Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

Diagnosis Value of the Blood Urea Nitrogen-to-Creatinine Ratio in Determining the Need for Intervention of Acute Upper Gastrointestinal Bleeding

INTRODUCTION

The blood urea nitrogen (BUN)-to-creatinine (Cr) ratio (BUN/Cr ratio) may be used to evaluate the need for intervention of acute upper gastrointestinal bleeding (AUGIB). This study aimed to explore the predictive value of the BUN/Cr ratio in the need for intervention of AUGIB.

METHODS

This retrospective observational study included patients with AUGIB in the hospital's emergency department between August 2019 and May 2023. The patients were grouped according to whether they underwent an intervention for AUGIB. Patients treated between August 2019 and May 2022 were selected as the training set and the others as the validation set.

RESULTS

A total of 466 patients (328 males, 138 females) with AUGIB were enrolled in the intervention group (n = 167) and the no-intervention group (n = 299). In the training set, multivariable logistic regression showed that the BUN/Cr ratio (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.003-1.023, p = 0.009), hemoglobin (OR: 0.989, 95% CI: 0.981-0.997, p = 0.010), and a previous history of esophageal variceal bleeding (OR: 6.898, 95% CI: 3.989-11.929, p < 0.001) were independently associated with intervention for AUGIB. The area under receiver operating characteristic curve of BUN/Cr ratio and the prediction model based on logistic regression to predict the need for intervention of AUGIB were 0.604 (95% CI: 0.544-0.664) and 0.759 (95% CI: 0.706-0.812) in the training set and 0.634 (95% CI: 0.529, 0.740) and 0.708 (95% CI: 0.609, 0.806) in the validation set, respectively.

CONCLUSION

The BUN/Cr ratio was associated with the need for AUGIB intervention. Combining it with other parameters might improve its diagnostic value to predict the need for intervention of AUGIB.

The Prediction and Treatment of Bleeding Esophageal Varices in the Artificial Intelligence Era: A Review

Esophageal varices (EVs), a significant complication of cirrhosis, present a considerable challenge in clinical practice due to their high risk of bleeding and associated morbidity and mortality. This manuscript explores the transformative role of artificial intelligence (AI) in the management of EV, particularly in enhancing diagnostic accuracy and predicting bleeding risks. It underscores the potential of AI in offering noninvasive, efficient alternatives to traditional diagnostic methods such as esophagogastroduodenoscopy (EGD). The complexity of EV management is highlighted, necessitating a multidisciplinary approach that includes pharmacological therapy, endoscopic interventions, and, in some cases, surgical options tailored to individual patient profiles. Additionally, the paper emphasizes the importance of integrating AI into medical education and practice, preparing healthcare professionals for the evolving landscape of medical technology. It projects a future where AI significantly influences the management of gastrointestinal bleeding, improving clinical decision-making, patient outcomes, and overall healthcare efficiency. The study advocates for a patient-centered approach in healthcare, balancing the incorporation of innovative technologies with ethical principles and the diverse needs of patients to optimize treatment efficacy and enhance healthcare accessibility.

Diagnostic yield of esophagogastroduodenoscopy in upper gastrointestinal bleeding in pediatrics: a cross-sectional study at a tertiary center

Background

Esophagogastroduodenoscopy (EGD) is currently considered the first-line diagnostic procedure of choice for upper gastrointestinal bleeding (UGIB); however, the etiology of bleeding remains unknown in a subset of patients. This study aimed to evaluate the diagnostic yield of EGD in UGIB in pediatrics and determine the clinical predictors for positive endoscopic diagnosis.

Methods

A cross-sectional study was conducted at the pediatrics endoscopy unit, Ain Shams University, Cairo, Egypt, where 100 children were included. They were referred for EGD due to overt UGIB in the form of hematemesis and/or melena. Full medical history, thorough physical examination, laboratory investigations, and endoscopic and histopathologic findings were documented.

Results

Forty-seven males and 54 females were included. Their ages ranged from 3 months to 15 years, with a median age of 4 years. Sixty-five percent presented with hematemesis only, 7% presented with melena only, and 28% presented with hematemesis and melena. An endoscopic diagnosis could be reached in 62% of cases, with Helicobacter pylori (H. pylori) gastritis (23%) and reflux esophagitis (11%) as the most common endoscopic diagnoses, with the former being the most common in children above 4 years and the latter for younger ones. Other diagnoses included non-specific gastritis (8%) and esophageal varices (4%). Presentation with melena only was a negative predictor to reach a diagnosis by EGD, while splenomegaly and thrombocytopenia were independent predictors of variceal bleeding.

