|
1
|
Fujishiro M, Iguchi M, Ono S, Funasaka K, Sakata Y, Mikami T, Kataoka M, Shimaoka S, Michida T, Igarashi Y, Tanaka S. Guidelines for endoscopic management of nonvariceal upper gastrointestinal bleeding (second edition). Dig Endosc 2025; 37:447-469. [PMID: 40114631 DOI: 10.1111/den.15019] [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: 12/18/2024] [Accepted: 02/19/2025] [Indexed: 03/22/2025]
Abstract
The Japan Gastroenterological Endoscopy Society has prepared Guidelines for Endoscopic Practice in Nonvariceal Upper Gastrointestinal Bleeding as part of the initiative to develop evidence-based endoscopic practice guidelines. Hemorrhagic gastroduodenal (peptic) ulcers are the primary cause of nonvariceal upper gastrointestinal bleeding. With the advent of a super-aged society, the cases caused by Helicobacter pylori are on the decline, whereas those caused by drugs (e.g. aspirin) have been increasing. Endoscopic hemostasis is currently the first-line treatment for nonvariceal upper gastrointestinal bleeding, and various methods have been devised for this purpose. It is recommended to stabilize the vital signs of the patient before and after endoscopic hemostasis with appropriate management based on an assessment of the severity of illness, in addition to the administration of acid secretion inhibitors. These guidelines describe the evaluation and initial treatment of nonvariceal upper gastrointestinal bleeding, as well as the selection of endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding and its management after endoscopic hemostasis. This is achieved by classifying nonvariceal upper gastrointestinal bleeding into two main categories, namely, peptic ulcer and other types of gastrointestinal bleeding. We prepared statements for any available literature with supporting evidence, including the levels of evidence and recommendations. New evidence has been pooled since the publication of the first edition in this area; however, the levels of evidence and recommendations mostly remain low.
Collapse
Affiliation(s)
| | | | - Satoshi Ono
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Kohei Funasaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Tatsuya Mikami
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Tomoki Michida
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Shinji Tanaka
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| |
Collapse
|
|
2
|
Thiebaud PC, Wassermann E, de Caluwe M, Prebin C, Noel F, Dechartres A, Raynal PA, Leblanc J, Yordanov Y. Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding. Ann Emerg Med 2025; 85:31-42. [PMID: 39093247 DOI: 10.1016/j.annemergmed.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/17/2024] [Accepted: 06/20/2024] [Indexed: 08/04/2024]
Abstract
STUDY OBJECTIVE Early prognostic stratification could optimize the management of patients with upper gastrointestinal bleeding and reduce unnecessary hospitalizations. The aim of this study was to assess and compare the performance of existing prognostic scores in predicting therapeutic intervention and death. METHODS A systematic search of the literature identified existing prognostic scores. A multicenter retrospective cohort study included adult patients hospitalized for upper gastrointestinal bleeding from January 1, 2019, to December 31, 2020. The primary outcome was a composite including therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or 30-day death. Discrimination performance was estimated by the area under the curve (AUC). The ability to identify low-risk patients was analyzed using sensitivity and negative predictive value (NPV) for defined thresholds. RESULTS The systematic search identified 39 prognostic scores, 12 of which could be analyzed. Among the 990 patients included, therapeutic intervention and/or death occurred in 755 (76.4%) patients. Scores with the highest discriminative performance to predict the primary composite outcome were Glasgow-Blatchford score (GBS) (AUC 0.869 [0.842 to 0.895]), modified GBS (AUC 0.872 [0.847 to 0.898]) and modified GBS 2 (AUC 0.855 [0.827 to 0.884]). The best performance to identify low-risk patients was for GBS≤1 (sensitivity 0.99 [0.99 to 1.00], NPV 0.89 [0.75 to 0.97]) and modified GBS=0 (sensitivity 0.99 [0.98 to 1.00], NPV 0.84 [0.71 to 0.94]). CONCLUSIONS The GBS and the modified GBS are the 2 best performing scores because they achieve both key objectives: stratifying patients based on their risk of therapeutic intervention and/or death and identifying low-risk patients who may qualify for outpatient management.
Collapse
Affiliation(s)
- Pierre-Clément Thiebaud
- Université de Paris Cité, INSERM, UMR-S 942, Improving Emergency Care University Hospital Federation, Paris, France; Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France.
| | - Eliana Wassermann
- AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Unité de recherche clinique de l'Est Parisien, Paris, France
| | - Mathilde de Caluwe
- AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
| | - Clément Prebin
- AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
| | - Florent Noel
- AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
| | - Pierre-Alexis Raynal
- AP-HP.Sorbonne Université, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
| | - Judith Leblanc
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Unité de recherche clinique Est Parisien, Paris, France
| | - Youri Yordanov
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, UMR-S 1136, AP-HP, Hôpital Saint-Antoine, Service d'Accueil des Urgences, Paris, France
| |
Collapse
|
|
3
|
Gao W, Huang YS, Wang YD. Construction and validation of a predictive model for the risk of rebleeding in patients with esophageal and gastric varices hemorrhage. BMC Gastroenterol 2024; 24:471. [PMID: 39716072 DOI: 10.1186/s12876-024-03569-1] [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: 05/08/2024] [Accepted: 12/17/2024] [Indexed: 12/25/2024] Open
Abstract
BACKGROUND AND PURPOSE Esophageal and gastric varices hemorrhage (EGVH) is a life-threatening condition with the 6-week mortality rate of 15-25%. Up to 60% of patients with EGVH may experience rebleeding with a mortality rate of 33%. The existing scoring systems, such as RS scoring system (Rockall score, RS) and GBS scoring system (Glasgow-Blatchford score, GBS), have limitations in predicting the risk of rebleeding. Our study was to construct and validate a novel predictive model for the risk of rebleeding in patients with EGVH and to compare the predictive power of the predictive model with GBS and pRS. METHODS Data of patients with EGVH was collected in the First Affiliated Hospital of Dalian Medical University from January 2016 to June 2020. Binary logistic and stepwise regression was performed to construct a predictive model. We compared the predictive power of the new predictive model to the GBS and pRS scoring systems. RESULTS Clinical data from a total of 265 patients with EGVH was collected. Six factors including systolic blood pressure, transfusion requirement, CA199, platelet count, upper esophageal varices and severity of esophageal varices were included in our new predictive model. The AUCs of the specificity of the predictive model, GBS and pRS are 0.82, 0.60 and 0.56. CONCLUSION This study successfully constructed a predictive model for the risk of rebleeding in patients with EGVH. This predictive model demonstrated higher predictive ability than pRS and GBS scoring systems for assessing rebleeding risk in EGVH patients.
Collapse
Affiliation(s)
- Wei Gao
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116011, China
| | - Yu-Shuang Huang
- Dalian Public Health Clinical Center, Liaoning Province, Dalian, China
| | - Ying-De Wang
- Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, 116011, China.
| |
Collapse
|
|
4
|
Shung DL, Chan CE, You K, Nakamura S, Saarinen T, Zheng NS, Simonov M, Li DK, Tsay C, Kawamura Y, Shen M, Hsiao A, Sekhon JS, Laine L. Validation of an Electronic Health Record-Based Machine Learning Model Compared With Clinical Risk Scores for Gastrointestinal Bleeding. Gastroenterology 2024; 167:1198-1212. [PMID: 38971198 PMCID: PMC11493512 DOI: 10.1053/j.gastro.2024.06.030] [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: 02/13/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND & AIMS Guidelines recommend use of risk stratification scores for patients presenting with gastrointestinal bleeding (GIB) to identify very-low-risk patients eligible for discharge from emergency departments. Machine learning models may outperform existing scores and can be integrated within the electronic health record (EHR) to provide real-time risk assessment without manual data entry. We present the first EHR-based machine learning model for GIB. METHODS The training cohort comprised 2546 patients and internal validation of 850 patients presenting with overt GIB (ie, hematemesis, melena, and hematochezia) to emergency departments of 2 hospitals from 2014 to 2019. External validation was performed on 926 patients presenting to a different hospital with the same EHR from 2014 to 2019. The primary outcome was a composite of red blood cell transfusion, hemostatic intervention (ie, endoscopic, interventional radiologic, or surgical), and 30-day all-cause mortality. We used structured data fields in the EHR, available within 4 hours of presentation, and compared the performance of machine learning models with current guideline-recommended risk scores, Glasgow-Blatchford Score, and Oakland Score. Primary analysis was area under the receiver operating characteristic curve. Secondary analysis was specificity at 99% sensitivity to assess the proportion of patients correctly identified as very low risk. RESULTS The machine learning model outperformed the Glasgow-Blatchford Score (area under the receiver operating characteristic curve, 0.92 vs 0.89; P < .001) and Oakland Score (area under the receiver operating characteristic curve, 0.92 vs 0.89; P < .001). At the very-low-risk threshold of 99% sensitivity, the machine learning model identified more very-low-risk patients: 37.9% vs 18.5% for Glasgow-Blatchford Score and 11.7% for Oakland Score (P < .001 for both comparisons). CONCLUSIONS An EHR-based machine learning model performs better than currently recommended clinical risk scores and identifies more very-low-risk patients eligible for discharge from the emergency department.
