endoscopy or interventional radiology and surgery now plays a limited role in the treatment of gastrointestinal bleeds. Approximately 2-4% of patients admitted with GI bleeds, however, require surgery to control their haemorrhage.
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Affiliation(s)
- Claire L Donohoe
- Dept of Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Timothy A Rockall
- Dept of Surgery, Royal Surrey County Hospital, Guildford, Surrey, UK.
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Tapaskar N, Jones B, Mei S, Sengupta N. Comparison of clinical prediction tools and identification of risk factors for adverse outcomes in acute lower GI bleeding. Gastrointest Endosc 2019; 89:1005-1013.e2. [PMID: 30576651 DOI: 10.1016/j.gie.2018.12.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Limited data exist on prediction of adverse outcomes in patients with acute lower GI bleeding (LGIB). The purpose of our study was to compare the ability of existing validated clinical risk scores to predict relevant outcomes in LGIB. METHODS We performed a prospective observational study of patients admitted with LGIB who underwent colonoscopy at a single center between April 2016 and September 2017. Seven risk scores were calculated at admission (Strate, NOBLADS, Sengupta, Oakland, Blatchford, AIMS65, and Charlson Comorbidity Index). The risk of severe LGIB was determined via univariable and multivariable logistic regression. Area under the receiver operating characteristic curve (AUC) analysis was used to compare the scores. RESULTS We included 170 patients admitted with LGIB requiring colonoscopy. Fifty-two percent (n = 89) fit criteria for severe bleeding. Patients with severe bleeding had lower admission hemoglobin levels (8.6 g/dL vs 11.1 g/dL; P = .0001), were more likely to have blood transfusions (85% vs 36%; P < .0001), intensive care unit stays (49% vs 19%; P < .0001), and had a longer length of stay (6 days vs 4 days; P = .0009). The Oakland score was best for prediction of severe bleeding (AUC, .74), Blatchford score for blood transfusion (AUC, .87), and Strate score for in-hospital recurrent bleeding (AUC, .66) and endoscopic intervention (AUC, .62). The strongest individual predictors of severe bleeding were low admission hemoglobin (odds ratio, 1.28 per 1-g/dL decrease; P = .0015; 95% confidence interval, 1.10-1.49) and low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02; 95% confidence interval, 1.16-5.56). CONCLUSION Admission albumin and hemoglobin levels were the strongest predictors of severe bleeding. No singular clinical risk tool had the best predictive ability across all outcomes.
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Affiliation(s)
- Natalie Tapaskar
- Department of Medicine, The University of Chicago Medical Center, Chicago, Illinois, USA
| | - Blake Jones
- Department of Medicine, The University of Chicago Medical Center, Chicago, Illinois, USA
| | - Steve Mei
- Section of Gastroenterology, Hepatology & Nutrition, The University of Chicago Medical Center, Chicago, Illinois, USA
| | - Neil Sengupta
- Section of Gastroenterology, Hepatology & Nutrition, The University of Chicago Medical Center, Chicago, Illinois, USA
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Senel T, Ates I, Demir BF, Arikan MF, Karaahmetoglu S, Altiparmak E, Yilmaz N. The diagnostic and prognostic value of platelet indices in gastrointestinal bleeding. Am J Emerg Med 2019; 37:657-663. [DOI: 10.1016/j.ajem.2018.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 01/28/2023] Open
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Hreinsson JP, Sigurdardottir R, Lund SH, Bjornsson ES. The SHA 2PE score: a new score for lower gastrointestinal bleeding that predicts low-risk of hospital-based intervention. Scand J Gastroenterol 2018; 53:1484-1489. [PMID: 30457020 DOI: 10.1080/00365521.2018.1532019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Lower gastrointestinal bleeding (LGIB) risk scores have mainly focused on identifying high-risk patients. A risk score aimed at predicting which patients will not require hospital-based intervention may reduce unnecessary hospital admissions. The aim of the current study was to develop such a risk score. MATERIAL AND METHODS A retrospective, population-based study that included patients presenting to the emergency room (ER) with LGIB from 2010 to 2013. Hospital-based intervention was defined as blood transfusion, endoscopic hemostasis, arterial embolization or surgery. The study cohort was split into train (70%) and test (30%) data. Train data were used to produce a multiple logistic regression model and a risk score that was validated on the test data. RESULTS Overall, 581 patients presented 625 times to the ER, mean age 61 (±22), males 49%. Of train data patients, 72% did not require hospital-based intervention. Independent predictors of low-risk patients (did not require hospital-based intervention) were systolic pressure ≥100mmHg (Odds ratio [OR] 4.9), hemoglobin >12g/dL (OR 103), hemoglobin 10.5-12.0g/dL (OR 19), no antiplatelets (OR 3.7), no anticoagulants (OR 2.2), pulse ≤100 (OR 2.9), and visible bleeding in the ER (OR 3.8). When validating the score on the test data, only 2% were wrongly predicted to be low-risk, the negative predictive value was 96% and the area under curve was 0.83. CONCLUSIONS A new risk score has been developed for LGIB that may help identify low-risk patients in the ER that can be managed in an outpatient setting, thereby lowering unnecessary hospital admissions.
