Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage

Derivation and validation of a novel risk score to predict need for haemostatic intervention in acute upper gastrointestinal bleeding (London Haemostat Score)

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency, which takes up considerable healthcare resources. However, only approximately 20%-30% of bleeds require urgent haemostatic intervention. Current standard of care is for all patients admitted to hospital to undergo endoscopy within 24 hours for risk stratification, but this is difficult to achieve in practice, invasive and costly.

AIM

To develop a novel non-endoscopic risk stratification tool for AUGIB to predict the need for haemostatic intervention by endoscopic, radiological or surgical treatments. We compared this with the Glasgow-Blatchford Score (GBS).

DESIGN

Model development was carried out using a derivation (n=466) and prospectively collected validation cohort (n=404) of patients who were admitted with AUGIB to three large hospitals in London, UK (2015-2020). Univariable and multivariable logistic regression analysis was used to identify variables that were associated with increased or decreased chances of requiring haemostatic intervention. This model was converted into a risk scoring system, the London Haemostat Score (LHS).

RESULTS

The LHS was more accurate at predicting need for haemostatic intervention than the GBS, in the derivation cohort (area under the receiver operating curve (AUROC) 0.82; 95% CI 0.78 to 0.86 vs 0.72; 95% CI 0.67 to 0.77; p<0.001) and validation cohort (AUROC 0.80; 95% CI 0.75 to 0.85 vs 0.72; 95% CI 0.67 to 0.78; p<0.001). At cut-off scores at which LHS and GBS identified patients who required haemostatic intervention with 98% sensitivity, the specificity of the LHS was 41% vs 18% with the GBS (p<0.001). This could translate to 32% of inpatient endoscopies for AUGIB being avoided at a cost of only a 0.5% false negative rate.

CONCLUSIONS

The LHS is accurate at predicting the need for haemostatic intervention in AUGIB and could be used to identify a proportion of low-risk patients who can undergo delayed or outpatient endoscopy. Validation in other geographical settings is required before routine clinical use.

Predictors of Rebleeding in Non-variceal Upper Gastrointestinal Bleeding of Peptic Ulcer Etiology in Kashmiri Population

Background Upper gastrointestinal bleeding (UGIB) represents a substantial clinical and economic burden and rebleeding is one of the most important predictors of morbidity and mortality. Identifying patients who are likely to rebleed is a critical component of effectively managing patients with bleeding peptic ulcers. So, the study was undertaken to look for predictors of rebleeding in patients with bleeding peptic ulcers and try to find out the new scoring system to predict rebleeding in our population. Material and methods A retrospective analysis of prospectively maintained hospital data of UGIB patients was done and 480 patients of endoscopically documented peptic ulcers whose complete data was available were taken for study. Results Among the studied patients, men constituted 84.6%, and most of the patients were in the third to sixth decade of life with a mean age of 40.9±15.9 years, 76% were from rural areas. Only males with a mean age of 38.4±19.8 rebled with a rebleeding rate of 2.9% only. Half of the patients who rebled were in shock at the time of presentation. Those who rebled received more units of blood transfusion (mean 3±1.8), had a large mean ulcer size of Forest class IIa and IIb and epinephrine injection monotherapy group with varied statistical significance. Among rebleeders (n=14), eight patients were managed by a second endoscopic therapy, and six (42.8%) rebleeders and 1.25% of patients in total needed surgery. Two patients ultimately died giving overall mortality of 0.4% and mortality of 14.3% among rebleeders. Conclusion Our study found a very low rebleeding rate and mortality which could be explained by a young population with fewer co-morbidities and better response to proton pump inhibitor therapy. The significant parameters related to rebleeding were shock at presentation, degree of smoking, units of blood transfused, ulcer size, and high-risk endoscopic stigmata.

Re-bleeding and all-cause mortality risk in non-variceal upper gastrointestinal bleeding: focusing on patients receiving oral anticoagulant therapy

OBJECTIVE

Non-variceal upper gastrointestinal bleeding (NVUGIB) in patients receiving oral anticoagulants (OACs) may be fatal; however, little is known about re-bleeding and all-cause mortality after successful hemostasis. We investigated the clinical characteristics and risk factors for re-bleeding and death after successful hemostasis.

METHODS

Patients receiving OACs and diagnosed with NVUGIB between 2007 and 2021 were enrolled. All NVUGIB incidents were confirmed if definite bleeding in the upper gastrointestinal tract was detected via esophagogastroduodenoscopy.