Conclusion

EGD is the investigation of choice in children suffering from hematemesis especially in older age groups. Clinical and laboratory parameters might help in the prediction of the underlying etiology.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage

BACKGROUND

Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH.

OBJECTIVES

To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome.  MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion).

AUTHORS' CONCLUSIONS

We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.

Endoscopic Findings in Patients With Upper Gastrointestinal Bleeding in Ogun State, Nigeria

Introduction

Although the global incidence of upper gastrointestinal bleeding (UGIB) appears to have reduced substantially in the past few decades, acute UGIB still carries significant morbidity and mortality worldwide. There are currently no published data on UGIB in Ogun State, Nigeria. This study examined the endoscopic findings in patients with UGIB in Ogun State. 

Methodology

The study was a retrospective cross-sectional survey of patients with UGIB who had upper gastrointestinal endoscopy at three endoscopy centers in Ogun State, Southwest Nigeria, from January 2015 to December 2021. Patients’ data, which included age, gender, and endoscopic findings, were extracted from the endoscopy registers into a spreadsheet and analyzed statistically. Summary statistics included means ± standard deviation for continuous variables and frequencies and percentages for categorical variables. Categorical variables were compared for differences by chi-square test or Fisher’s exact test as appropriate. The statistical significance cutoff was p-value <0.05.

Results

A total of 171 had endoscopy for UGIB during the period under review but 168 had complete data. Out of the 168, 113 (67.3%) were males, giving a male-to-female ratio of 2:1. The mean age of the patients was 52.4 ± 18.1 years, with an age range of 7-85 years. The modal age group was ≥60 years (75; 39.9%). The most common endoscopic finding was peptic ulcer disease (77; 45.8%), followed by esophagogastric varices (27; 16.1%), erosive mucosal disease (25; 14.9 %), portal hypertensive gastropathy (15; 8.9%), suspected malignancies (11; 6.6%), hemorrhagic gastritis (7; 4.2%), gastric antral vascular ectasia (2; 1.2%), and Mallory-Weiss tear (1; 0.6%), respectively. Forty-four patients (26.2%) had no lesion that could explain UGIB. 

Conclusion

Peptic ulcer disease was the most common cause of UGIB among our patient population, and the elderly male patients were the most affected.

A Protocol for a Systematic Review and Meta-Analysis of Hospital Readmissions Following Acute Upper Gastrointestinal Bleeding

This protocol outlines the planned methodology for a systematic review and meta-analysis. The primary objective of the review is to identify all-cause readmission rates for individuals hospitalized for an upper GI bleed (UGIB). Secondary objectives will include GI bleed-specific readmission rates, mortality (all-cause and GI bleed-specific), readmission diagnosis, and length of stay on readmission visit. High-risk subgroups will also be explored including age, sex, type of GI bleed (e.g., variceal or not), anti-coagulation status, and comorbidity status. Through this review, the research team aims to describe an important quality indicator, which has implications for both patient safety post-discharge after an UGIB and healthcare resource utilization.

Management of Patient with Simultaneous Overt Gastrointestinal Bleeding and Myocardial Infarction with ST-Segment Elevation - Priority Endoscopy

Background

The current ERC guidelines are the source of many positive changes, reduction of mortality, length of hospitalization and improvement of prognosis of STEMI patients. However, there is a small group of patients whose slight modification in guidelines would further reduce in-hospital mortality and hospitalization costs. These are patients with concomitant STEMI infarction and gastrointestinal bleeding.

Methods

Two separate methods of treatment were compared in patients with concomitant gastrointestinal bleeding and ST-segment elevation myocardial infarction. The first – traditional approach, in the line with the ESC guidelines, the second innovative, with priority for endoscopy.

Results

Despite the innovative approach, the patient with endoscopy before PCI was discharged without complication. A patient who has undergone coronary intervention and who has been started on typical antiplatelet therapy prior to gastroenterological diagnosis has died due to massive bleeding.