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Affiliation(s)
- Johann P Hreinsson
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
| | - Ragna Sigurdardottir
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
| | - Sigrun H Lund
- c Centre of Public Health Sciences , University of Iceland , Reykjavik , Iceland
| | - Einar S Bjornsson
- a Department of Internal Medicine, Section of Gastroenterology and Hepatology , Landspitali - The National University Hospital , Reykjavik , Iceland.,b Faculty of Medicine , University of Iceland , Reykjavik , Iceland
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Almadi MA, Barkun AN. Patient Presentation, Risk Stratification, and Initial Management in Acute Lower Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2018; 28:363-377. [PMID: 29933781 DOI: 10.1016/j.giec.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The approach to lower gastrointestinal bleeding (LGIB) has evolved over the last few years to incorporate a multidisciplinary management strategy. Although the causes of LGIB vary depending on the age and comorbid conditions of patients, the initial resuscitation and principles of optimizing patients' condition before endoscopic evaluation, when appropriate, are the cornerstones to clinical care. The role of risk stratification is to triage patients as well as to mobilize health care resources based on predicted outcomes. Individualized management according to patients' comorbid conditions has been a focus in most recent guidelines.
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Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada.
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Aoki T, Yamada A, Nagata N, Niikura R, Hirata Y, Koike K. External validation of the NOBLADS score, a risk scoring system for severe acute lower gastrointestinal bleeding. PLoS One 2018; 13:e0196514. [PMID: 29698506 PMCID: PMC5919702 DOI: 10.1371/journal.pone.0196514] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 04/14/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND We aimed to evaluate the generalizability of NOBLADS, a severe lower gastrointestinal bleeding (LGIB) prediction model which we had previously derived when working at a different institution, using an external validation cohort. NOBLADS comprises the following factors: non-steroidal anti-inflammatory drug use, no diarrhea, no abdominal tenderness, blood pressure ≤ 100 mmHg, antiplatelet drug use, albumin < 3.0 g/dL, disease score ≥ 2, and syncope. METHODS We retrospectively analyzed 511 patients emergently hospitalized for acute LGIB at the University of Tokyo Hospital, from January 2009 to August 2016. The areas under the receiver operating characteristic curves (ROCs-AUCs) for severe bleeding (continuous and/or recurrent bleeding) were compared between the original derivation cohort and the external validation cohort. RESULTS Severe LGIB occurred in 44% of patients. Several clinical factors were significantly different between the external and derivation cohorts (p < 0.05), including background, laboratory data, NOBLADS scores, and diagnosis. The NOBLADS score predicted the severity of LGIB with an AUC value of 0.74 in the external validation cohort and one of 0.77 in the derivation cohort. In the external validation cohort, the score predicted the risk for blood transfusion need (AUC, 0.71), but was not adequate for predicting intervention need (AUC, 0.54). The in-hospital mortality rate was higher in patients with a score ≥ 5 than in those with a score < 5 (AUC, 0.83). CONCLUSIONS Although the external validation cohort clinically differed from the derivation cohort in many ways, we confirmed the moderately high generalizability of NOBLADS, a clinical risk score for severe LGIB. Appropriate triage using this score may support early decision-making in various hospitals.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Hirata
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW Hematochezia is a common clinical presentation, with significant morbidity and economic burden. These patients often require costly interventions including hospitalization, blood transfusions, and radiologic or endoscopic procedures. The purpose of this review is to give a rational, concise approach to the patient with hematochezia, with special consideration of recent advances in the literature. RECENT FINDINGS Recent studies pertaining to hematochezia have evaluated risk stratification, endoscopic intervention, evaluation of small bowel bleeding, and management of anticoagulation. SUMMARY A step-wise approach to hematochezia helps determine the cause and provide the appropriate management of these patients. We propose five steps beginning with hemodynamic assessment and risk stratification, then focused history and physical examination, endoscopic intervention when warranted, and consideration of small bowel bleeding in selected instances.
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Nagata N, Sakurai T, Shimbo T, Moriyasu S, Okubo H, Watanabe K, Yokoi C, Yanase M, Akiyama J, Uemura N. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol 2017. [PMID: 28634133 DOI: 10.1016/j.cgh.2017.06.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a retrospective cohort study of patients with and without gastrointestinal bleeding (GIB) to determine whether GIB increases the risks of thromboembolism and death. METHODS We collected data from 522 patients with acute severe GIB and 1044 patients without GIB (control subjects, matched for age, sex, year of diagnosis, history of thromboembolism, and use of antithrombotic drugs) who underwent endoscopy at the National Center for Global Health and Medicine in Japan from January 2009 through December 2014. Hazard ratios of GIB for thromboembolism and mortality risk were estimated, adjusting for confounders. We also compared standardized mortality ratios between the GIB cohort and the age- and sex-matched general population in Japan. RESULTS During a mean follow up of 23.7 months, thromboembolism was identified in 11.5% of patients with GIB and 2.4% of control subjects (hazard ratio, 5.3; 95% confidence interval, 3.3-8.5; P < .001). Multivariate analysis revealed GIB as a risk factor for all-thromboembolic events, cerebrovascular events, and cardiovascular events. During a mean follow-up of 24.6 months, 15.9% of patients with GIB and 8.6% of control subjects died (hazard ratio, 2.1; 95% confidence interval, 1.6-2.9; P < .001). Multivariate analysis revealed GIB as a risk factor for all-cause mortality. Compared with the general population, patients with GIB were at increased risk of death (standardized mortality ratio, 12.0). CONCLUSIONS In a retrospective analysis of patients undergoing endoscopy in Japan, we identified acute GIB was a significant risk factor for late thromboembolism and death, compared with patients without GIB. GIB also increased risk of death compared with the general population.