Collapse
Affiliation(s)
- Dennis L Shung
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Biomedical Informatics and Data Science, Department of Medicine, Yale School of Medicine, New Haven, Connecticut.
| | - Colleen E Chan
- Department of Statistics and Data Science, Yale University, New Haven, Connecticut
| | - Kisung You
- Department of Mathematics, City University of New York, Baruch College, New York, New York
| | - Shinpei Nakamura
- Department of Statistics and Data Science, Yale University, New Haven, Connecticut
| | - Theo Saarinen
- Department of Statistics, University of Berkeley, Berkeley, California
| | - Neil S Zheng
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Darrick K Li
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Cynthia Tsay
- Department of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Yuki Kawamura
- University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Matthew Shen
- Department of Statistics, University of Berkeley, Berkeley, California
| | - Allen Hsiao
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jasjeet S Sekhon
- Clinical and Translational Research Accelerator, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Political Science, Yale University, New Haven, Connecticut
| | - Loren Laine
- Section of Digestive Diseases, Department of Medicine, Yale School of Medicine, New Haven, Connecticut; West Haven Veterans Affairs Medical Center, West Haven, Connecticut
| |
Collapse
|
|
5
|
Di Gioia G, Sangineto M, Paglia A, Cornacchia MG, Parente F, Serviddio G, Romano AD, Villani R. Limits of pre-endoscopic scoring systems in geriatric patients with upper gastrointestinal bleeding. Sci Rep 2024; 14:20225. [PMID: 39215015 PMCID: PMC11364688 DOI: 10.1038/s41598-024-70577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Abstract
Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admission worldwide and several risk scores have been developed to predict clinically relevant outcomes. Despite the geriatric population being a high-risk group, age is often overlooked in the assessment of many risk scores. In this study we aimed to compare the predictive accuracy of six pre-endoscopic risk scoring systems in a geriatric population hospitalised with UGIB. We conducted a multi-center cross-sectional study and recruited 136 patients, 67 of these were 65-81.9 years old ("< 82 years"), 69 were 82-100 years old ("≥ 82 years"). We performed six pre-endoscopic risk scores very commonly used in clinical practice (i.e. Glasgow-Blatchford Bleeding and its modified version, T-score, MAP(ASH), Canada-United Kingdom-Adelaide, AIMS65) in both age cohorts and compared their accuracy in relevant outcomes predictions: 30-days mortality since hospitalization, a composite outcome (need of red blood transfusions, endoscopic treatment, rebleeding) and length of hospital stay. T-score showed a significantly worse performance in mortality prediction in the "≥ 82 years" group (AUROC 0.53, 95% CI 0.27-0.75) compared to "< 82 years" group (AUROC 0.88, 95% CI 0.77-0.99). In the composite outcome prediction, except for T-score, younger participants had higher sensitivities than those in the "≥ 82 years" group. All risk scores showed low performances in the prediction of length of stay (AUROCs ≤ 0.70), and, except for CANUKA score, there was a significant difference in terms of accuracy among age cohorts. Most used UGIB risk scores have a low accuracy in the prediction of clinically relevant outcomes in the geriatric population; hence novel scores should account for age or advanced age in their assessment.
Collapse
Affiliation(s)
- Giuseppe Di Gioia
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Moris Sangineto
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.
| | - Annalisa Paglia
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- Internal Medicine Unit, Ospedale Vito Fazzi, Lecce, Italy
| | - Maria Giulia Cornacchia
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Gaetano Serviddio
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Antonino Davide Romano
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Rosanna Villani
- Liver Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| |
Collapse
|
|
6
|
Kim HM, Kang D, Park JY, Cho YK, Choi MG, Park JM. Mortality Risk Scoring System in Patients after Bleeding from Cancers in the Upper Gastrointestinal Tract. Gut Liver 2024; 18:222-230. [PMID: 37722853 PMCID: PMC10938150 DOI: 10.5009/gnl230069] [Citation(s) in RCA: 1] [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: 02/24/2023] [Revised: 06/05/2023] [Accepted: 06/15/2023] [Indexed: 09/20/2023] Open
Abstract
Background/Aims : Risk scoring systems for upper gastrointestinal (UGI) bleeding have not been well validated for tumor bleeding. This study aimed to identify risk factors for mortality in patients with UGI cancer bleeding and to develop a predictive model. Methods : Consecutive patients with UGI cancers who underwent esophagogastroduodenoscopy for suspected bleeding were retrospectively included. Patient characteristics, endoscopic findings and 30-day mortality were assessed. A predictive model was made based on risk factors for mortality using logistic regression, and the area under the curve (AUC) of this model was calculated. It was then compared with other risk scoring systems. Results : In a total of 264 patients, 193 had tumor bleeding. Among them, 108 (56.0%), 76 (39.4%), and nine (4.7%) patients received conservative treatment, endoscopic therapy, and non-endoscopic hemostasis, respectively. Rebleeding occurred in 23 (21.3%), 26 (34.2%), and one (11.1%) patient(s), respectively. Our new model is composed of altered mental status, renal failure, rebleeding, age older than 65 years, and low serum albumin (all p<0.05). This model predicted 30-day mortality with an AUC of 0.79 (95% confidence interval, 0.72 to 0.86), which was significantly higher than AUCs of the Glasgow-Blatchford score, Rockall, and AIMS65 score (AUC=0.61, 0.64, and 0.69, respectively, all p<0.05). Conclusions : Our new scoring system provides a better prediction of 30-day mortality than existing scoring systems in patients with UGI cancer bleeding. This new scoring system can be used to predict and prepare these patients who are known to have high mortality.
Collapse
Affiliation(s)
- Hyun Min Kim
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Donghoon Kang
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Young Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Kyung Cho
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Photomedicine Research Institute, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Photomedicine Research Institute, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
|
7
|
Xi D, Garg K, Lambert JS, Rajput-Ray M, Madigan A, Avramovic G, Gilbert L. Scrutinizing Clinical Biomarkers in a Large Cohort of Patients with Lyme Disease and Other Tick-Borne Infections. Microorganisms 2024; 12:380. [PMID: 38399784 PMCID: PMC10893018 DOI: 10.3390/microorganisms12020380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Standard clinical markers can improve tick-borne infection (TBI) diagnoses. We investigated immune and other clinical biomarkers in 110 patients clinically diagnosed with TBIs before (T0) and after antibiotic treatment (T2). At T0, both the initial observation group and patients without seroconversion for tick-borne pathogens exhibited notably low percentages and counts of CD3 percentage (CD3%), CD3+ cells, CD8+ suppressors, CD4 percentage (CD4%), and CD4+ helper cells, with the latter group showing reductions in CD3%, CD3+, and CD8+ counts in approximately 15-22% of cases. Following treatment at the T2 follow-up, patients typically experienced enhancements in their previously low CD3%, CD3+ counts, CD4%, and CD4+ counts; however, there was no notable progress in their low CD8+ counts, and a higher number of patients presented with insufficient transferrin levels. Moreover, among those with negative serology for tick-borne infections, there was an improvement in low CD3% and CD3+ counts, which was more pronounced in patients with deficient transferrin amounts. Among those with CD57+ (n = 37) and CD19+ (n = 101) lymphocyte analysis, 59.46% of patients had a low CD57+ count, 14.85% had a low CD19 count, and 36.63% had a low CD19 percentage (CD19%). Similar findings were observed concerning low CD57+, CD19+, and CD19% markers for negative TBI serology patients. Overall, this study demonstrates that routine standard clinical markers could assist in a TBI diagnosis.
Collapse
Affiliation(s)
- David Xi
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland; (D.X.); (J.S.L.); (G.A.)
| | | | - John S. Lambert
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland; (D.X.); (J.S.L.); (G.A.)
- Infectious Diseases Department, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
- Infectious Diseases Department, The Rotunda Hospital, D01 P5W9 Dublin, Ireland
| | - Minha Rajput-Ray
- Curaidh Clinic: Innovative Solutions for Pain, Chronic Disease and Work Health, Perth PH2 8EH, UK;
| | - Anne Madigan
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland; (D.X.); (J.S.L.); (G.A.)
| | - Gordana Avramovic
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland; (D.X.); (J.S.L.); (G.A.)
| | | |
Collapse
|
|
8
|
Schuster KF, Thompson CC, Ryou M. Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding. Clin Endosc 2024; 57:73-81. [PMID: 37253640 PMCID: PMC10834283 DOI: 10.5946/ce.2022.293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/14/2023] [Accepted: 03/06/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND/AIMS Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model. METHODS A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated. RESULTS All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract. CONCLUSION This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.
Collapse
Affiliation(s)
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Marvin Ryou
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
|
9
|
Alali AA, Boustany A, Martel M, Barkun AN. Strengths and limitations of risk stratification tools for patients with upper gastrointestinal bleeding: a narrative review. Expert Rev Gastroenterol Hepatol 2023; 17:795-803. [PMID: 37496492 DOI: 10.1080/17474124.2023.2242252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Despite advances in the management of patients with upper gastrointestinal bleeding (UGIB), associated morbidity and mortality remain significant. Most patients, however, will experience favorable outcomes without a need for hospital-based interventions. Risk assessment scores may assist in such early risk-stratification. These scales may optimize identification of low-risk patients, resulting in better resource utilization, including a reduced need for early endoscopy and fewer hospital admissions. The aim of this article is to provide an updated detailed review of risk assessment scores in UGIB. AREA COVERED A literature review identified past and currently available pre-endoscopic risk assessment scores for UGIB, with a focus on low-risk prediction. Strengths and weaknesses of the different scales are discussed as well as their impact on clinical decision-making. EXPERT OPINION The current evidence supports using the Glasgow Blatchford Score as it is the most accurate tool available when attempting to identify low-risk patients who can be safely managed on an outpatient basis. Currently, no risk assessment tool appears accurate enough in confidently classifying patients as high risk. Future research should utilize more standardized methodologies, while favoring interventional trial designs to better characterize the clinical impact attributable to the use of such risk stratification schemes.
Collapse
Affiliation(s)
- Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Antoine Boustany
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Myriam Martel
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| |
Collapse
|
|
10
|
Goff S, Friedman E, Toro B, Almonte M, Wilson C, Lu X, Yu D, Friedenberg F. Utility of the CANUKA Scoring System in the Risk Assessment of Upper GI Bleeding. J Clin Gastroenterol 2023; 57:595-600. [PMID: 36730919 DOI: 10.1097/mcg.0000000000001735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 06/13/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The Canada-United Kingdom-Adelaide (CANUKA) score was developed to stratify patients who experience upper gastrointestinal bleeding (UGIB) to predict who could be discharged from the emergency department. Our aim was to determine if the CANUKA score could be utilized for UGIB in-patients undergoing endoscopy in predicting adverse outcomes. We additionally sought to establish a CANUKA score cut point to predict adverse outcomes and in-hospital mortality and compare this to established scoring systems. METHODS Between January 1, 2018 to June 30, 2019 all patients who underwent upper endoscopy after admission for UGIB were identified. We assigned a CANUKA score and compared the area under the receiver operating curve to established scoring systems. RESULTS Our data set included 641 patients, with a mean age of 59.5±14.5 years. A CANUKA score ≥10 was associated with an adverse outcome [unadjusted odds ratio, 3.08 (1.79, 5.27)]. No patients experienced an adverse outcome with a CANUKA score <4. No patients died with a CANUKA score <6. Those with a CANUKA score of <10 had an in-hospital mortality of 2.1% compared with 6.8% for those with a score ≥10 ( P =0.008). AIMS65 had the best area under the receiver operating characteristic curve (0.809) for predicting mortality. CONCLUSIONS The CANUKA score may serve utility as a predictor of adverse outcomes and mortality in patients admitted with UGIB undergoing endoscopy. Future studies, ideally prospective and multicenter, will be needed to validate its clinical utility.