RESULTS

A total of 132 patients receiving OACs were diagnosed with NVUGIB. Males were the majority (72, 54.5%), and bleeding was detected mostly in the stomach (99, 75%) and was most often due to peptic ulcers (PU) (88, 66.7%). After successful hemostasis of index NVUGIB, 40 patients (30.3%) experienced re-bleeding. Among them, 15 (37.5%) died, and among those, 3 (2.3%) were related to re-bleeding. Multivariate analysis revealed that duodenal bleeding (odds ratio [OR]: 3.305; 95% confidence interval [CI]: 1.152-9.479, p = 0.026) and Charlson comorbidity index score (CCI) (OR: 1.22; 95% CI: 1.052-1.419, p = 0.009) were significant risk factors for re-bleeding. Index albumin levels (OR: 0.134; 95% CI: 0.035-0.506, p = 0.003), previous PU or upper gastrointestinal bleeding (UGIB) history (OR: 4.626; 95% CI: 1.375-15.567, p = 0.013), and CCI (OR: 1.293; 95% CI: 1.058-1.581, p = 0.012) were related all-cause mortality.

CONCLUSION

CCI and duodenal bleeding are risk factors for re-bleeding in patients with NVUGIB who were receiving OACs, while low index albumin levels and previous PU and UGIB history are associated with all-cause mortality.

Unmasking lower gastrointestinal bleeding under administration of norepinephrine

BACKGROUND

Bleeding in the gastrointestinal tract is common and transarterial embolization enables the clinician to control gastrointestinal bleeding. Contrast extravasation is a prerequisite for successful embolization. Provocative angiography is helpful in the detection of elusive bleeding.

AIM

We performed a retrospective analysis of angiographic treatment in patients with lower gastrointestinal hemorrhage and initially negative angiographies, as well as the role of norepinephrine (NE) in unmasking bleeding.

METHODS

We analyzed 41 patients with lower gastrointestinal bleeding after angiography who had undergone treatment over a period of 10 years. All patients had a positive shock index and needed intensive care.

RESULTS

In three of four patients, angiography disclosed the site of bleeding when NE was used during the procedure for hemodynamic stabilization.

CONCLUSION

We suggest that angiography performed after the administration of NE in unstable patients with gastrointestinal bleeding and an initially negative angiography has the potential to unmask bleeding sites for successful embolization. However, this statement must be confirmed in prospective studies.

Development and validation of a model to predict rebleeding within three days after endoscopic hemostasis for high-risk peptic ulcer bleeding

Background

Peptic ulcer bleeding remains a typical medical emergency with significant morbidity and mortality. Peptic ulcer rebleeding often occurs within three days after emergent endoscopic hemostasis. Our study aims to develop a nomogram to predict rebleeding within three days after emergent endoscopic hemostasis for high-risk peptic ulcer bleeding.

Methods

We retrospectively reviewed the data of 386 patients with bleeding ulcers and high-risk stigmata who underwent emergent endoscopic hemostasis between March 2014 and October 2018. The least absolute shrinkage and selection operator method was used to identify predictors. The model was displayed as a nomogram. Internal validation was carried out using bootstrapping. The model was evaluated using the calibration plot, decision-curve analyses, and clinical impact curve.

Results

Overall, 386 patients meeting the inclusion criteria were enrolled, with 48 patients developed rebleeding within three days after initial endoscopic hemostasis. Predictors contained in the nomogram included albumin, prothrombin time, shock, haematemesis/melena and Forrest classification. The model showed good discrimination and good calibration with a C-index of 0.854 (C-index: 0.830 via bootstrapping validation). Decision-curve analyses and clinical impact curve also demonstrated that it was clinically valuable.

Conclusion

This study presents a nomogram that incorporates clinical, laboratory, and endoscopic features, effectively predicting rebleeding within three days after emergent endoscopic hemostasis and identifying high-risk rebleeding patients with peptic ulcer bleeding.

Trial registration This clinical trial has been registered in the ClinicalTrials.gov (ID: NCT04895904) approved by the International Committee of Medical Journal Editors (ICMJE).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02145-9.

Impact of time to esophagogastroduodenoscopy in patients with nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis

INTRODUCTION

There is conflicting evidence regarding the benefit of urgent esophagogastroduodenoscopy (EGD) for reducing mortality and rebleeding, in the context of nonvariceal upper gastrointestinal bleeding.

AIM

To describe the decrease in the risk for mortality, rebleeding, and red blood cell transfusion, with the performance of urgent EGD, in patients with nonvariceal upper gastrointestinal bleeding.