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Affiliation(s)
- Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | | | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba, Japan
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Carlin N, Asslo F, Sison R, Shaaban H, Baddoura W, Manji F, Depasquale J. Dual Antiplatelet Therapy and the Severity Risk of Lower Intestinal Bleeding. J Emerg Trauma Shock 2017; 10:98-102. [PMID: 28855770 PMCID: PMC5566042 DOI: 10.4103/jets.jets_110_15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Dual antiplatelet (Plt) therapy with aspirin and clopidogrel is recommended for up to 1 year following acute coronary syndrome. Many of these cardiac patients are also on anithrombotic therapy like warfarin. Lower gastrointestinal bleeding (LGIB) is the main adverse event of this treatment. AIMS The main purpose of this study was to analyze the relationship of dual anti-Plt therapy and the risk of LGIB. METHODS Patients' electronic charts were reviewed to include a total of 19 variables, which included age, sex, ethnicity, daily use aspirin of any dose, daily use of clopidogrel, use of nonsteroidal anti-inflammatory drugs (NSAIDs) at least twice in the last week prior to admission and the daily use of anticoagulants (warfarin, heparin), and were obtained from history and physical examination reports, lab transcripts and procedural reports. SETTINGS/DESIGN A retrospective cohort study of the records of 3436 patients admitted to our hospital from January 1, 2009, to December 31, 2011, was evaluated. All the patients included were admitted through the emergency department with complaints of or relating to LGIB. The primary outcome studied was severe LGIB as defined by the requirement of at least two units of packed red blood cells and/or a decrease in the hematocrit of 20% or more or recurrent bleeding after 24 h of clinical stability with additional transfusions required. Other outcomes included surgical intervention. STATISTICAL METHODS/ANALYSIS Univariate analysis using t-test on continuous variables and Chi-square test on categorical variables were done before carrying out logistic regression analysis. Logistic regression analyses were conducted to measures of association between the variables and LGIB. Logistic regression analysis was not carried for surgical intervention and death because none of the variables was significant from univariate tests. RESULTS A total of 511 patients were found to have true LGIB. Among these subjects, 61 were shown to be on dual or multiple antithrombotic therapies. Further exploration revealed that while the use of multiple blood thinning agents may, in fact, pose a significant risk to overall LGIB, it did not significantly increase the risk for severe bleeding as outlined above. CONCLUSION The use of multiple blood thinning agents does not significantly increase the risk for severe LGIB.
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Affiliation(s)
- Neal Carlin
- Department of Internal Medicine and Gastroenterology, St Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Fady Asslo
- Department of Internal Medicine and Gastroenterology, St Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Raymund Sison
- Department of Internal Medicine and Hematology/Oncology, St Michael's Medical Center, Newark, NJ, USA
| | - Hamid Shaaban
- Department of Internal Medicine and Hematology/Oncology, St Michael's Medical Center, Newark, NJ, USA
| | - Walid Baddoura
- Department of Internal Medicine and Gastroenterology, St Joseph's Regional Medical Center, Paterson, NJ, USA
| | - Faiza Manji
- Department of Internal Medicine and Hematology/Oncology, St Michael's Medical Center, Newark, NJ, USA
| | - Joseph Depasquale
- Department of Internal Medicine and Gastroenterology, St Joseph's Regional Medical Center, Paterson, NJ, USA
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Ng KS, Nassar N, Soares D, Stewart P, Gladman MA. Acute lower gastrointestinal haemorrhage: outcomes and risk factors for intervention in 949 emergency cases. Int J Colorectal Dis 2017; 32:1327-1335. [PMID: 28712008 DOI: 10.1007/s00384-017-2844-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Outcomes of acute lower gastrointestinal haemorrhage (ALGIH) are mostly derived from studies performed in the sub-acute/elective rather than the emergency department (ED) setting. The aims of this study were to determine the incidence and outcomes of patients presenting to a tertiary hospital ED with ALGIH and to identify associated clinicopathological risk factors. METHOD A retrospective observational cohort study of consecutive patients presenting with ALGIH to a tertiary hospital ED was performed. Primary outcome measures included mortality and hospital (including high dependency [HDU]) admission. Secondary outcome measures included rates of (i) blood transfusion, (ii) radiological/endoscopic investigation(s) and (iii) therapeutic intervention. RESULTS ALGIH accounted for 949 (512 M, mean age 62.3 years) of 130,262 (0.73%) ED presentations, of which 285 patients (30.1%) were on anti-platelet/coagulant therapy. There were five deaths (0.5%). Hospital admission was required in 498 patients (52.5%), of which 19 (3.8%) required HDU monitoring. Hospital admission was twice as likely in males and four times more likely in patients >75 years old and those taking multiple anti-platelet/coagulant therapy (P < 0.05). Blood product transfusion was required in 172 patients (34.5%), specialist investigations in 230 (46.2%) and therapeutic intervention in 51 (10.2%) (surgery in 24 [4.8%]; endoscopic haemostasis in 20 [4.0%] and angiographic embolisation in 9 [1.8%] patients). CONCLUSION ALGIH accounts for 1% of all ED presentations, with half requiring hospital admission. Mortality and surgical intervention rates are low and although most patients can be managed supportively, access to interventional radiology/endoscopy is important.
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Affiliation(s)
- Kheng-Seong Ng
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Natasha Nassar
- Menzies Centre for Health Policy, School of Public Health, University of Sydney, Sydney, Australia
| | - Deanne Soares
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Patrick Stewart
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia
| | - Marc A Gladman
- Academic Colorectal Unit, Sydney Medical School, University of Sydney, Hospital Road, Concord, NSW, Australia. .,Adelaide Medical School, Faculty of Health & Medical Sciences, The University of Adelaide, Medical School South, Frome Road, Adelaide, 5005, Australia.