Collapse
Affiliation(s)
| | | | | | | | | | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia PA
| | - Daohai Yu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia PA
| | | |
Collapse
|
|
11
|
Orpen-Palmer J, Stanley AJ. A Review of Risk Scores within Upper Gastrointestinal Bleeding. J Clin Med 2023; 12:3678. [PMID: 37297873 PMCID: PMC10253886 DOI: 10.3390/jcm12113678] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Upper gastrointestinal bleeding is a common medical emergency. Thorough initial assessment and appropriate resuscitation are essential to stabilise the patient. Risk scores provide an important tool to discriminate between lower- and higher-risk patients. Very low-risk patients can be safely discharged for out-patient management, while higher-risk patients can receive appropriate in-patient care. The Glasgow Blatchford Score, with a score of 0-1, performs best in the identification of very low-risk patients who will not require hospital based intervention or die, and is recommended by most guidelines to facilitate safe out-patient management. The performance of risk scores in the identification of specific adverse events to define high-risk patients is less accurate, with no individual score performing consistently well. Ongoing developments in the use of machine learning models and artificial intelligence in predicting poor outcomes in UGIB appear promising and will likely form the basis of dynamic risk assessment in the future.
Collapse
Affiliation(s)
- Josh Orpen-Palmer
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
| | | |
Collapse
|
|
12
|
Pognonec C, Dirhoussi Z, Cury N, Moreau M, Billard C, Yordanov Y, Thiebaud PC. External validation of Glasgow-Blatchford, modified Glasgow-Blatchford and CANUKA scores to identify low-risk patients with upper gastrointestinal bleeding in emergency departments: a retrospective cohort study. Emerg Med J 2023; 40:451-457. [PMID: 37185303 DOI: 10.1136/emermed-2022-213052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Upper gastrointestinal bleeding (UGIB) is a medical emergency with an approximate mortality of 10%, which results in a high hospitalisation rate. The Glasgow-Blatchford score (GBS) is recommended to identify low-risk patients who can be discharged from the emergency department (ED). A modified GBS (mGBS) and CANUKA score have recently been proposed but have not been well studied. The aim of this study was to assess whether the use of GBS, mGBS or CANUKA score could identify patients at low risk of death or need for intervention. METHODS A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Demographic and medical data needed to calculate GBS and CANUKA were collected, as well as outcomes data. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days. In-hospital mortality was also collected. Sensitivity, specificity and predictive values were measured for the score thresholds of interest. RESULTS A total of 386 patients were included. Median age was 60 years (38-78), 65.3% (n=252) were male and 60% (n=233) were hospitalised. A GBS≤1, mGBS=0 and CANUKA≤2 categorised 24.9%, 18.2% and 18.9% of patients as low risk, respectively. There was a need for intervention in 2.2%, 4.6% and 0% of those patients categorised as low risk by GBS, mGBS and CANUKA, respectively. No deaths occurred in the patients identified as low risk, regardless of the score used. All scores had a high sensitivity and negative predictive value. CONCLUSIONS In patients with UGIB, the use of a GBS≤1 or CANUKA score ≤2 appears to be safe for identifying patients at low risk of death or need for intervention.
Collapse
Affiliation(s)
- Célina Pognonec
- Hôpital Cochin, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Université Paris Cité, Paris, France
| | - Zidane Dirhoussi
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
| | - Nicolas Cury
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
| | - Marie Moreau
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
| | - Charlotte Billard
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
| | - Youri Yordanov
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, UMR-S 1136, Sorbonne Universite, Paris, France
| | - Pierre-Clément Thiebaud
- Hôpital Saint-Antoine, Service d'Accueil des Urgences, Assistance Publique - Hôpitaux de Paris, AP-HP.Sorbonne Université, Paris, France
| |
Collapse
|
|
13
|
Allo G, Gillessen J, Gülcicegi D, Kasper P, Chon SH, Goeser T, Bürger M. Comparison of Lactate Clearance with Established Risk Assessment Tools in Predicting Outcomes in Acute Upper Gastrointestinal Bleeding. J Clin Med 2023; 12:jcm12072716. [PMID: 37048800 PMCID: PMC10095270 DOI: 10.3390/jcm12072716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
Early risk stratification is mandatory in acute upper gastrointestinal bleeding (AUGIB) to guide optimal treatment. Numerous risk scores were introduced, but lack of practicability led to limited use in daily clinical practice. Lactate clearance is an established risk assessment tool in a variety of diseases, such as trauma and sepsis. Therefore, this study compares the predictive ability of pre-endoscopic lactate clearance and established risk scores in patients with AUGIB at the University Hospital of Cologne. Active bleeding was detected in 27 (25.2%) patients, and hemostatic intervention was performed in 35 (32.7%). In total, 16 patients (15%) experienced rebleeding and 12 (11.2%) died. Initially, lactate levels were elevated in 64 cases (59.8%), and the median lactate clearance was 18.7% (2.7-48.2%). Regarding the need for endoscopic intervention, the predictive ability of Glasgow Blatchford Score, pre-endoscopic Rockall score, initial lactate and lactate clearance did not differ significantly, and their area under the receiver operating characteristic curves were 0.658 (0.560-0.747), 0.572 (0.473-0.667), 0.572 (0.473-0.667) and 0.583 (0.483-0.677), respectively. Similar results were observed in relation to rebleeding and mortality. In conclusion, lactate clearance had comparable predictive ability compared to established risk scores. Further prospective research is necessary to clarify the potential role of lactate clearance as a reliable risk assessment tool in AUGIB.
Collapse
Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Dilan Gülcicegi
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral and Cancer and Transplant Surgery, University Hospital of Cologne, University of Cologne, 50937 Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| |
Collapse
|
|
14
|
Wakatsuki T, Mannami T, Furutachi S, Numoto H, Umekawa T, Mitsumune M, Sakaki T, Nagahara H, Fukumoto Y, Yorifuji T, Shimizu S. Glasgow‐Blatchford score combined with nasogastric aspirate as a new diagnostic algorithm for patients with nonvariceal upper gastrointestinal bleeding. DEN OPEN 2023; 3:e185. [PMCID: PMC9663679 DOI: 10.1002/deo2.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 10/15/2022] [Accepted: 10/22/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Toshiyuki Wakatsuki
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Tomohiko Mannami
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Shinichi Furutachi
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Hiroki Numoto
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Tsuyoshi Umekawa
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Mayu Mitsumune
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Tsukasa Sakaki
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Hanako Nagahara
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Yasushi Fukumoto
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences Okayama Japan
| | - Shin'ichi Shimizu
- Department of Gastroenterology National Hospital Organization Okayama Medical Center Okayama Japan
| |
Collapse
|
|
15
|
Ungureanu BS, Gheonea DI, Florescu DN, Iordache S, Cazacu SM, Iovanescu VF, Rogoveanu I, Turcu-Stiolica A. Predicting mortality in patients with nonvariceal upper gastrointestinal bleeding using machine-learning. Front Med (Lausanne) 2023; 10:1134835. [PMID: 36873879 PMCID: PMC9982090 DOI: 10.3389/fmed.2023.1134835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/06/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Non-endoscopic risk scores, Glasgow Blatchford (GBS) and admission Rockall (Rock), are limited by poor specificity. The aim of this study was to develop an Artificial Neural Network (ANN) for the non-endoscopic triage of nonvariceal upper gastrointestinal bleeding (NVUGIB), with mortality as a primary outcome. METHODS Four machine learning algorithms, namely, Linear Discriminant Analysis (LDA), Quadratic Discriminant Analysis (QDA), logistic regression (LR), K-Nearest Neighbor (K-NN), were performed with GBS, Rock, Beylor Bleeding score (BBS), AIM65, and T-score. RESULTS A total of 1,096 NVUGIB hospitalized in the Gastroenterology Department of the County Clinical Emergency Hospital of Craiova, Romania, randomly divided into training and testing groups, were included retrospectively in our study. The machine learning models were more accurate at identifying patients who met the endpoint of mortality than any of the existing risk scores. AIM65 was the most important score in the detection of whether a NVUGIB would die or not, whereas BBS had no influence on this. Also, the greater AIM65 and GBS, and the lower Rock and T-score, the higher mortality will be. CONCLUSION The best accuracy was obtained by the hyperparameter-tuned K-NN classifier (98%), giving the highest precision and recall on the training and testing datasets among all developed models, showing that machine learning can accurately predict mortality in patients with NVUGIB.
Collapse
Affiliation(s)
- Bogdan Silviu Ungureanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Dan Ionut Gheonea
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Dan Nicolae Florescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Sevastita Iordache
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Sergiu Marian Cazacu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Vlad Florin Iovanescu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Ion Rogoveanu
- Department of Gastroenterology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| |
Collapse
|
|
16
|
Ando-Matsuoka R, Yagi K, Takaoka M, Sakajiri Y, Shibata T, Sawada R, Maruo A, Miyata K, Aizawa F, Hamano H, Niimura T, Izawa-Ishizawa Y, Goda M, Sakaguchi S, Zamami Y, Yamanishi Y, Ishizawa K. Differential effects of proton pump inhibitors and vonoprazan on vascular endothelial growth factor expression in cancer cells. Drug Dev Res 2023; 84:75-83. [PMID: 36484282 DOI: 10.1002/ddr.22013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 10/24/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Proton pump inhibitors (PPIs) are potent inhibitors of gastric acid secretion, used as first-line agents in treating peptic ulcers. However, we have previously reported that PPIs may diminish the therapeutic effect of anti-vascular endothelial growth factor (VEGF) drugs in patients with cancer. In this study, we explored the effects of vonoprazan, a novel gastric acid secretion inhibitor used for the treatment of peptic ulcers, on the secretion of VEGF in cancer cells and attempted to propose it as an alternative PPI for cancer chemotherapy. The effects of PPI and vonoprazan on VEGF expression in cancer cells were compared by real-time reverse transcription-polymerase chain reaction and ELISA. The interaction of vonoprazan and PPIs with transcriptional regulators by docking simulation analysis. In various cancer cell lines, including the human colorectal cancer cell line (LS174T), PPI increased VEGF messenger RNA expression and VEGF protein secretion, while this effect was not observed with vonoprazan. Molecular docking simulation analysis showed that vonoprazan had a lower binding affinity for estrogen receptor alpha (ER-α), one of the transcriptional regulators of VEGF, compared to PPI. Although the PPI-induced increase in VEGF expression was counteracted by pharmacological ER-α inhibition, the effect of vonoprazan on VEGF expression was unchanged. Vonoprazan does not affect VEGF expression in cancer cells, which suggests that vonoprazan might be an alternative to PPIs, with no interference with the therapeutic effects of anti-VEGF cancer chemotherapy.