Conclusion

For ethical reasons and in connection with the cardiological guidelines of the management of ACS, a study of patients with ASC a high risk of intestinal bleeding, in which endoscopy will have priority, and only later PCI, will probably never be performed. Although, as the described case shows, despite exceeding the 90 minutes time to implement PCI (<120 minutes) in logistic terms such behavior is completely feasible.

Validation of a decision rule to predict patients at low risk of variceal upper gastrointestinal hemorrhage

BACKGROUND

Determining the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides ED therapy, but can be difficult to determine on clinical grounds. A simple decision rule, using only platelet and international normalized ratio (INR) values, was previously derived in a single center and had high sensitivity (97%). We sought to validate this decision rule using multi-center data.

MATERIALS AND METHODS

We performed this decision rule validation using data collected from 21 Canadian hospitals, comprising 2020 patients. The parent study enrolled patients aged ≥18 years at participating hospitals with nonvariceal or variceal UGIB from January 2004 through May 2005. To validate the existing decision rule, we computed the test characteristics of the rule on this study population. The existing decision rule, in order to predict patients at low risk for variceal hemorrhage, is designed to be highly sensitive for variceal UGIB. In the previously derived rule, patients are not low risk if either is present: INR ≥1.3 or platelet count ≤200 × 10⁹/L. We additionally added a third common-sense criterion to the decision rule in a separate analysis: whether the patient has previously had variceal hemorrhage.

RESULTS

2001 patients were eligible for analysis, including 214 (10.7%) with a variceal source of gastrointestinal hemorrhage. Median age was 69 (IQR 55-79), and 764 (38%) were women. The two-step rule correctly identified 204 of the 214 (95.3%) patients with variceal hemorrhage; adding prior variceal hemorrhage as a variable identified 5 more patients (209/214 [97.7%]). Of the 2001 patients, 953 (47%) would have been classified as low risk for variceal hemorrhage; of these patients, 5 (0.5%) experienced variceal hemorrhage. The sensitivity of the rule in this validation cohort was 95.3% (95% CI 91.6-97.7%), with a negative likelihood ratio of 0.09 (95% CI 0.05-0.16). Adding prior variceal hemorrhage increased sensitivity to 97.7% (95% CI 94.6-99.2%), with a negative likelihood ratio of 0.04 (95% CI 0.02-0.11).

CONCLUSION

We have validated a simple decision rule to identify patients at low risk for variceal UGIB. This two-step (three-step if prior history of variceal hemorrhage is known) rule is simple to use, and may enable safe deferment of unnecessary or harmful therapies.

Comparison of clinical outcomes between variceal and non-variceal gastrointestinal bleeding in patients with cirrhosis

BACKGROUND AND AIM

Acute upper gastrointestinal bleeding (UGIB) in cirrhosis is associated with significant morbidity and mortality and can be classified as acute variceal bleeding (AVB) or non-variceal bleeding (NVB). Differences in mortality, hospital length of stay (LOS), and 30-day readmission have yet to be determined. As such, the study aimed to evaluate differences in these clinical outcomes in cirrhotic patients admitted with UGIB.

METHODS

This retrospective study included all cirrhotic patients hospitalized for UGIB who underwent upper endoscopy from July 2014 to July 2016. AVB was defined as the presence of varices on endoscopy with high-risk stigmata such as cherry-red spots. Mortality, intensive care unit admission, hospital LOS, and 30-day hospital readmission were recorded and compared among patients with AVB and NVB.

RESULTS

A total of 116 patients with cirrhosis were included, 73 with AVB and 43 with NVB. Patients with NVB were older than those with AVB (60.4 ± 11.1 vs 55.0 ± 9.5, P = 0.006) whereas patients with AVB were more likely to have known esophageal varices (64.4% vs 37.2%, P = 0.007). Patients with AVB and NVB had similar mortality (15.1% vs 9.3%, P = 0.57), hospital LOS (4.9, interquartile range: 3.6-6.9 days vs 5.0, interquartile range: 2.7-8.3 days), and 30-day readmission rates (19.2% vs 30.2%, P = 0.18). Severity of clinical presentation was associated with increased LOS and overall mortality, including the need for intensive care unit admission, but these were not associated with 30-day readmission rates.

CONCLUSION

There were no differences in clinical outcomes, including mortality, in cirrhotic patients admitted with AVB and NVB.