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Prehospital Transfusion for Gastrointestinal Bleeding. Air Med J 2017; 36:315-319. [PMID: 29122112 DOI: 10.1016/j.amj.2017.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) bleeding is a common medical emergency with significant morbidity and mortality. Many patients are coagulopathic, which may perpetuate bleeding. Remote damage control resuscitation, including early correction of coagulopathy and anemia, may benefit exsanguinating patients with GI bleeding. METHODS We conducted a retrospective review of patients with acute GI bleeding who received packed red blood cells (pRBC) and/or plasma during transportation to our institution between 2010 and 2014. A comparison group of patients who were not transfused en route was selected, and demographics, outcomes, and response to resuscitation were compared. RESULTS A total of 112 patients with GI bleeding received pRBC (82%, n = 92 pRBC, mean 1.7 ± 0.9 units), plasma (62%, n = 69, mean 1.7 ± 0.8 units) or both (44%, n = 49) en-route. The comparison group comprised 49 patients transported by helicopter who were not transfused en-route. Demographics, crystalloid resuscitation, transfusion prior to transfer, rate of intervention, ICU days, length of stay, and mortality were similar between groups. Patients transfused en route had a significant increase in hemoglobin from 8.3 ± 2.2 to 8.9 ± 2.1 (P = .03) and decrease in INR from 2.0 ± 1.0 to 1.6 ± 1.4 (P = .01), whereas those not transfused en route experienced stable hemoglobin (8.7 ± 2.8 to 9.4 ± 2.5; P = .21) and INR values (1.9 ± 1.0 to 1.6 ± 1.4; P = .32). Both groups had a significant improvement in hemodynamic parameters with resuscitation. CONCLUSION Prehospital damage control resuscitation with pRBC and/or plasma resulted in the improvement of hemodynamic instability, coagulopathy and anemia in patients with acute GI bleeding. Almost all patients required additional inpatient interventions and/or transfusions, suggesting that pre-hospital transfusion is being utilized for appropriately selected patients.
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Zamparini E, Ahmed P, Belhassan M, Horaist C, Bouguerba A, Ayed S, Barchasz J, Boukari M, Goldgran-Toledano D, Yaacoubi S, Bornstain C, Nahon S, Vincent F. Orientation des patients adultes consultant aux urgences pour hémorragie digestive (hors hypertension portale prouvée ou présumée) : intérêt des scores pronostiques. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Cotter TG, Buckley NS, Loftus CG. Approach to the Patient With Hematochezia. Mayo Clin Proc 2017; 92:797-804. [PMID: 28473039 DOI: 10.1016/j.mayocp.2016.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/03/2016] [Accepted: 12/09/2016] [Indexed: 02/07/2023]
Abstract
The evaluation of the patient with hematochezia can be complex because of the broad differential diagnosis and the number of management strategies available. In this article, a simplified approach to the history and physical examination is presented, with management illustrated in a case-oriented manner.
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Affiliation(s)
| | - Niamh S Buckley
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Conor G Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN.
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Sengupta N, Tapper EB. Derivation and Internal Validation of a Clinical Prediction Tool for 30-Day Mortality in Lower Gastrointestinal Bleeding. Am J Med 2017; 130:601.e1-601.e8. [PMID: 28065767 DOI: 10.1016/j.amjmed.2016.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/09/2016] [Accepted: 12/15/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are limited data to predict which patients with lower gastrointestinal bleeding are at risk for adverse outcomes. We aimed to develop a clinical tool based on admission variables to predict 30-day mortality in lower gastrointestinal bleeding. METHODS We used a validated machine learning algorithm to identify adult patients hospitalized with lower gastrointestinal bleeding at an academic medical center between 2008 and 2015. The cohort was split randomly into derivation and validation cohorts. In the derivation cohort, we used multiple logistic regression on all candidate admission variables to create a prediction model for 30-day mortality, using area under the receiving operator characteristic curve and misclassification rate to estimate prediction accuracy. Regression coefficients were used to derive an integer score, and mortality risk associated with point totals was assessed. RESULTS In the derivation cohort (n = 4044), 8 variables were most associated with 30-day mortality: age, dementia, metastatic cancer, chronic kidney disease, chronic pulmonary disease, anticoagulant use, admission hematocrit, and albumin. The model yielded a misclassification rate of 0.06 and area under the curve of 0.81. The integer score ranged from -10 to 26 in the derivation cohort, with a misclassification rate of 0.11 and area under the curve of 0.74. In the validation cohort (n = 2060), the score had an area under the curve of 0.72 with a misclassification rate of 0.12. After dividing the score into 4 quartiles of risk, 30-day mortality in the derivation and validation sets was 3.6% and 4.4% in quartile 1, 4.9% and 7.3% in quartile 2, 9.9% and 9.1% in quartile 3, and 24% and 26% in quartile 4, respectively. CONCLUSIONS A clinical tool can be used to predict 30-day mortality in patients hospitalized with lower gastrointestinal bleeding.
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Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medical Center, Ill.
| | - Elliot B Tapper
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor
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Affiliation(s)
- Ian M Gralnek
- From the Institute of Gastroenterology and Hepatology (I.M.G.) and Medical Imaging Institute (Z.N.), Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (I.M.G.) - both in Israel; and the Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle (L.L.S.)
| | - Ziv Neeman
- From the Institute of Gastroenterology and Hepatology (I.M.G.) and Medical Imaging Institute (Z.N.), Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (I.M.G.) - both in Israel; and the Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle (L.L.S.)
| | - Lisa L Strate
- From the Institute of Gastroenterology and Hepatology (I.M.G.) and Medical Imaging Institute (Z.N.), Emek Medical Center, Afula, and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa (I.M.G.) - both in Israel; and the Department of Medicine, Division of Gastroenterology, University of Washington School of Medicine, Seattle (L.L.S.)