Collapse
Affiliation(s)
- Rie Ando-Matsuoka
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Kenta Yagi
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Mayu Takaoka
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yuko Sakajiri
- Department of Bioscience and Bioinformatics, Faculty of Computer Science and Systems Engineering, Kyushu Institute of Technology, Fukuoka, Japan
| | - Tomokazu Shibata
- Department of Bioscience and Bioinformatics, Faculty of Computer Science and Systems Engineering, Kyushu Institute of Technology, Fukuoka, Japan
| | - Ryusuke Sawada
- Department of Bioscience and Bioinformatics, Faculty of Computer Science and Systems Engineering, Kyushu Institute of Technology, Fukuoka, Japan
| | - Akinori Maruo
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Koji Miyata
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Fuka Aizawa
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Hirofumi Hamano
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Takahiro Niimura
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Yuki Izawa-Ishizawa
- Department of Pharmacology, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Mitsuhiro Goda
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan
| | - Satoshi Sakaguchi
- Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Yoshito Zamami
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Yoshihiro Yamanishi
- Department of Bioscience and Bioinformatics, Faculty of Computer Science and Systems Engineering, Kyushu Institute of Technology, Fukuoka, Japan
| | - Keisuke Ishizawa
- Department of Clinical Pharmacology and Therapeutics, University of Tokushima Graduate School of Biomedical Sciences, Tokushima, Japan.,Department of Pharmacy, Tokushima University Hospital, Tokushima, Japan.,Clinical Research Center for Developmental Therapeutics, Tokushima University Hospital, Tokushima, Japan
| |
Collapse
|
|
17
|
Laursen SB, Stanley AJ, Laine L, Schaffalitzky de Muckadell OB. Rebleeding in peptic ulcer bleeding - a nationwide cohort study of 19,537 patients. Scand J Gastroenterol 2022; 57:1423-1429. [PMID: 35853234 DOI: 10.1080/00365521.2022.2098050] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/22/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rebleeding is a frequent complication of peptic ulcer bleeding (PUB). The associated prognosis remains rather unclear because previous studies generally also included non-ulcer lesions. OBJECTIVE We aimed to identify predictors for rebleeding; clarify the prognostic consequence of rebleeding; and develop a score for predicting rebleeding. METHODS Nationwide cohort study of consecutive patients presenting to hospital with PUB in Denmark from 2006-2014. Logistic regression analyses were used to identify predictors for rebleeding, evaluate the association between rebleeding and 30-day mortality, and develop a score to predict rebleeding. Patients with persistent bleeding were excluded. RESULTS Among 19,258 patients (mean age 74 years, mean ASA-score 2.4), 10.8% rebled, and 10.2% died. Strongest predictors for rebleeding were endoscopic high-risk stigmata of bleeding (Odds Ratio (OR): 2.12 [95% Confidence Interval (CI): 1.91-2.36]), bleeding from duodenal ulcers (OR: 1.87 [95% CI: 1.69-2.08]), and presentation with hemodynamic instability (OR: 1.55 [95% CI: 1.38-1.73]). Among patients with all three factors (7.9% of total), 24% rebled, 50% with rebleeding failed endoscopic therapy, and 23% died. Rebleeding was associated with increased mortality (OR: 2.04 [95% CI: 1.78-2.32]). We were unable to develop an accurate score to predict rebleeding. CONCLUSION Rebleeding occurs in ∼10% of patients with PUB and is overall associated with a two-fold increase in 30-day mortality. Patients with hemodynamic instability, duodenal ulcers, and high-risk endoscopic stigmata are at highest risk of rebleeding. When rebleeding occurs in such patients, consultation with surgery and/or interventional radiology should be obtained prior to repeat endoscopy.
Collapse
Affiliation(s)
- Stig B Laursen
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| | - Adrian J Stanley
- Department of Gastroenterology, Walton Building, Glasgow Royal Infirmary, Glasgow, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ove B Schaffalitzky de Muckadell
- Department of Gastroenterology, Odense University Hospital, Odense C, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense C, Denmark
| |
Collapse
|
|
18
|
Jamil Z, Perveen S, Khalid S, Aljuaid M, Shahzad M, Ahmad B, Waheed Y. Child-Pugh Score, MELD Score and Glasgow Blatchford Score to Predict the In-Hospital Outcome of Portal Hypertensive Patients Presenting with Upper Gastrointestinal Bleeding: An Experience from Tertiary Healthcare System. J Clin Med 2022; 11:6654. [PMID: 36431131 PMCID: PMC9693334 DOI: 10.3390/jcm11226654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
The two most familiar scores used for prognostication of liver cirrhosis are the Model for End-stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP), while the Glasgow-Blatchford (GB) score is used for sorting non-variceal upper gastrointestinal hemorrhage into high- or low-risk categories. This study evaluates the validity of the CTP, MELD, and GB scoring systems in prognosticating the in-hospital outcome of bleeding portal hypertensive patients. In this study, the ROC curve and Younden index determine the efficacy of three scoring systems. The results indicate that CTP was the most efficient score as the predictor of outcome (AUC = 0.9, cut-off value > 7); followed by MELD (AUC = 0.8, cut-off value > 18) and then the GB score (AUC = 0.64, cut-off value > 14) (p < 0.05). In pair-wise comparison, the difference between CTP and MELD was insignificant (p > 0.05). Patients with a CTP score of >7 had notably higher in-hospital mortality (19.8% vs. 0.9%, p < 0.0001). Similarly, mortality with a MELD score > 18 was significant (14.8% vs. 5.9% (p < 0.0001). The GB score was not a good indicator of the outcome. Platelets, albumin, CTP, and MELD scores were the independent contributors to mortality. Thus, as liver cirrhosis prognosticators, CTP and MELD scores can also both be used as predictive scores of the in-hospital outcomes of bleeding patients due to portal hypertension. Compared to the GB score, CTP and MELD scores are fairly efficient predictors in these patients.
Collapse
Affiliation(s)
- Zubia Jamil
- Department of Medicine, Foundation University School of Health Sciences, Foundation University Islamabad, DHA Phase I, Islamabad 44000, Pakistan
| | - Shahida Perveen
- Department of Medicine, Foundation University School of Health Sciences, Foundation University Islamabad, DHA Phase I, Islamabad 44000, Pakistan
| | - Samreen Khalid
- Department of Medicine, Foundation University School of Health Sciences, Foundation University Islamabad, DHA Phase I, Islamabad 44000, Pakistan
| | - Mohammed Aljuaid
- Department of Health Administration, College of Business Administration, King Saud University, Riyadh 11587, Saudi Arabia
| | - Memoona Shahzad
- Primary Care, Shoebury Health Center, Campfields Road, Shoeburyness, Southend-on-Sea SS3 9BX, UK
| | - Bashir Ahmad
- Department of Biotechnology, International Islamic University, Islamabad 44000, Pakistan
| | - Yasir Waheed
- Office of Research, Innovation & Commercialization, Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad 44000, Pakistan
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Byblos 1401, Lebanon
| |
Collapse
|
|
19
|
Myneedu K, Gajendran M, Contreras A, Robles A, Ladd AM. A Glasgow-Blatchford Bleeding Score of >2 Is a Poor Predictor of Endoscopic Intervention in Nonvariceal Upper GI Bleeding. South Med J 2022; 115:833-837. [PMID: 36318950 DOI: 10.14423/smj.0000000000001467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Recent data show that a Glasgow-Blatchford Bleeding Score (GBS) >2 does not identify patients with upper gastrointestinal (GI) bleeding who benefit from inpatient esophagogastroduodenoscopy (EGD). This study aimed to determine the rate of endoscopic hemostatic interventions (HI) in patients with nonvariceal acute GI bleeding (NVAUGIB) admitted with a GBS >2. Secondary aims included comparison of clinical outcomes in patients with and without HI and cost of nontherapeutic EGDs. METHODS We conducted a retrospective review of medical records of patients admitted to a referral hospital for NVAUGIB from January 2015 to December 2017. Mortality, blood transfusion rates, length of stay, length of intensive care unit stay, and cost of a nontherapeutic EGD were outcomes of interest. Patients 18 years of age and older of both sexes were included. The accuracy of the GBS >2 cutoff was determined using receiver operating characteristic curve analysis. RESULTS A total of 357 patients were included and only 58 (16.2%) required HI. The area under the curve for GBS >2 as a predictor of HI was 0.57. The performance of HI did not influence mortality (P = 0.33), blood transfusion rates (P = 0.51), length of stay (P = 0.2), or length of intensive care unit stay (P = 0.36). The estimated cost of performing nontherapeutic EGD was approximately $855,000 for the 299 patients who did not need HI. CONCLUSIONS A GBS cutoff of >2 is not an accurate criterion to triage patients with NVAUGIB for inpatient emergent EGD. More clinically meaningful and cost-effective methods to triage these patients are necessary.