MATERIALS AND METHODS

We carried out a search for cohort studies or controlled clinical trials, published from December 1966 to May 2020, that compared urgent EGD versus elective EGD in the management of adults with nonvariceal upper gastrointestinal bleeding, utilizing the MEDLINE, Embase, LILACS, and Cochrane Central Register of Controlled Trials databases. Our primary outcome was the hospital mortality comparison. The incidence of rebleeding and the mean number of red blood cell units transfused were also compared. A random effects model was utilized for the meta-analysis.

RESULTS

Twenty-one studies that met the eligibility criteria were included, involving 489,622 patients. We found no differences in the mortality of subjects exposed to urgent EGD versus elective EGD (RR 1.12 [0.72-1.72]). There was a significant increase in the risk for rebleeding (RR 1.30 [1.05-1.60]) in the subjects exposed to urgent EGD, and fewer red blood cell units were transfused in those patients (RR 0.52 [0.05-0.99]).

CONCLUSIONS

Urgent EGD in subjects with nonvariceal upper gastrointestinal bleeding does not appear to have a significant impact on short-term mortality.

Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding

BACKGROUND

Nonvariceal upper digestive bleeding (NVUDB) represents a severe emergency condition and is associated with significant morbidity and mortality. Despite a decrease in the incidence due to the widespread use of potent therapy with proton pump inhibitors as well as the implementation of modern endoscopic techniques, the mortality rate associated with NVUDB is still high.

AIM

To identify the clinical, biological, and endoscopic parameters associated with a poor outcome in patients with NVUDB to allow the stratification of risk, which will lead to the implementation of the most accurate management.

METHODS

We performed a retrospective study including patients who were admitted to the Gastroenterology Department of Clinical Emergency County Hospital Timisoara, Romania, with a diagnosis of NVUDB between 1 January 2008 and 31 December 2016. All the data were collected from the patient’s records, including demographic data, medication history, hemodynamic status, paraclinical tests, and endoscopic features as well as the methods of hemostasis, rate of rebleeding, need for surgery and death; we also assessed the Rockall score of the patients, length of hospitalization and associated comorbidities. All these parameters were evaluated as potential risk factors associated with rebleeding and death in patients with NVUDB.

RESULTS

We included a batch of 1581 patients with NVUDB, including 523 (33%) females and 1058 (67%) males with a median age of 66 years. The main cause of NVUDB was peptic ulcer (73% of patients). More than one-third of the patients needed endoscopic treatment. Rebleeding rate was 7.72%; surgery due to failure of endoscopic hemostasis was needed in 3.22% of cases; the in-hospital mortality rate was 8.09%, and the bleeding-episode-related mortality rate was 2.97%. Although our predictive models for rebleeding and death had a low sensitivity, the specificity was very high, suggesting a better discriminative capacity for identifying patients with better outcomes. Our results showed that the Rockall score was associated with both rebleeding and death; comorbidities such as respiratory conditions, liver cirrhosis and sepsis increased significantly the risk of in-hospital mortality (OR of 3.29, 2.91 and 8.03).

CONCLUSION

Our study revealed that the Rockall score, need for endoscopic therapy, necessity of transfusion and sepsis were risk factors for rebleeding. Moreover, an increased Rockall score and the presence of comorbidities were predictive factors for in-hospital mortality.

Gastroduodenal ulcer bleeding in elderly patients on low dose aspirin therapy

AIM

To determine the clinical characteristics of elderly patients of hemorrhagic gastroduodenal ulcer on low-dose aspirin (LDA) therapy.

METHODS

A total of 1105 patients with hemorrhagic gastroduodenal ulcer treated in our hospital between January 2000 and March 2016 were grouped by age and drugs used, and these groups were compared in several factors. These groups were compared in terms of length of hospital stay, presence/absence of hemoglobin (Hb) decrease, presence/absence of blood transfusion, Forrest I, percentage of Helicobacter pylori infection, presence/absence of underlying disease, and percentage of severe cases.

RESULTS

The percentage of blood transfusion (62.6% vs 47.7 %, P < 0.001), Hb decrease (53.8% vs 40.8%, P < 0.001), and the length of hospital stay (23.5 d vs 16.7 d, P < 0.001) were significantly greater in those on drug therapy. The percentage of blood transfusion (65.3% vs 47.8%, P < 0.001), Hb decrease (54.2% vs 42.1%, P < 0.001), and length of hospital stay (23.3 d vs 17.5 d, P < 0.001) were significantly greater in the elderly. In comparison with the LDA monotherapy group, the percentage of severe cases was significantly higher in the LDA combination therapy group when elderly patients were concerned (16.1% vs 34.0%, P = 0.030). Meanwhile, among those on LDA monotherapy, there was no significant difference between elderly and non-elderly (16.1% vs 16.0%, P = 0.985).