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Loftus TJ, Brakenridge SC, Croft CA, Smith RS, Efron PA, Moore FA, Mohr AM, Jordan JR. Neural network prediction of severe lower intestinal bleeding and the need for surgical intervention. J Surg Res 2016; 212:42-47. [PMID: 28550920 DOI: 10.1016/j.jss.2016.12.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 11/23/2016] [Accepted: 12/22/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prognosis for patients with severe acute lower intestinal bleeding (ALIB) may be assessed by complex artificial neural networks (ANNs) or user-friendly regression-based models. Comparisons between these modalities are limited, and predicting the need for surgical intervention remains elusive. We hypothesized that ANNs would outperform the Strate rule to predict severe bleeding and would also predict the need for surgical intervention. METHODS We performed a 4-y retrospective analysis of 147 adult patients who underwent endoscopy, angiography, or surgery for ALIB. Baseline characteristics, Strate risk factors, management parameters, and outcomes were analyzed. The primary outcomes were severe bleeding and surgical intervention. ANNs were created in SPSS. Models were compared by area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals. RESULTS The number of Strate risk factors for each patient correlated significantly with the outcome of severe bleeding (r = 0.29, P < 0.001). However, the Strate model was less accurate than an ANN (AUROC 0.66 [0.57-0.75] versus 0.98 [0.95-1.00], respectively) which incorporated six variables present on admission: hemoglobin, systolic blood pressure, outpatient prescription for Aspirin 325 mg daily, Charlson comorbidity index, base deficit ≥5 mEq/L, and international normalized ratio ≥1.5. A similar ANN including hemoglobin nadir and the occurrence of a 20% decrease in hematocrit was effective in predicting the need for surgery (AUROC 0.95 [0.90-1.00]). CONCLUSIONS The Strate prediction rule effectively stratified risk for severe ALIB, but was less accurate than an ANN. A separate ANN accurately predicted the need for surgery by combining risk factors for severe bleeding with parameters quantifying blood loss. Optimal prognostication may be achieved by integrating pragmatic regression-based calculators for quick decisions at the bedside and highly accurate ANNs when time and resources permit.
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Affiliation(s)
- Tyler J Loftus
- Department of Surgery, University of Florida Health, Gainesville, Florida; Department of Sepsis and Critical Illness Research Center in Gainesville, University of Florida Health, Gainesville, Florida
| | - Scott C Brakenridge
- Department of Surgery, University of Florida Health, Gainesville, Florida; Department of Sepsis and Critical Illness Research Center in Gainesville, University of Florida Health, Gainesville, Florida
| | - Chasen A Croft
- Department of Surgery, University of Florida Health, Gainesville, Florida
| | | | - Philip A Efron
- Department of Surgery, University of Florida Health, Gainesville, Florida; Department of Sepsis and Critical Illness Research Center in Gainesville, University of Florida Health, Gainesville, Florida
| | - Frederick A Moore
- Department of Surgery, University of Florida Health, Gainesville, Florida; Department of Sepsis and Critical Illness Research Center in Gainesville, University of Florida Health, Gainesville, Florida
| | - Alicia M Mohr
- Department of Surgery, University of Florida Health, Gainesville, Florida; Department of Sepsis and Critical Illness Research Center in Gainesville, University of Florida Health, Gainesville, Florida
| | - Janeen R Jordan
- Department of Surgery, University of Florida Health, Gainesville, Florida.
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Aoki T, Nagata N, Shimbo T, Niikura R, Sakurai T, Moriyasu S, Okubo H, Sekine K, Watanabe K, Yokoi C, Yanase M, Akiyama J, Mizokami M, Uemura N. Development and Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2016; 14:1562-1570.e2. [PMID: 27311620 DOI: 10.1016/j.cgh.2016.05.042] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/12/2016] [Accepted: 05/31/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We aimed to develop and validate a risk scoring system to determine the risk of severe lower gastrointestinal bleeding (LGIB) and predict patient outcomes. METHODS We first performed a retrospective analysis of data from 439 patients emergently hospitalized for acute LGIB at the National Center for Global Health and Medicine in Japan, from January 2009 through December 2013. We used data on comorbidities, medication, presenting symptoms, and vital signs, and laboratory test results to develop a scoring system for severe LGIB (defined as continuous and/or recurrent bleeding). We validated the risk score in a prospective study of 161 patients with acute LGIB admitted to the same center from April 2014 through April 2015. We assessed the system's accuracy in predicting patient outcome using area under the receiver operating characteristics curve (AUC) analysis. All patients underwent colonoscopy. RESULTS In the first study, 29% of the patients developed severe LGIB. We devised a risk scoring system based on nonsteroidal anti-inflammatory drugs use, no diarrhea, no abdominal tenderness, blood pressure of 100 mm Hg or lower, antiplatelet drugs use, albumin level less than 3.0 g/dL, disease scores of 2 or higher, and syncope (NOBLADS), which all were independent correlates of severe LGIB. Severe LGIB developed in 75.7% of patients with scores of 5 or higher compared with 2% of patients without any of the factors correlated with severe LGIB (P < .001). The NOBLADS score determined the severity of LGIB with an AUC value of 0.77. In the validation (second) study, severe LGIB developed in 35% of patients; the NOBLADS score predicted the severity of LGIB with an AUC value of 0.76. Higher NOBLADS scores were associated with a requirement for blood transfusion, longer hospital stay, and intervention (P < .05 for trend). CONCLUSIONS We developed and validated a scoring system for risk of severe LGIB based on 8 factors (NOBLADS score). The system also determined the risk for blood transfusion, longer hospital stay, and intervention. It might be used in decision making regarding intervention and management.
