Acute Lower Gastrointestinal Bleeding: Characteristics and Clinical Outcome of Patients Treated With an Intensive Protocol

A clinical predictive model for risk stratification of patients with severe acute lower gastrointestinal bleeding

BACKGROUND

Lower gastrointestinal bleeding (LGIB) is a common presentation of surgical admissions, imposing a significant burden on healthcare costs and resources. There is a paucity of standardised clinical predictive tools available for the initial assessment and risk stratification of patients with LGIB. We propose a simple clinical scoring model to prognosticate patients at risk of severe LGIB and an algorithm to guide management of such patients.

METHODS

A retrospective cohort study was conducted, identifying consecutive patients admitted to our institution for LGIB over a 1-year period. Baseline demographics, clinical parameters at initial presentation and treatment interventions were recorded. Multivariate logistic regression was performed to identify factors predictive of severe LGIB. A clinical management algorithm was developed to discriminate between patients requiring admission, and to guide endoscopic, angiographic and/or surgical intervention.

RESULTS

226/649 (34.8%) patients had severe LGIB. Six variables were entered into a clinical predictive model for risk stratification of LGIB: Tachycardia (HR ≥ 100), hypotension (SBP < 90 mmHg), anaemia (Hb < 9 g/dL), metabolic acidosis, use of antiplatelet/anticoagulants, and active per-rectal bleeding. The optimum cut-off score of ≥ 1 had a sensitivity of 91.9%, specificity of 39.8%, and positive and negative predictive Values of 45% and 90.2%, respectively, for predicting severe LGIB. The area under curve (AUC) was 0.77.

CONCLUSION

Early diagnosis and management of severe LGIB remains a challenge for the acute care surgeon. The predictive model described comprises objective clinical parameters routinely obtained at initial triage to guide risk stratification, disposition and inpatient management of patients.

Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding

BACKGROUND

The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times.

AIM

To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB).

METHODS

We compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB (n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry (n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment.

RESULTS

Patients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently (P < 0.001).

CONCLUSION

Endoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese

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.

Colonoscopic Finding of Patients with Lower Gastrointestinal Bleeding at Different Age Group in Eastern Part of India - An Observational Study

Incidence of lower gastrointestinal (GI) bleeding (LGIB) is increasing over time. It can be seen in all age group patients, commonly associated with pre-existing comorbidities and is one of the common indications of colonoscopy. This study was done to identify common causes of LGIB in eastern part of India, because there is no previous study from Eastern India to identify the common causes of lower GI bleeding diagnosed by colonoscopy in different age group patients. Consecutive 64 patients with LGIB were included in this study from June 2018 to March 2019. We divided our study population into three groups, such as group A (20 years to 40 years), group B (41 years to 60 years), and group C (more than 60 years). Data were entered into Excel and then transferred into SPSS version 22 for statistical analysis. Mean age of study population was 49.83 ± 19.06 years. Normal colonoscopic finding was seen in 7 patients (10.9%). Most common colonoscopic findings of our study population were hemorrhoids (n=32; 50%), anal fissure (n=11; 17.2%) and isolated rectal ulcer (n=9; 14.1%). Colorectal growth was seen in 6 patients (9.4%), among them female patients were more commonly affected than male patients. Therefore, most common causes of LGIB in eastern part of India are hemorrhoids, anal fissure and isolated rectal ulcer. Male individuals are more commonly affected by LGIB.

Lower Gastrointestinal Bleeding in Patients With Cirrhosis-Etiology and Outcomes

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.

Changes in Lower Gastrointestinal Bleeding Presentation, Management, and Outcomes Over a 10-Year Span

BACKGROUND

There are only limited data available on changes in the etiology, management, and clinical outcomes in patients with lower gastrointestinal bleeding over the past decade.

STUDY

We compared 2 groups of consecutive patients hospitalized with lower gastrointestinal bleeding during 2 time periods: 2005 to 2007 (301 patients) and 2015 to 2017 (249 patients).

RESULTS

Compared with the 2005 to 2007 group, the mean Charlson comorbidity index in the 2015 to 2017 group was higher (5.0±2.6 vs. 6.0±3.0, P=0.028), whereas the use of computerized tomographic angiography and small bowel capsule endoscopy was more common (12.9% vs. 58.1%, P<0.001, and 28.8% vs. 69.0%, P=0.031, respectively). In 2005 to 2007, ischemic colitis (12.0%) was the most common confirmed etiology of bleeding and diverticular bleeding the second most common (8.6%), whereas in 2015 to 2017, diverticular bleeding was the most common etiology (10.4%), followed by angiodysplasia (8.4%). Small bowel bleeding sources were confirmed more often in the 2015 to 2017 group (P=0.017). Endoscopic treatment was attempted in 16.6% of patients in 2005 to 2007 versus 25.3% in 2015 to 2017 (P=0.015). Higher rebleeding rates, longer hospitalization durations (4.6±4.3 vs. 5.5±3.4 d, P=0.019), and a higher proportion of patients needing a transfusion (62.0% vs. 78.4%, P=0.016) were noted in 2015 to 2017.

CONCLUSIONS

Over a 10-year span, there were several notable changes: (1) more comorbidities in patients hospitalized for lower gastrointestinal bleeding; (2) marked increase in the use of computerized tomographic angiography and capsule endoscopy for diagnostic evaluation; and (3) longer hospitalization durations and greater need for blood transfusion, possibly reflecting the selection of sicker patients for in-patient management in 2015 to 2017.

Lactic Acid Is an Independent Predictor of Mortality and Improves the Predictive Value of Existing Risk Scores in Patients Presenting With Acute Gastrointestinal Bleeding

Background

There are validated clinical risk scores for risk stratifying patients presenting with acute upper gastrointestinal bleed (GIB), including Glasgow-Blatchford score (GBS), Pre-endoscopic Rockall score (RS-PE) and post-endoscopic complete Rockall Score (RS-C), and AIMS65. Several studies have explored the predictive value of lactic acid (LA) in the context of GI bleeding, but the prognostic role of LA and its incremental value in combination with existing clinical risk scores is not well defined.

Methods

We conducted a retrospective analysis of consecutive patients presenting to the emergency department of a single large academic tertiary care center from January 2014 to December 2015 with a charted diagnosis of acute GIB, inclusive of both upper and lower sources. We evaluated the independent role of LA as well as three clinical risk scores for predicting in-hospital mortality in these patients.

Results

Out of 704 patients admitted with acute GI bleeding, 366 patients had LA measured on presentation to the emergency department. The mean LA level, GBS, RS-PE and RS-C were found to be significantly higher in non-survivors, while there was no difference in the mean AIMS65 score between survivors and non-survivors. A multivariate logistic regression analysis showed that LA level was an independent predictor of in-hospital mortality. The area under the curve (AUC) for the receiver operator characteristic for RS-C, RS-PE, and GBS were 0.742, 0.675, and 0.652, respectively. When integrating LA into the above risk scores, the AUC for RS-C, RS-PE, and GBS showed statistical significance improvements to 0.780 (P = 0.04), 0.774 (P = 0.012), and 0.706 (P = 003), respectively.

Conclusions

In unselected patients with GIB who presented to the emergency department, LA is an independent predictor of in-hospital mortality. Integration of LA into RS-C, RS-PE, and GBS risk scores improved their ability to predict in-hospital mortality. The modified LA-based RS-PE (L-Rockall pre-endoscopic) score demonstrated predictive value comparable to the post-endoscopic RS-C.