Identifying Emergency Department Patients at Low Risk for a Variceal Source of Upper Gastrointestinal Hemorrhage

BACKGROUND

Assessing the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides therapy, but can be difficult to determine on clinical grounds. The objective of this study was to determine if there are easily ascertainable clinical and laboratory findings that can identify a patient as low risk for a variceal source of hemorrhage.

METHODS

This was a retrospective cohort study of adult ED patients with UGIB between January 2008 and December 2014 who had upper endoscopy performed during hospitalization. Clinical and laboratory data were abstracted from the medical record. The source of the UGIB was defined as variceal or nonvariceal based on endoscopic reports. Binary recursive partitioning was utilized to create a clinical decision rule. The rule was internally validated and test characteristics were calculated with 1,000 bootstrap replications.

RESULTS

A total of 719 patients were identified; mean age was 55 years and 61% were male. There were 71 (10%) patients with a variceal UGIB identified on endoscopy. Binary recursive partitioning yielded a two-step decision rule (platelet count > 200 × 10⁹ /L and an international normalized ratio [INR] < 1.3), which identified patients who were low risk for a variceal source of hemorrhage. For the bootstrapped samples, the rule performed with 97% sensitivity (95% confidence interval [CI] = 91%-100%) and 49% specificity (95% CI = 44%-53%).

CONCLUSION

Although this derivation study must be externally validated before widespread use, patients presenting to the ED with an acute UGIB with platelet count of >200 × 10⁹ /L and an INR of <1.3 may be at very low risk for a variceal source of their upper gastrointestinal hemorrhage.

Pediatric gastrointestinal bleeding: Perspectives from the Italian Society of Pediatric Gastroenterology

There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the “Gastro-Ped Bleed Team” of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE via PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: “upper GIB” and “pediatric” [all fields]; “lower GIB” and “pediatric” [all fields]; “obscure GIB” and “pediatric” [all fields]; “GIB” and “endoscopy” [all fields]; “GIB” and “therapy” [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Helicobacter Pylori Infection in a Group of Egyptian Children With Upper Gastro-Intestinal Bleeding

Background

Upper gastrointestinal bleeding is a life threatening condition in children. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage. Helicobacter pylori (H. pylori) is a Gram negative spiral-shaped bacterium that is found in the gastric mucous layer or adherent to the epithelial lining of the stomach. It causes more than 90% of duodenal ulcers and up to 70-80% of gastric ulcers. The relationship between H. pylori infection and upper GIT bleeding in children is still un-clear. This study aimed to estimate the incidence of H. pylori infection in children presented with upper GIT bleeding and correlation between H. pylori infection and endoscopic findings of the cause of bleeding.

Methods

The study included 70 children presented with upper GIT bleeding indicated for upper gastrointestinal endoscopy admitted in pediatric department, Minia University Hospital, Egypt during the period from February 2010 to December 2012. Thirty healthy children were included as a control group with age and sex matched. After medical history taking and physical examination all children were exposed for laboratory investigations (CBC, prothrombin time and concentration, liver function tests, hepatitis viral markers, blood urea and serum creatinine and Helicobacter pylori stool antigen test). Upper endoscopy was done for patients only. Patients were classified into variceal and non variceal groups according to upper endoscopy.

Results

Helico-pylori infection was significantly higher in children with non-variceal bleeding than controls (P = 0.02) and children with variceal bleeding (P = 0.03) with no significant difference between children with variceal bleeding and controls (P = 0.9). Both weights and BMIs centile were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 and 0.01 & 0.001 respectively). AST, ALT and direct bilirubin levels were significantly higher in variceal group than controls (P = 0.001, 0.004 & 0.001 respectively). Prothrombin concentration and albumin levels were significantly lower in variceal group than controls (P = 0.001 & 0.01 respectively). Hemoglobin levels were significantly lower in variceal and non-variceal groups than controls (P = 0.01 & 0.001 respectively). No significant differences were present as regards age, sex, height or platelets count between cases (variceal and non-variceal) and controls.

Conclusions

H. pylori infection is significantly higher in children with non-variceal bleeding than controls. No significant difference between children with variceal bleeding and controls. Triad of increased ALT, decreased albumin levels and negative H. pylori infection could be a significant triad in predicting variceal bleeding as a cause of upper GIT bleeding in children.

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding

BACKGROUND

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source.

OBJECTIVE

To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation.

METHODS

A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding.

RESULTS

The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]).

CONCLUSION

Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.