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Affiliation(s)
- Tomonori Aoki
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Naoyoshi Nagata
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan.
| | - Takuro Shimbo
- Ohta Nishinouchi Hospital, Koriyama, Fukushima, Japan
| | - Ryota Niikura
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Bunkyo, Tokyo, Japan
| | - Toshiyuki Sakurai
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Shiori Moriyasu
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Hidetaka Okubo
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Katsunori Sekine
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Kazuhiro Watanabe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Chizu Yokoi
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Mikio Yanase
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Junichi Akiyama
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Masashi Mizokami
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Kohnodai Hospital, Ichikawa City, Chiba, Japan
| | - Naomi Uemura
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Kohnodai Hospital, Ichikawa City, Chiba, Japan
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Laine L. Risk Assessment Tools for Gastrointestinal Bleeding. Clin Gastroenterol Hepatol 2016; 14:1571-1573. [PMID: 27521511 DOI: 10.1016/j.cgh.2016.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/05/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Loren Laine
- Yale School of Medicine, New Haven, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
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Kwak MS, Cha JM, Han YJ, Yoon JY, Jeon JW, Shin HP, Joo KR, Lee JI. The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding. J Korean Med Sci 2016; 31:1611-6. [PMID: 27550490 PMCID: PMC4999404 DOI: 10.3346/jkms.2016.31.10.1611] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/28/2016] [Indexed: 01/01/2023] Open
Abstract
The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.
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Affiliation(s)
- Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea.
| | - Yong Jae Han
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyun Phil Shin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kwang Ro Joo
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Joung Il Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding. Am J Gastroenterol 2016; 111:459-74. [PMID: 26925883 PMCID: PMC5099081 DOI: 10.1038/ajg.2016.41] [Citation(s) in RCA: 276] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 01/02/2016] [Indexed: 12/11/2022]
Abstract
This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Hemodynamic status should be initially assessed with intravascular volume resuscitation started as needed. Risk stratification based on clinical parameters should be performed to help distinguish patients at high- and low-risk of adverse outcomes. Hematochezia associated with hemodynamic instability may be indicative of an upper gastrointestinal (GI) bleeding source and thus warrants an upper endoscopy. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. The endoscopic hemostasis modality used (mechanical, thermal, injection, or combination) is most often guided by the etiology of bleeding, access to the bleeding site, and endoscopist experience with the various hemostasis modalities. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. Radiographic interventions (tagged red blood cell scintigraphy, computed tomographic angiography, and angiography) should be considered in high-risk patients with ongoing bleeding who do not respond adequately to resuscitation and who are unlikely to tolerate bowel preparation and colonoscopy. Strategies to prevent recurrent bleeding should be considered. Nonsteroidal anti-inflammatory drug use should be avoided in patients with a history of acute lower GI bleeding, particularly if secondary to diverticulosis or angioectasia. Patients with established high-risk cardiovascular disease should not stop aspirin therapy (secondary prophylaxis) in the setting of lower GI bleeding. [corrected]. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection.
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Abstract
Lower gastrointestinal bleeding (LGIB) is a frequent reason for hospitalization especially in the elderly. Patients with LGIB are frequently admitted to the intensive care unit and may require transfusion of packed red blood cells and other blood products especially in the setting of coagulopathy. Colonoscopy is often performed to localize the source of bleeding and to provide therapeutic measures. LGIB may present as an acute life-threatening event or as a chronic insidious condition manifesting as iron deficiency anemia and positivity for fecal occult blood. This article discusses the presentation, diagnosis, and management of LGIB with a focus on conditions that present with acute blood loss.
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Affiliation(s)
- Emad Qayed
- Grady Memorial Hospital, Emory University School of Medicine, 49 Jesse Hill Junior Drive, Atlanta, GA 30303, USA
| | - Gaurav Dagar
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53188, USA
| | - Rahul S Nanchal
- Critical Care Fellowship Program, Medical Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Suite E 5200, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Diverticular stigmata of recent hemorrhage: find one, probe one, treat one. Gastrointest Endosc 2016; 83:424-6. [PMID: 26773638 DOI: 10.1016/j.gie.2015.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/11/2015] [Indexed: 12/11/2022]
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Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis 2016; 31:175-88. [PMID: 26454431 DOI: 10.1007/s00384-015-2400-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE Lower gastrointestinal (GI) bleeding is defined as bleeding distal to the ligament of Treitz. In the UK, it represents approximately 3 % of all surgical referrals to the hospital. This review aims to provide review of the current evidence regarding the management of this condition. METHODS Literature was searched using Medline, Pubmed, and Cochrane for relevant evidence by two researchers. This was conducted in a manner that enabled a narrative review of the evidence covering the aetiology, clinical assessment and management options of continuously bleeding patients. FINDINGS The majority of patients with acute lower GI bleeding can be treated conservatively. In cases where ongoing bleeding occurs, colonoscopy is still the first line of investigation and treatment. Failure of endoscopy and persistent instability warrant angiography, possibly preceded by CT angiography and proceeding to superselective embolisation. Failure of embolisation warrants surgical intervention. CONCLUSIONS There are still many unanswered questions. In particular, the development of a more reliable predictive tool for mortality, rebleeding and requirement for surgery needs to be the ultimate priority. There are a small number of encouraging developments on combination therapy with regard to angiography, endoscopy and surgery. Additionally, the increasing use of haemostatic agents provides an additional tool for the management of bleeding endoscopically in difficult situations.