Collapse
Affiliation(s)
- Kanchana Myneedu
- From Shrewsbury Internal Medicine, UMass Memorial Health, Shrewsbury, Massachusetts, the Division of Gastroenterology, University of Texas Health Science Center at San Antonio, the Division of Infectious Disease, University of South Florida, Tampa, the Division of Gastroenterology, Texas Tech University Health Sciences Center El Paso, and the Department of Internal Medicine. Division of Gastroenterology, University of New Mexico, Albuquerque
| | - Mahesh Gajendran
- From Shrewsbury Internal Medicine, UMass Memorial Health, Shrewsbury, Massachusetts, the Division of Gastroenterology, University of Texas Health Science Center at San Antonio, the Division of Infectious Disease, University of South Florida, Tampa, the Division of Gastroenterology, Texas Tech University Health Sciences Center El Paso, and the Department of Internal Medicine. Division of Gastroenterology, University of New Mexico, Albuquerque
| | - Alberto Contreras
- From Shrewsbury Internal Medicine, UMass Memorial Health, Shrewsbury, Massachusetts, the Division of Gastroenterology, University of Texas Health Science Center at San Antonio, the Division of Infectious Disease, University of South Florida, Tampa, the Division of Gastroenterology, Texas Tech University Health Sciences Center El Paso, and the Department of Internal Medicine. Division of Gastroenterology, University of New Mexico, Albuquerque
| | - Alejandro Robles
- From Shrewsbury Internal Medicine, UMass Memorial Health, Shrewsbury, Massachusetts, the Division of Gastroenterology, University of Texas Health Science Center at San Antonio, the Division of Infectious Disease, University of South Florida, Tampa, the Division of Gastroenterology, Texas Tech University Health Sciences Center El Paso, and the Department of Internal Medicine. Division of Gastroenterology, University of New Mexico, Albuquerque
| | - Antonio Mendoza Ladd
- From Shrewsbury Internal Medicine, UMass Memorial Health, Shrewsbury, Massachusetts, the Division of Gastroenterology, University of Texas Health Science Center at San Antonio, the Division of Infectious Disease, University of South Florida, Tampa, the Division of Gastroenterology, Texas Tech University Health Sciences Center El Paso, and the Department of Internal Medicine. Division of Gastroenterology, University of New Mexico, Albuquerque
| |
Collapse
|
|
20
|
Sasaki Y, Abe T, Kawamura N, Keitoku T, Shibata I, Ohno S, Ono K, Makishima M. Prediction of the need for emergency endoscopic treatment for upper gastrointestinal bleeding and new score model: a retrospective study. BMC Gastroenterol 2022; 22:337. [PMID: 35820868 PMCID: PMC9277905 DOI: 10.1186/s12876-022-02413-8] [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: 05/18/2022] [Accepted: 07/05/2022] [Indexed: 12/02/2022] Open
Abstract
Background Gastrointestinal bleeding is one of the major gastrointestinal diseases. In this study, our objective was to compare Glasgow-Blatchford score (GBS), AIMS65 score, MAP score, Modified GBS, and Iino score as outcome measures for upper gastrointestinal bleeding. In addition, we extracted factors associated with hemostatic procedures including endoscopy, and proposed a new robust score model. Methods From January 2015 to December 2019, 675 patients with symptoms such as hematemesis who visited the National Hospital Organization Disaster Medical Center and underwent urgent upper endoscopy with diagnosis of suspected non-variceal upper gastrointestinal bleeding were retrospectively reviewed. We evaluated the GBS, AIMS65 score, MAP score, Modified GBS, and Iino score, and assessed the outcomes of patients requiring hemostatic treatments at the subsequent emergency endoscopy. We performed logistic regression analysis of factors related to endoscopic hemostasis and upper gastrointestinal bleeding, created a new score model, and evaluated the prediction of hemostatic treatment and mortality in the new score and the existing scores. Results The factors associated with endoscopic treatment were hematemesis, heart rate, HB (hemoglobin), blood pressure, blood urea nitrogen (BUN). Based on these predictors and the partial regression coefficients, a new score named H3B2 (using the initial letters of hematemesis, heart rate, HB, blood pressure, and BUN) was generated. H3B2 score was slightly more discriminatory compared to GBS and Modified GBS (area under the receiver operating characteristic curves (AUROC): 0.73 versus 0.721 and 0.7128, respectively) in predicting hemostatic treatment in emergency endoscopy. The H3B2 score also showed satisfactory prediction accuracy for subsequent deaths (AUROC: 0.6857. P < 0.001). Conclusions We proposed a new score, the H3B2 score, consisting of simple and objective indices in cases of suspected upper gastrointestinal bleeding. The H3B2 score is useful in identifying high-risk patients with suspected upper gastrointestinal bleeding who require urgent hemostatic treatment including emergency endoscopy.
Collapse
Affiliation(s)
- Yoshihiro Sasaki
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan. .,Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Tomoko Abe
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Norio Kawamura
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Taisei Keitoku
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Isamu Shibata
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Shino Ohno
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Keiichi Ono
- Department of Gastroenterology, National Disaster Medical Center, 3256 Midoricho, Tachikawa-shi, Tokyo, 190-0014, Japan
| | - Makoto Makishima
- Division of Biochemistry, Department of Biomedical Sciences, Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| |
Collapse
|
|
21
|
Dogru U, Yuksel M, Ay MO, Kaya H, Ozdemır A, Isler Y, Bulut M. The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study. SAO PAULO MED J 2022; 140:531-539. [PMID: 35544884 PMCID: PMC9491474 DOI: 10.1590/1516-3180.2021.0735.13102021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/13/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients. OBJECTIVE To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding. DESIGN AND SETTING Prospective cohort study in an emergency department in Bursa, Turkey. METHODS Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated. RESULTS A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001). CONCLUSION The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.
Collapse
Affiliation(s)
- Umran Dogru
- MD. Emergency Medicine Specialist, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Melih Yuksel
- MD. Associate Professor of Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Mehmet Oguzhan Ay
- MD. Associate Professor of Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Halil Kaya
- MD. Professor of Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Aksel Ozdemır
- MD. Emergency Medicine Specialist, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Yesim Isler
- MD. Emergency Medicine Specialist, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Mehtap Bulut
- MD. Professor of Emergency Medicine, Department of Emergency Medicine, University of Health Sciences, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| |
Collapse
|
|
22
|
Jo N, Oh J, Kang H, Lim TH, Ko BS. Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding. Clin Exp Emerg Med 2022; 9:101-107. [PMID: 35692092 PMCID: PMC9288874 DOI: 10.15441/ceem.21.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB). Methods A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed. Results In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively. Conclusion The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.
Collapse
Affiliation(s)
- Namwoo Jo
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, Hanyang University College of Medicine, Seoul, Korea
| |
Collapse
|
|
23
|
Benedeto-Stojanov D, Bjelaković M, Stojanov D, Aleksovski B. Prediction of in-hospital mortality after acute upper gastrointestinal bleeding: cross-validation of several risk scoring systems. J Int Med Res 2022; 50:3000605221086442. [PMID: 35301889 PMCID: PMC8943321 DOI: 10.1177/03000605221086442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We aimed to identify the clinical, biochemical, and endoscopic features associated with in-hospital mortality after acute upper gastrointestinal bleeding (AUGIB), focusing on cross-validation of the Glasgow-Blatchford score (GBS), full Rockall score (RS), and Cedars-Sinai Medical Center Predictive Index (CSMCPI) scoring systems. METHODS Our prospective cross-sectional study included 156 patients with AUGIB. Several statistical approaches were used to assess the predictive accuracy of the scoring systems. RESULTS All three scoring systems were able to accurately predict in-hospital mortality (area under the receiver operating characteristic curve [AUC] > 0.9); however, the multiple logistic model separated the presence of hemodynamic instability (state of shock) and the CSMCPI as the only significant predictive risk factors. In compliance with the overall results, the CSMCPI was consistently found to be superior to the other two systems (highest AUC, highest sensitivity and specificity, highest positive and negative predictive values, highest positive likelihood ratio, lowest negative likelihood ratio, and 1-unit increase in CSMCPI associated with 6.3 times higher odds of mortality), outperforming the GBS and full RS. CONCLUSIONS We suggest consideration of the CSMCPI as a readily available and reliable tool for accurately predicting in-hospital mortality after AUGIB, thus providing an essential backbone in clinical decision-making.
Collapse
Affiliation(s)
| | - Milica Bjelaković
- Clinic of Gastroenterology and Hepatology, Clinical Center Niš, 18000 Niš, Serbia
| | | | - Boris Aleksovski
- Ss. Cyril and Methodius University in Skopje, Faculty of Natural Sciences and Mathematics-Skopje, Institute of Biology, Arhimedova 3, PO Box 162, 1000 Skopje, North Macedonia
| |
Collapse
|
|
24
|
AIMS65 predicts prognosis of patients with duodenal ulcer bleeding; a comparison with other risk-scoring systems. Eur J Gastroenterol Hepatol 2021; 33:1480-1484. [PMID: 33252414 DOI: 10.1097/meg.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Duodenal ulcer bleeding has a higher risk of mortality than bleeding from other portions of the gastrointestinal tract. AIMS65 is an effective risk-scoring system to predict prognosis of upper gastrointestinal bleeding and can be easily calculated without endoscopic findings. In this study, we investigate the usefulness of AIMS65 to predict prognosis of patients with duodenal ulcer bleeding. METHODS Two hundred and fifty-five patients with endoscopically diagnosed duodenal ulcer bleeding at Kurashiki Central hospital from July 2007 to June 2017 were studied. We compared AIMS65, Glasgow Blatchford score (GBS), admission Rockall, and full Rockall scoring systems for predicting in-hospital mortality by calculating area under the receiver operating characteristic curve (AUROC). RESULTS In-hospital mortality due to duodenal ulcer bleeding occurred in 17 (6.7%). Scores of all scoring systems were significantly higher in patients with in-hospital mortality than in patients without it. AUROC values for predicting in-hospital mortality was 0.83 in AIMS65, 0.74 in GBS, 0.76 in admission Rockall score, and 0.82 in full Rockall score, a statistically insignificant difference among the systems. In AIMS65, score more than or equal to 2 was an optimal value to predict in-hospital mortality, with sensitivities of 88.2% and specificities of 59.7%, respectively. CONCLUSIONS AIMS65 predicted in-hospital mortality of patients with duodenal ulcer bleeding as accurately as did other scoring systems. Given its simplicity of calculation, AIMS65 may be a more clinically practical system in the management of bleeding duodenal ulcer patients.
Collapse
|
|
25
|
Carlsen NV, Laursen SB, Schaffalitzky de Muckadell OB. Hypotension develops one to two hours before other symptoms in peptic ulcer rebleeding; a matched cohort study. Scand J Gastroenterol 2021; 56:1011-1016. [PMID: 34282993 DOI: 10.1080/00365521.2021.1948607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rebleeding is a frequent complication of peptic ulcer bleeding (PUB) and is associated with increased mortality. Blood pressure and heart rate are two easy non-invasive measurements to evaluate the hemodynamics and therefore a standard observation during hospitalization. OBJECTIVE We aimed to investigate the dynamics of systolic blood pressure and heart rate up to time of peptic ulcer rebleeding. DESIGN Retrospective matched cohort study. Hemodynamics in patients with peptic ulcer rebleeding was compared to hemodynamics in a matched control group consisting of patients with PUB without rebleeding. Blood pressure and heart rate in the six hours up to diagnosis of rebleeding was compared with baseline in the case cohort as well as with the matched control group. RESULTS Thirty-eight patients with peptic ulcer rebleeding and 66 controls were included. Mean age was 75 years, 62% were males and 30-day mortality was 23%. Baseline systolic blood pressure in cases was 114 mmHg. Compared to baseline, we found significant decrease in systolic blood pressure two hours before rebleeding (4 mmHg; p = 0.041) and one hour before rebleeding (14 mmHg; p = 0.0002). Mean systolic blood pressure 30 min before rebleeding was 89 mmHg. No significant change was found in heart rate (p = 0.99). In the control group no change was found in systolic blood pressure or heart rate. CONCLUSION In patients with peptic ulcer rebleeding, hypotension develops 1-2 h before other symptoms of rebleeding. Thus, close monitoring of blood pressure is needed in order to ensure early identification of rebleeding in high-risk patients.