CONCLUSION

A combination of LDA with antithrombotic drugs or non-steroidal anti-inflammatory drugs (NSAIDs) contributes to aggravation. And advanced age is not an aggravating factor when LDA monotherapy is used.

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

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

Rebleeding after initial endoscopic hemostasis in peptic ulcer disease

Endoscopic hemostasis is the first-line treatment for upper gastrointestinal bleeding (UGIB). Although several factors are known to be risk factors for rebleeding, little is known about the use of antithrombotics. We tried to verify whether the use of antithrombotics affects rebleeding rate after a successful endoscopic hemostasis for peptic ulcer disease (PUD). UGIB patients who underwent successful endoscopic hemostasis were included. Rebleeding was diagnosed when the previously treated lesion bled again within 30 days of the initial episode. Of 522 UGIB patients with PUD, rebleeding occurred in 93 patients (17.8%). The rate of rebleeding was higher with aspirin medication (P=0.006) and after a long endoscopic hemostasis (P<0.001). Of all significant variables, procedure time longer than 13.5 min was related to the rate of rebleeding (OR, 2.899; 95% CI, 1.768-4.754; P<0.001) on the logistic regression analysis. The rate of rebleeding after endoscopic hemostasis for PUD is higher in the patients after a long endoscopic hemostasis. Endoscopic hemostasis longer than 13.5 min is related to rebleeding after a successful endoscopic hemostasis for PUD.

[Current management of nonvariceal upper gastrointestinal bleeding in Spain]

BACKGROUND

Mortality related to nonvariceal upper gastrointestinal bleeding (NVUGIB) has not changed. More information is needed to improve the management of this entity. The aims of this study were: a) to determine the characteristics of bleeding episodes, b) to describe the clinical approaches routinely used in NVUGIB, and c) to identify adverse outcomes related to endoscopic or medical treatments in Spain.

METHODS

The European survey of nonvariceal upper GI bleeding (ENERGiB) was an observational, retrospective cohort study on NVUGIB with endoscopic evaluation carried out across Europe. The present study focused on Spanish patients in the ENERGiB study. The patients were managed according to routine care. The mean and standard deviation were calculated for quantitative variables and absolute and relative frequencies were calculated for categorical variables.

RESULTS

Patients (n=403) were mostly men (71%), with a mean age of 65 years, and co-morbidities (62.5%). Most of the patients were managed by gastroenterologists (57.1%) or internal medicine teams (25.1%). A proton pump inhibitor was used empirically in 80% before endoscopy. Bleeding persistence occurred in 6.4% and recurrence in 6.7%. The mortality rate at 30 days was 3.5%.

CONCLUSIONS

This study contributes to the characterization of Spanish patients and NVUGIB episodes in a real clinical setting and identifies the routine management of this entity, which is in line with the standards proposed by recent clinical practice guidelines. A notable finding was that age and the number of comorbidities in NVUGIB patients were increasing. These factors could explain the persistent mortality rate, despite the evident advances in the management of this entity.

Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer

BACKGROUND

Determining the risk of rebleeding after endoscopic therapy for peptic ulcer bleeding (PUB) may be useful for establishing additional haemostatic measures in very high-risk patients.

AIM

To identify predictors of rebleeding after endoscopic therapy.

METHODS

Bibliographic database searches were performed to identify studies assessing rebleeding after endoscopic therapy for PUB. All searches and data abstraction were performed in duplicate. A parameter was considered to be an independent predictor of rebleeding when it was detected as prognostic by multivariate analyses in ≥2 studies. Pooled odds ratios (pOR) were calculated for prognostic variables.

RESULTS

Fourteen studies met the prespecified inclusion criteria. Pre-endoscopic predictors of rebleeding were: (i) Haemodynamic instability: significant in 9 of 13 studies evaluating the variable (pOR: 3.30, 95% CI: 2.57-4.24); (ii) Haemoglobin value: significant in 2 of 10 (pOR: 1.73, 95% CI: 1.14-2.62) and (iii) Transfusion: significant in two of six (pOR not calculable). Endoscopic predictors of rebleeding were: (i) Active bleeding: significant in 6 of 12 studies (pOR: 1.70, 95% CI: 1.31-2.22); (ii) Large ulcer size: significant in 8 of 12 studies (pOR: 2.81, 95% CI: 1.98-4.00); (iii) Posterior duodenal ulcer location: significant in four of eight studies (pOR: 3.83, 95% CI: 1.38-10.66) and (iv) High lesser gastric curvature ulcer location: significant in three of eight studies (pOR: 2.86; 95% CI: 1.69-4.86).