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Affiliation(s)
- Andrew J Moss
- Department of Surgery, Peterborough City Hospital, Peterborough, Cambridgeshire, PE3 9GZ, UK
| | - Hussein Tuffaha
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK.
| | - Arshad Malik
- Department of Surgery, Ipswich Hospital NHS Trust, Ipswich, IP4 5PD, UK
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Abstract
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.
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Abstract
This article provides an overview of the evaluation and management of lower gastrointestinal bleeding (LGIB) in children. The common etiologies at different ages are reviewed. Conditions with endoscopic importance for diagnosis or therapy include solitary rectal ulcer syndrome, polyps, vascular lesions, and colonic inflammation and ulceration. Diagnostic modalities for identifying causes of LGIB in children include endoscopy and colonoscopy, cross-sectional and nuclear medicine imaging, video capsule endoscopy, and enteroscopy. Pre-endoscopic preparation and decision-making unique to pediatrics is highlighted. The authors conclude with a summary of current and emerging therapeutic hemostatic techniques that can be used in pediatric patients.
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Affiliation(s)
- Benjamin Sahn
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA.
| | - Samuel Bitton
- Division of Pediatric Gastroenterology & Nutrition, Steven & Alexandra Cohen Children's Medical Center of New York, Hofstra North Shore-LIJ School of Medicine, North Shore - Long Island Jewish Health System, 1991 Marcus Avenue, Suite M 100, New Hyde Park, NY 11042, USA
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Ayaru L, Ypsilantis PP, Nanapragasam A, Choi RCH, Thillanathan A, Min-Ho L, Montana G. Prediction of Outcome in Acute Lower Gastrointestinal Bleeding Using Gradient Boosting. PLoS One 2015; 10:e0132485. [PMID: 26172121 PMCID: PMC4501707 DOI: 10.1371/journal.pone.0132485] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/15/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There are no widely used models in clinical care to predict outcome in acute lower gastro-intestinal bleeding (ALGIB). If available these could help triage patients at presentation to appropriate levels of care/intervention and improve medical resource utilisation. We aimed to apply a state-of-the-art machine learning classifier, gradient boosting (GB), to predict outcome in ALGIB using non-endoscopic measurements as predictors. METHODS Non-endoscopic variables from patients with ALGIB attending the emergency departments of two teaching hospitals were analysed retrospectively for training/internal validation (n=170) and external validation (n=130) of the GB model. The performance of the GB algorithm in predicting recurrent bleeding, clinical intervention and severe bleeding was compared to a multiple logic regression (MLR) model and two published MLR-based prediction algorithms (BLEED and Strate prediction rule). RESULTS The GB algorithm had the best negative predictive values for the chosen outcomes (>88%). On internal validation the accuracy of the GB algorithm for predicting recurrent bleeding, therapeutic intervention and severe bleeding were (88%, 88% and 78% respectively) and superior to the BLEED classification (64%, 68% and 63%), Strate prediction rule (78%, 78%, 67%) and conventional MLR (74%, 74% 62%). On external validation the accuracy was similar to conventional MLR for recurrent bleeding (88% vs. 83%) and therapeutic intervention (91% vs. 87%) but superior for severe bleeding (83% vs. 71%). CONCLUSION The gradient boosting algorithm accurately predicts outcome in patients with acute lower gastrointestinal bleeding and outperforms multiple logistic regression based models. These may be useful for risk stratification of patients on presentation to the emergency department.
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Affiliation(s)
- Lakshmana Ayaru
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Abigail Nanapragasam
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ryan Chang-Ho Choi
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Anish Thillanathan
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Lee Min-Ho
- Department of Gastroenterology, Charing Cross and Hammersmith Hospitals, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Giovanni Montana
- Department of Biomedical Engineering, Kings College London, London, United Kingdom
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Kim J, Kim YH, Lee KH, Lee YJ, Park JH. Diagnostic Performance of CT Angiography in Patients Visiting Emergency Department with Overt Gastrointestinal Bleeding. Korean J Radiol 2015; 16:541-9. [PMID: 25995683 PMCID: PMC4435984 DOI: 10.3348/kjr.2015.16.3.541] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 02/16/2015] [Indexed: 01/07/2023] Open
Abstract
Objective To investigate the diagnostic performance of computed tomography angiography (CTA) in identifying the cause of bleeding and to determine the clinical features associated with a positive test result of CTA in patients visiting emergency department with overt gastrointestinal (GI) bleeding. Materials and Methods We included 111 consecutive patients (61 men and 50 women; mean age: 63.4 years; range: 28-89 years) who visited emergency department with overt GI bleeding. They underwent CTA as a first-line diagnostic modality from July through December 2010. Two radiologists retrospectively reviewed the CTA images and determined the presence of any definite or potential bleeding focus by consensus. An independent assessor determined the cause of bleeding based on other diagnostic studies and/or clinical follow-up. The diagnostic performance of CTA and clinical characteristics associated with positive CTA results were analyzed. Results To identify a definite or potential bleeding focus, the diagnostic yield of CTA was 61.3% (68 of 111). The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value were 84.8% (67 of 79), 96.9% (31 of 32), 98.5% (67 of 68), and 72.1% (31 of 43), respectively. Positive CTA results were associated with the presence of massive bleeding (p = 0.001, odds ratio: 11.506). Conclusion Computed tomography angiography as a first-line diagnostic modality in patients presenting with overt GI bleeding showed a fairly high accuracy. It could identify definite or potential bleeding focus with a moderate diagnostic yield and a high PPV. CTA is particularly useful in patients with massive bleeding.