Collapse
Affiliation(s)
- Nikolaj Vestergaard Carlsen
- Department of Clinical Research, University of Southern Denmark, Odence, Denmark.,Department of Gastroenterology S, Odense University Hospital, Odence C, Denmark
| | | | | |
Collapse
|
|
26
|
Ejtehadi F, Sivandzadeh GR, Hormati A, Ahmadpour S, Niknam R, Pezeshki Modares M. Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review. Middle East J Dig Dis 2021; 13:177-185. [PMID: 36606214 PMCID: PMC9489462 DOI: 10.34172/mejdd.2021.223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/02/2021] [Indexed: 01/07/2023] Open
Abstract
Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.
Collapse
Affiliation(s)
- Fardad Ejtehadi
- Associate Professor of Medicine, Gastroentrohepatology Research Center, Namazi Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Gholam Reza Sivandzadeh
- Assistant Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ahmad Hormati
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sajjad Ahmadpour
- Assistant Professor of Radiopharmacy, Gastroenterology and Hepatology Diseases Research Center, Qom University of Medical Sciences, Qom, Iran
| | - Ramin Niknam
- Associate Professor of Medicine, Gatroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Pezeshki Modares
- Assistant professor of Gastroenterology, Gastrointestinal and Liver Diseases Research Center, Firozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
|
27
|
Galusko V, Protty M, Haboubi HN, Verhemel S, Bundhoo S, Yeoman AD. Endoscopy findings in patients on dual antiplatelet therapy following percutaneous coronary intervention. Postgrad Med J 2021; 98:591-597. [PMID: 33879553 DOI: 10.1136/postgradmedj-2021-139928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/01/2021] [Accepted: 04/06/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE OF STUDY This study examines the associations between dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB), to explore possible predictors of outcomes. STUDY DESIGN Retrospective analysis of 3342 patients who underwent PCI between 1 August 2011 and 31 December 2018 in a single centre was carried out. Oesophagogastroduodenoscopies (OGDs) for patients 12 months post-PCI were analysed. RESULTS Blood loss occurred in 2% of all (3342) patients post-PCI within 12 months. 128 patients (63% male, mean age (SD) of 69.8 (10) years) who had PCI subsequently underwent an OGD within 12 months of the index PCI procedure. GIB occurred within the first 30 days of DAPT in 36% (n=13/36) of cases. There were no thrombotic events associated with cessation of one antiplatelet agent. Increased age, haemoglobin (Hb) ≤109 g/L and Glasgow-Blatchford score ≥8 were associated with increased 12-month mortality. An Hb drop of ≥30 g/L was a sensitive and specific marker for significant pathology and evidence of bleeding on OGD (sensitivity=0.83, specificity=0.81). CONCLUSIONS GIB bleeding occurred infrequently in the patients post-PCI on DAPT. Risk assessment scores (such as Glasgow-Blatchford and Rockall scores) are useful tools to assess the urgency of OGD and need for endoscopic therapy.
Collapse
Affiliation(s)
- Victor Galusko
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Majd Protty
- Department of Cardiology, Royal Gwent Hospital, Newport, UK.,Systems Immunity University Research Institute, Cardiff University, Cardiff, UK
| | - Hasan N Haboubi
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Sarah Verhemel
- Department of Cardiology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Shantu Bundhoo
- Department of Cardiology, Royal Gwent Hospital, Newport, UK
| | - Andrew D Yeoman
- Department of Gastroenterology, Royal Gwent Hospital, Newport, UK
| |
Collapse
|
|
28
|
Mishra S, Kumar P, Sasmal PK, Mishra TS. Iatrogenic injury of duodenum: malady of a therapeutic misadventure. BMJ Case Rep 2021; 14:14/4/e242294. [PMID: 33858906 PMCID: PMC8054064 DOI: 10.1136/bcr-2021-242294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.
Collapse
Affiliation(s)
- Swastik Mishra
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Pankaj Kumar
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - Prakash Kumar Sasmal
- Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | | |
Collapse
|
|
29
|
Laursen SB, Oakland K, Laine L, Bieber V, Marmo R, Redondo-Cerezo E, Dalton HR, Ngu J, Schultz M, Soncini M, Gralnek I, Jairath V, Murray IA, Stanley AJ. ABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study. Gut 2021; 70:707-716. [PMID: 32723845 DOI: 10.1136/gutjnl-2019-320002] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Existing scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB. DESIGN AND SETTING International cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score's performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk. PARTICIPANTS AND RESULTS We included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81-84) than existing scores (AUROCs: 0.65-0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4-7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p<0.001). In LGIB, patients with low, medium and high ABC scores had in-hospital mortality rates of 0.6%, 6.3% and 18%, respectively. CONCLUSIONS In contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.
Collapse
Affiliation(s)
- Stig Borbjerg Laursen
- Department of Medical Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare UK, London, UK
| | - Loren Laine
- Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Vered Bieber
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Riccardo Marmo
- Gastroenterology Unit, Azienda Sanitaria Locale Salerno, Polla Sa, Italy
| | - Eduardo Redondo-Cerezo
- Department of Gastroenterology, University Hospital Centre Virgen de las Nieves, Granada, Spain
| | - Harry R Dalton
- Gastroenterology Unit, Royal Cornwall Hospital, Truro, UK
| | - Jeffrey Ngu
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Michael Schultz
- Department of Medicine, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
- Gastroenterology Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Marco Soncini
- Department of Internal Medicine, Alessandro Manzoni Hospital, Lecco, Italy
| | - Ian Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Vipul Jairath
- Department of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
| | - Iain A Murray
- Gastroenterology Unit, Royal Cornwall Hospital, Truro, UK
| | | |
Collapse
|
|
30
|
Gong EJ, Hsing LC, Seo HI, Seo M, Jun BG, Park JK, Lee SJ, Han KH, Kim YD, Jeong WJ, Cheon GJ, Kim MJ. Selected nasogastric lavage in patients with nonvariceal upper gastrointestinal bleeding. BMC Gastroenterol 2021; 21:113. [PMID: 33676407 PMCID: PMC7937281 DOI: 10.1186/s12876-021-01690-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/24/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Risk stratification before endoscopy is crucial for proper management of patients suspected as having upper gastrointestinal bleeding (UGIB). There is no consensus regarding the role of nasogastric lavage for risk stratification. In this study, we investigated the usefulness of nasogastric lavage to identify patients with UGIB requiring endoscopic examination. METHODS From January 2017 to December 2018, patients who visited the emergency department with a clinical suspicion of UGIB and who underwent nasogastric lavage before endoscopy were eligible. Patients with esophagogastric variceal bleeding were excluded. The added predictive ability of nasogastric lavage to the Glasgow-Blatchford score (GBS) was estimated using category-free net reclassification improvement and integrated discrimination improvement. RESULTS Data for 487 patients with nonvariceal UGIB were analyzed. The nasogastric aspirate was bloody in 67 patients (13.8 %), coffee-ground in 227 patients (46.6 %), and clear in 193 patients (39.6 %). The gross appearance of the nasogastric aspirate was associated with the presence of UGIB. Model comparisons showed that addition of nasogastric lavage findings to the GBS improved the performance of the model to predict the presence of UGIB. Subgroup analysis showed that nasogastric lavage improved the performance of the prediction model in patients with the GBS ≤ 11, whereas no additive value was found when the GBS was greater than 11. CONCLUSIONS Nasogastric lavage is useful for predicting the presence of UGIB in a subgroup of patients, while its clinical utility is limited in high-risk patients with a GBS of 12 or more.
Collapse
Affiliation(s)
- Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Li-Chang Hsing
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Hyun Il Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea. .,Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, 38 Bangdong-gil, Sacheon-Myeon, Gangwon-do, 25440, Gangneung, Korea.
| | - Myeongsook Seo
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Baek Gyu Jun
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Jong Kyu Park
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Jin Lee
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Koon Hee Han
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Young Don Kim
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Woo Jin Jeong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| |
Collapse
|
|
31
|
Hreinsson JP, Jonsson A, Bjornsson ES. Acute upper gastrointestinal bleeding: a population-based, five-year follow-up study. Scand J Gastroenterol 2021; 56:1-5. [PMID: 33226862 DOI: 10.1080/00365521.2020.1849384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Data on long-term rebleeding risk and mortality in acute upper gastrointestinal bleeding (AUGIB) patients are scarce and comparison to controls are lacking. Aimsof the study were to assess long-term prognosis of AUGIB patients and compare to controls. METHODS A population-based retrospective case-control study conducted at the National University Hospital of Iceland and included all patients who underwent endoscopy in 2010-2011. AUGIB was defined as haematemesis or coffee ground vomiting leading to hospitalization or occurring in a hospitalized patient. Controls underwent endoscopy in 2010-2011, matched for sex/age. Rebleeding was defined as AUGIB >14 days up to five years after index bleeding. RESULTS Overall, 303 patients had AUGIB, mean age 67 (±18), controls66 years (±19), females, 51 and 46%, respectively. The five-year rebleeding rate for AUGIB patients was 13% (95%CI 9-17%), higher than the rate of bleeding events in controls, 3% (95%CI 1-5%; log-rank <0.001), hazard ratio (HR) 6.0 (95%CI 2.4-15) when correcting for comorbidities, NSAID's, PPI's and antithrombotics. The mortality of AUGIB patients at end of follow-up was higher when compared to controls, 39% (95%CI 49-33%) vs. 26% (95%CI 30-21%), log-rank <0.001, comorbidity-adjusted HR 1.4 (1.1-1.9). A subanalysis of non-variceal AUGIB yielded similar results in regard to rebleeding and mortality rates. CONCLUSIONS AUGIB patients were at 6-fold risk of rebleeding compared to bleeding events in controls at five years of follow-up. Five-year mortality was higher in AUGIB patients when compared to controls even when correcting for age and comorbidities, suggesting that an episode of AUGIB indicates serious frailty.