CONCLUSIONS

Major predictors for rebleeding in patients receiving endoscopic therapy are haemodynamic instability, active bleeding at endoscopy, large ulcer size, ulcer location, haemoglobin value and the need for transfusion. These risk factors may be useful for guiding clinical management in patients with PUB.

Epidemiology and demographics of upper gastrointestinal bleeding: prevalence, incidence, and mortality

Despite major advances in diagnosis, prevention, and treatment, nonvariceal upper gastrointestinal bleeding still is a serious problem in clinical practice. Current evidence indicates that most peptic ulcer bleeding-linked deaths are not a direct sequela of the bleeding ulcer itself. Instead, mortality derives from multiorgan failure, cardiopulmonary conditions, or terminal malignancy, suggesting that improving further current treatments for the bleeding ulcer may have a limited impact on mortality unless supportive therapies are developed for the global management of these patients.

Clinical predictors of poor outcomes among patients with nonvariceal upper gastrointestinal bleeding in Europe

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common medical emergency associated with substantial morbidity and mortality. Despite advances in endoscopic and pharmacological treatment during the past two decades, the incidence of mortality associated with NVUGIB has remained relatively constant.

AIM

To report outcomes and predictive factors for bleeding continuation/re-bleeding and mortality of NVUGIB in clinical practice in different European countries.

METHODS

This observational, retrospective cohort study (NCT00797641; ENERGIB) was conducted in Belgium, Greece, Italy, Norway, Portugal, Spain and Turkey. Eligible patients were hospitalised (new admissions or inpatients), presenting with overt NVUGIB with endoscopy from 1 October to 30 November, 2008. Patients were managed according to routine care, and data regarding bleeding continuation/re-bleeding, pharmacological treatment, surgery and mortality during 30-days after the initial bleed were collected. A multivariate analysis of clinical factors predictive of poor outcomes was conducted.

RESULTS

Overall, 2660 patients (64.7% men; mean age 67.7 years) were evaluable. Significant differences across countries in bleeding continuation/re-bleeding (range: 9-15.8%) or death (2.5-8%) at 30 days were explained by clinical factors (number of comorbidities, age > 65 years, history of bleeding ulcers, in-hospital bleeding, type of lesion or type of concomitant medication). Other factors (country, size of hospital, profile of team managing the event, or endoscopic/pharmacological therapy received) did not affect these outcomes. Similar predictors were observed in patients with high-risk stigmata.

CONCLUSION

Differences in the outcomes of nonvariceal upper gastrointestinal bleeding in clinical practice across some European countries are explained mainly by patient-related factors, and not by management factors.

Role of antithrombotic therapy and nonsteroidal anti-inflammatory drug use in bleeding gastroduodenal ulcers

OBJECTIVE

The aim of this study was to analyze the effects of anti-thrombotic therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) on gastroduodenal bleeding.

PATIENTS AND METHODS

The study subjects were 544 patients (421 males and 123 females, mean age, 64.2 years) who were treated endoscopically for bleeding gastroduodenal ulcers from January 1995 to August 2008. Of the 544 patients, 276 (50.7%) had a history of treatment for > or =1 month with an antithrombotic agent or NSAIDs, including low-dose aspirin (n=94), other NSAIDs (n=91), warfarin (n=43), or any combination of the three (combination treatment group; n=48). On the other hand, 268 patients had not previously received any of these drugs (control group). Clinical features and endoscopic therapeutic results were assessed and compared.

RESULTS

Helicobacter pylori infection was detected in 187 of the 241 (77.6%) patients examined. Of the 544 patients, 199 (36.6%) attended the Department of Cardiology or Cardiovascular Surgery, and 170 (31.3%) patients were already being treated with antiulcer medication, including proton pump inhibitors (n=18 [3.3%]). Forty (7.4%) patients suffered from rebleeding after intervention; the incidence of ulcer rebleeding was not significantly different between patients being treated with any such drugs (4.7% [13/276]) and those that had not previously received any antithrombotic agent or NSAIDs (10.1% [27/268]).

CONCLUSION

Antithrombotic therapy and NSAIDs use contributed to bleeding in 50.7% of patients with gastroduodenal ulcers. These drugs are a major cause of ulcer bleeding, but are not necessarily considered a risk factor for rebleeding after endoscopic hemostasis.