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Affiliation(s)
- Jihang Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Young Hoon Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Kyoung Ho Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Yoon Jin Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
| | - Ji Hoon Park
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Seongnam 436-707, Korea
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The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc 2014; 79:875-85. [PMID: 24703084 DOI: 10.1016/j.gie.2013.10.039] [Citation(s) in RCA: 127] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/22/2013] [Indexed: 02/06/2023]
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Benítez Cantero JM, Jurado García J, Ruiz Cuesta P, González Galilea A, Muñoz García-Borruel M, García Sánchez V, Gálvez Calderón C. [Early evaluation of anaemia in patients with acute gastrointestinal bleeding: venous blood gas analysis compared to conventional laboratory]. Med Clin (Barc) 2013; 141:332-7. [PMID: 23103108 DOI: 10.1016/j.medcli.2012.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/10/2012] [Accepted: 07/12/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE Evaluation of patients with acute gastrointestinal bleeding (AGB) requires early clinical evaluation and analysis. The aim of this study is to evaluate early concordance of hemoglobin (Hb) and hematocrit (HTC) levels determined by conventional venous blood gas analysis (VBG) and by conventional Laboratory in Emergencies (LAB). PATIENTS AND METHODS Observational and prospective study of patients admitted in the Gastrointestinal Haemorrhage Unit with both high and low AGB. Demographic and clinical variables and simultaneous venous blood samples were obtained to determine Hb and HTC by VBG and LAB. Concordance in both methods was analysed by intra-class correlation coefficient (ICC) and Bland-Altman analysis. RESULTS One hundred and thirty-two patients were included: 87 (65.9%) males, average age 66.8 years. VBG overestimated Hb in 0.49 g/dl (95% confidence interval: 0.21-0.76) with respect to LAB. Concordance was very high in Hb (ICC 0.931) and high in HTC (0.899), with the Bland-Altman graphs showing both concordance and overestimation of Hb levels determined by VBG. In 19 patients (14.39%), Hb by VBG exceeded in more than 1g/dL the final determination obtained by LAB. CONCLUSIONS Early determination of Hb and HTC in patients with AGB by VBG provides reliable results in the initial evaluation of anaemia. VBG systematically overestimates Hb values by less than 0.5 g/dl, and therefore clinical and hemodynamic evaluation of the bleeding patient should prevail over analytical results.
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Manejo de la hemorragia digestiva baja aguda: documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:534-45. [DOI: 10.1016/j.gastrohep.2013.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 04/11/2013] [Indexed: 12/16/2022]
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Precision of noninvasive hemoglobin-level measurement by pulse co-oximetry in patients admitted to intensive care units for severe gastrointestinal bleeds*. Crit Care Med 2012; 40:2576-82. [DOI: 10.1097/ccm.0b013e318258fb4f] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Newman J, Fitzgerald JEF, Gupta S, von Roon AC, Sigurdsson HH, Allen-Mersh TG. Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding. Colorectal Dis 2012; 14:1020-6. [PMID: 21910819 DOI: 10.1111/j.1463-1318.2011.02824.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- J Newman
- Department of General Surgery, Chelsea & Westminster NHS Hospital Trust, London, UK
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Lhewa DY, Strate LL. Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding. World J Gastroenterol 2012; 18:1185-90. [PMID: 22468081 PMCID: PMC3309907 DOI: 10.3748/wjg.v18.i11.1185] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 08/25/2011] [Accepted: 08/31/2011] [Indexed: 02/06/2023] Open
Abstract
Acute lower gastrointestinal bleeding (LGIB) is a frequent gastrointestinal cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Endoscopic and radiographic measures are available for the evaluation and treatment of LGIB including flexible sigmoidoscopy, colonoscopy, angiography, radionuclide scintigraphy and multi-detector row computed tomography. Although no modality has emerged as the gold standard in the management of LGIB, colonoscopy is the current preferred initial test for the majority of the patients presenting with hematochezia felt to be from a colon source. Colonoscopy has the ability to diagnose all sources of bleeding from the colon and, unlike the radiologic modalities, does not require active bleeding at the time of the examination. In addition, therapeutic interventions such as cautery and endoclips can be applied to achieve hemostasis and prevent recurrent bleeding. Studies suggest that colonoscopy, particularly when performed early in the hospitalization, can decrease hospital length of stay, rebleeding and the need for surgery. However, results from available small trials are conflicting and larger, multicenter studies are needed. Compared to other management options, colonoscopy is a safe procedure with complications reported in less than 2% of patients, including those undergoing urgent examinations. The requirement of bowel preparation (typically 4 or more liters of polyethylene glycol), the logistical complexity of coordinating after-hours colonoscopy, and the low prevalence of stigmata of hemorrhage complicate the use of colonoscopy for LGIB, particularly in urgent situations. This review discusses the above advantages and disadvantages of colonoscopy in the management of acute lower gastrointestinal bleeding in further detail.
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Rodriguez Moranta F, Berrozpe A, Guardiola J. Rendimiento de la colonoscopia en la hemorragia digestiva baja. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:551-7. [DOI: 10.1016/j.gastrohep.2011.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/07/2011] [Indexed: 01/16/2023]
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