Collapse
Affiliation(s)
- Johann P Hreinsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Armann Jonsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Einar S Bjornsson
- Department of Internal Medicine, Section of Gastroenterology and Hepatology, The National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| |
Collapse
|
|
32
|
Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure. J Clin Med 2020; 9:jcm9124083. [PMID: 33348860 PMCID: PMC7766138 DOI: 10.3390/jcm9124083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.
Collapse
|
|
33
|
Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Expert Rev Gastroenterol Hepatol 2019; 13:1161-1167. [PMID: 31791160 DOI: 10.1080/17474124.2019.1698292] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/25/2019] [Indexed: 12/13/2022]
Abstract
Introduction: Acute upper-gastrointestinal bleeding (AUGIB) is a common medical emergency, with an incidence of 103-172 per 100,000 in the United Kingdom (UK) and mortality of 2% to 10%. Early and accurate prediction of the severity of an AUGIB episode may help guide management, including in or outpatient management, level of care required, and timing of endoscopy. This article aims to address the clinical utility of the various pre-endoscopic risk assessment tools used in AUGIB.Areas covered: The authors undertook a literature review of the current evidence on the pre-endoscopic risk assessment scores. Additional the authors discuss the recently published novel risk assessment scores.Expert opinion: The evidence shows that GBS is the most clinically useful risk assessment score in correctly identifying very low-risk patients suitable for outpatient management. At present, research is ongoing to assess machine learning in the assessment of patients presenting with AUGIB. More research is needed but it shows promise for the future.
Collapse
Affiliation(s)
- Jennifer Tham
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Adrian Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| |
Collapse
|
|
34
|
|
|
35
|
Chandnani S, Rathi P, Udgirkar SS, Sonthalia N, Contractor Q, Jain S. CLINICAL UTILITY OF RISK SCORES IN VARICEAL BLEEDING. ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:286-293. [PMID: 31633727 DOI: 10.1590/s0004-2803.201900000-54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.
Collapse
Affiliation(s)
- Sanjay Chandnani
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Pravin Rathi
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | | | - Nikhil Sonthalia
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Qais Contractor
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Samit Jain
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| |
Collapse
|
|
36
|
Chaudhary S, Stanley AJ. Optimal timing of endoscopy in patients with acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol 2019; 42-43:101618. [PMID: 31785731 DOI: 10.1016/j.bpg.2019.05.005] [Citation(s) in RCA: 6] [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: 01/05/2019] [Accepted: 05/23/2019] [Indexed: 01/31/2023]
Abstract
Endoscopy is the gold standard for evaluating and treating acute upper gastrointestinal bleeding (UGIB). The optimal timing of endoscopy is a very important consideration in the overall management of UGIB, but there is on going uncertainty regarding timing of the procedure, particularly in those with more severe bleeding. This is reflected by inconsistencies between current guidelines. Although evidence suggests endoscopy should be undertaken within 24 h for all admitted patients with UGIB, a small group of patients with severe bleeding or high-risk features may require more urgent endoscopy. The exact timing of the procedure in this high-risk group remains unclear, with recent data suggesting that performing endoscopy too early may be associated with worse outcome. In this article we examine the evidence for optimal timing of endoscopy in patients presenting with UGIB and suggest a clinical approach to this important aspect of patient management.
Collapse
|
|
37
|
Shung D, Simonov M, Gentry M, Au B, Laine L. 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: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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.
Collapse
Affiliation(s)
- Dennis Shung
- Yale School of Medicine Section of Digestive Diseases, P.O. Box 208019, New Haven, CT, 06520-8019, USA.
| | - Michael Simonov
- Yale School of Medicine Section of Digestive Diseases, P.O. Box 208019, New Haven, CT, 06520-8019, USA
| | - Mark Gentry
- Yale School of Medicine Section of Digestive Diseases, P.O. Box 208019, New Haven, CT, 06520-8019, USA
| | - Benjamin Au
- Yale School of Medicine Section of Digestive Diseases, P.O. Box 208019, New Haven, CT, 06520-8019, USA
| | - Loren Laine
- Yale School of Medicine Section of Digestive Diseases, P.O. Box 208019, New Haven, CT, 06520-8019, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| |
Collapse
|
|
38
|
Oakland K. Risk stratification in upper and upper and lower GI bleeding: Which scores should we use? Best Pract Res Clin Gastroenterol 2019; 42-43:101613. [PMID: 31785738 DOI: 10.1016/j.bpg.2019.04.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/15/2019] [Indexed: 02/07/2023]
Abstract
Risk assessment is widely used in upper gastrointestinal bleeding (UGIB) however no score accurately predicts all important clinical outcomes. This review discusses the performance of the Rockall score, pre-endsocopy Rockall score, Glasgow-Blatchford score, AIMS-65 and newer scores such as Progetto Nazionale Emorragia Digestiva and CANUKA scores. The quality of external validation varies considerably for each score. There is a relative lack of risk scores available for use in lower GI bleeding (LGIB) but recent developments have focussed on the identification of low risk patients. The BLEED, NOBLADS, Strate and Sengupta scores have been developed to predict severe bleeding or death, each with varying performance. The Oakland score has been developed to identify patients at low risk of adverse outcomes who may be suitable for outpatient management. The comparative performance of the LGIB scores and Rockall, Glasgow-Blatchford and AIMS-65 in the prediction of outcomes in LGIB is also discussed.
Collapse
Affiliation(s)
- Kathryn Oakland
- Digestive Diseases and Renal Department, HCA Healthcare UK, 242 Marylebone Road, London, NW1 6JL, United Kingdom.
| |
Collapse
|
|
39
|
Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study. Indian J Gastroenterol 2019; 38:158-166. [PMID: 30830583 DOI: 10.1007/s12664-018-0928-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/19/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores like Glasgow-Blatchford bleeding score (GBS), modified Glasgow-Blatchford bleeding score (mGBS), full Rockall score (FRS) including endoscopic findings, clinical Rockall score (CRS), and albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 (AIMS65) are used for risk stratification in patients with upper gastrointestinal bleeding (UGIB). The utility of these scores in variceal UGIB (VUGIB) is not well defined. In this prospective study, we aimed to assess the performance of these scores in patients with non-variceal (NVUGIB) and VUGIB. METHODS We included 1011 patients (during March 2017 and August 2018) including 439 with NVUGIB and 572 VUGIB. Performance of GBS, mGBS, FRS, CRS, and AIMS65 for various outcome measures was analyzed using the area under receiver operator characteristic curve (AUROC). RESULTS The accuracy of prognostic scores in predicting the composite outcome including the need of hospital-based intervention and 42-day mortality was higher in NVUGIB as compared with VUGIB, AUROC: CRS: 0.641 vs. 0.537; FRS: 0.669 vs. 0.625; GBS: 0.719 vs. 0.587; mGBS: 0.711 vs. 0.594; AIMS65: 0.567 vs. 0.548. GBS and mGBS at a cut-off score of 1 had the highest negative predictive value, 91.7% and 91.3%, respectively, for predicting composite outcome in NVUGIB. Similarly, these scores had better accuracy for predicting 42-day rebleeding in NVUGIB as compared to VUGIB, AUROC: CRS: 0.680 vs. 0.537; FRS: 0.698 vs. 0.565; GBS: 0.661 vs. 0.543; mGBS: 0.627 vs. 0.540; AIMS65: 0.695 vs. 0.606. CONCLUSION The prognostic scores such as CRS, FRS, GBS, mGBS, and AIMS65 predict the need for hospital-based management, rebleeding, and mortality better among patients with NVUGIB than VUGIB.
Collapse
|
|
40
|
Abstract
Upper gastrointestinal bleeding (UGIB) is a common medical emergency, with a reported mortality of 2-10%. Patients identified as being at very low risk of either needing an intervention or death can be managed as outpatients. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are recommended. After resuscitation is initiated, proton pump inhibitors (PPIs) and the prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis. Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices) and for high risk non-variceal bleeding (for example, injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel). Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs. Recurrent ulcer bleeding is treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery. Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt. In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early.
Collapse
Affiliation(s)
- Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK
| | - Loren Laine
- Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut, CT 06520, USA
| |
Collapse
|
|
41
|
Clinical Outcomes of Patients with Non-ulcer and Non-variceal Upper Gastrointestinal Bleeding: A Prospective Multicenter Study of Risk Prediction Using a Scoring System. Dig Dis Sci 2018; 63:3253-3261. [PMID: 30132232 DOI: 10.1007/s10620-018-5255-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/16/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS Compared with ulcer bleeding (UB) in non-variceal upper gastrointestinal bleeding (NVUGIB), non-ulcer bleeding (NUB) is often considered to have a low risk of poor outcomes and is treated less intensively without any risk stratification. We conducted this study to assess the predictability of scoring systems for NUB and compare the outcomes of NUB and UB. METHODS A total of 1831 UGIB patients were registered in the database during the period from February 2011 to December 2013. Among them, 1424 patients with NVUGIB were divided into two groups: Group UB (1101 patients with peptic ulcer bleeding) and Group NUB (323 patients with non-peptic ulcer-related bleeding). RESULTS The most common cause of bleeding in Group NUB was Mallory-Weiss tears (51.1%), followed by Dieulafoy lesions (18.9%). A receiver operating characteristic (ROC) analysis revealed that the pre-Rockall score [area under the ROC (AUROC) = 0.798; 95% CI 0.707-0.890] and full Rockall score (AUROC = 0.794; 95% CI 0.693-0.895) were relatively good at predicting overall mortality in NUB. Glasgow-Blatchford score (AUROC = 0.783; 95% CI 0.730-0.836) was the most closely correlated with the need for clinical intervention in NUB. Those who had Glasgow-Blatchford score of 0 did not require any interventions, including blood transfusions. There were no statistical differences in overall mortality (p = 0.387), bleeding-related mortality (p = 0.447), or the incidence of re-bleeding (p = 0.117) between the two groups. CONCLUSIONS Scoring systems are useful to predict mortality and the need for clinical intervention in patients with NUB.
Collapse
|
|
42
|
Wang F, Cui S, Wang F, Li F, Tang F, Zhang X, Gao Y, Lv H. Different scoring systems to predict 6-week mortality in cirrhosis patients with acute variceal bleeding: a retrospective analysis of 202 patients. Scand J Gastroenterol 2018; 53:885-890. [PMID: 29911438 DOI: 10.1080/00365521.2018.1481518] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Determine the optimal scoring system for evaluation of 6-week bleeding-related mortality in liver cirrhosis patients with acute variceal bleeding (AVB). Prediction effects of six scoring systems, AIMS65 score, Glasgow-Blatchford (GBS) score, full Rockall (FRS) score, the model for end-stage liver disease (MELD), the MELD-Na model and the Child-Turcotte-Pugh (CTP) score were analyzed in this study. METHODS A total of 202 liver cirrhosis patients with AVB were enrolled between 1 January 2014, and 31 December 2014. All subjects were scored according to AIMS65, GBS, FRS, MELD, MELD-Na and CTP scoring systems on the first day of admission. The primary endpoint of the study was 6-week mortality. The prediction effect of these scoring systems for 6-week mortality was compared by ROC curve and the area under the curve (AUC). RESULTS The scores of nonsurvival group evaluated by the AIMS65, GBS, FRS, MELD, MELD-Na and CTP (2.6 ± 1.1, 12.9 ± 2.7, 6.6 ± 1.8, 26.9 ± 6.5, 31.6 ± 9.3, 9.6 ± 2.2, respectively) were higher than those of the survival group (1.2 ± 1.1, 10.2 ± 3.4, 5.1 ± 1.6, 21.0 ± 6.4, 22.8 ± 8.2, 7.7 ± 2.0, respectively) (p < .01). The values of AUC and Youden index of AIMS65 and MELD-Na scoring systems [(0.808, 0.453) and (0.781, 0.516), respectively] were superior to those of MELD (0.761, 0.454), CTP (0.748, 0.399), FRS (0.738, 0.358) and GBS scoring systems (0.726, 0.370). CONCLUSIONS AIMS65 and MELD-Na scoring systems are recommended for evaluation of 6-week bleeding-related mortality in liver cirrhosis patients with AVB.
Collapse
Affiliation(s)
- Fang Wang
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Shu Cui
- b The Third Central Clinical College of Tianjin Medical University , Tianjin Third Central Hospital , Tianjin , China
| | - Fengmei Wang
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Fenghui Li
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Fei Tang
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Xu Zhang
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Yanying Gao
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| | - Hongmin Lv
- a Department of Gastroenterology and Hepatology of Tianjin Third Central Hospital , Tianjin Institute of Hepatobiliary Disease, Tianjin Key Laboratory of Artificial Cell, Artificial Cell Engineering Technology Research Center of Public Health Ministry , Tianjin , China
| |
Collapse
|
|
43
|
Cúrdia Gonçalves T, Barbosa M, Xavier S, Boal Carvalho P, Firmino Machado J, Magalhães J, Marinho C, Cotter J. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2018; 25:299-307. [PMID: 30480047 PMCID: PMC6243953 DOI: 10.1159/000486802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/07/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Although different scores have been suggested to predict outcomes in the setting of upper gastrointestinal bleeding (UGIB), few comparative studies between simplified versions of older scores and recent scores have been published. We aimed to evaluate the accuracy of pre- (PreRS) and postendoscopic Rockall scores (PostRS), the Glasgow-Blatchford score (GBS) and its simplified version (sGBS), as well as the AIMS65 score in predicting different clinical outcomes. METHODS In this retrospective study, PreRS, PostRS, GBS, sGBS, and AIMS65 score were calculated, and then, areas under the receiver operating characteristic curve were used to evaluate the performance of each score to predict blood transfusion, endoscopic therapy, surgery, admission to intensive/intermediate care unit, length of hospital stay, as well as 30-day rebleeding or mortality. RESULTS PreRS, PostRS, GBS, and sGBS were calculated for all the 433 included patients, but AIMS65 calculation was only possible for 315 patients. Only the PreRS and PostRS were able to fairly predict 30-day mortality. The GBS and sGBS were good in predicting blood transfusion and reasonable in predicting surgery. None of the studied scores were good in predicting the need for endoscopic therapy, admission to intensive/intermediate care unit, length of hospital stay, and 30-day rebleeding. CONCLUSIONS Owing to the identified limitations, none of the 5 studied scores could be singly used to predict all the clinically relevant outcomes in the setting of UGIB. The sGBS was as precise as the GBS in predicting blood transfusion and surgery. The PreRS and PostRS were the only scores that could predict 30-day mortality. An algorithm using the PreRS and the sGBS as an initial approach to patients with UGIB is presented and suggested.
Collapse
Affiliation(s)
- Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Mara Barbosa
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Sofia Xavier
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Pedro Boal Carvalho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | | | - Joana Magalhães
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Carla Marinho
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
- Life and Health Sciences Research Institute, School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| |
Collapse
|
|
44
|
Sung JJ, Chiu PW, Chan FKL, Lau JY, Goh KL, Ho LH, Jung HY, Sollano JD, Gotoda T, Reddy N, Singh R, Sugano K, Wu KC, Wu CY, Bjorkman DJ, Jensen DM, Kuipers EJ, Lanas A. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67:1757-1768. [PMID: 29691276 PMCID: PMC6145289 DOI: 10.1136/gutjnl-2018-316276] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.
Collapse
Affiliation(s)
- Joseph Jy Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Philip Wy Chiu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Francis K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - James Yw Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong
| | - Khean-Lee Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
| | - Lawrence Hy Ho
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Jose D Sollano
- UST Hospital, University of Santo Tomas, Manila, Philippines
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Nihon University School of Medicine, Tokyo, Japan
| | - Nageshwar Reddy
- Asian Institute of Gastroenterology, Asian Healthcare Foundation, Hyderabad, India
| | - Rajvinder Singh
- Department of Medicine, Lyell McEwin Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical School, Shimotsuke, Japan
| | - Kai-Chun Wu
- State Key Laboratory of Cancer Biology, Xijing Hospital of Digestive Diseases, Xi'an, China
| | | | | | | | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Angel Lanas
- Department of Gastroenterology, University Hospital, Zaragoza, Spain
| |
Collapse
|
|
45
|
Banister T, Spiking J, Ayaru L. Discharge of patients with an acute upper gastrointestinal bleed from the emergency department using an extended Glasgow-Blatchford Score. BMJ Open Gastroenterol 2018; 5:e000225. [PMID: 30233807 PMCID: PMC6135483 DOI: 10.1136/bmjgast-2018-000225] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To use an extended Glasgow-Blatchford Score (GBS) cut-off of ≤1 to aid discharge of patients presenting with acute upper gastrointestinal bleeding (AUGIB) from emergency departments. BACKGROUND The GBS accurately predicts the need for intervention and death in AUGIB, and a cut-off of 0 is recommended to identify patients for discharge without endoscopy. However, this cut-off is limited by identifying a low percentage of low-risk patients. Extension of the cut-off to ≤1 or ≤2 has been proposed to increase this proportion, but there is controversy as to the optimal cut-off and little data on performance in routine clinical practice. METHODS Dual-centre study in which patients with AUGIB and GBS ≤1 were discharged from the emergency department without endoscopy unless there was another reason for admission. Retrospective analysis of associated adverse outcome defined as a 30-day combined endpoint of blood transfusion, intervention or death. RESULTS 569 patients presented with AUGIB from 2015 to 2018. 146 (25.7%) had a GBS ≤1 (70, GBS=0; 76, GBS=1). Of these, 103 (70.5%) were managed as outpatients, and none had an adverse outcome. GBS ≤1 had a negative predictive value=100% and the GBS had an area under receiver operator characteristic (AUROC)=0.89 (95% CI 0.86 to 0.91) in predicting adverse outcomes. In 2008-2009, prior to risk scoring (n=432), 6.5% of patients presenting with AUGIB were discharged safely from the emergency department in comparison with 18.1% (p<0.001) in this cohort. A GBS cut-off ≤2 was associated with an adverse outcome in 8% of cases. CONCLUSION GBS of ≤1 is the optimal cut-off for the discharge of patients with an AUGIB from the emergency department.
Collapse
Affiliation(s)
- Thomas Banister
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
| | - Josesph Spiking
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
| | - Lakshmana Ayaru
- Department of Gastroenterology, Imperial College Healthcare and Imperial College London, London, UK
| |
Collapse
|
|
46
|
Tuncer H, Yardan T, Akdemir HU, Ayyildiz T. Comparison of four scoring systems for risk stratification of upper gastrointestinal bleeding. Pak J Med Sci 2018; 34:649-654. [PMID: 30034432 PMCID: PMC6041537 DOI: 10.12669/pjms.343.14956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: This study aimed to compare the performances of the Glasgow–Blatchford Bleeding Score (GBS), pre-endoscopic Rockall score (PRS), complete Rockall score (CRS), and Cedars–Sinai Medical Center Predictive Index (CSMCPI) in predicting clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). Methods: Patients who were admitted to the emergency department because of UGIB and underwent endoscopy within the first 24 hour were included in this study. The GBS, PRS, CRS, and CSMCPI were propectively calculated. The performances of these scores were assessed using a receiver operating characteristic curve. Results: A total of 153 patients were included in this study. For the prediction of high-risk patients, area under the curve (AUC) was obtained for GBS (0.912), PRS (0.968), CRS (0.991), and CSMCPI (0.918). For the prediction of rebleeding, AUC was obtained for GBS (0.656), PRS (0.625), CRS (0.701), and CSMCPI (0.612). For the prediction of 30-day mortality, AUC was obtained for GBS (0.658), PRS (0.757), CRS (0.823), and CSMCPI (0.745). Conclusion: These results suggest that effectiveness of CRS is higher than that of other scores in predicting high-risk patients, rebleeding and 30-day mortality in patients with UGIB.
Collapse
Affiliation(s)
- Hakan Tuncer
- Dr. HakanTuncer, MD. Department of Emergency Medicine, Bagcilar Education and Research Hospital, Istanbul, Turkey
| | - Turker Yardan
- Dr. TurkerYardan, MD. Department of Emergency Medicine, Associate Professor, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hizir Ufuk Akdemir
- Hizir Ufuk Akdemir, MD. Department of Emergency Medicine, Associate Professor, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Talat Ayyildiz
- Talat Ayyildiz, MD. Department of Gastroenterology, Associate Professor, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| |
Collapse
|
|
47
|
Stokbro LA, Schaffalitzky de Muckadell OB, Laursen SB. Arterial lactate does not predict outcome better than existing risk scores in upper gastrointestinal bleeding. Scand J Gastroenterol 2018; 53:586-591. [PMID: 29103333 DOI: 10.1080/00365521.2017.1397737] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Upper gastrointestinal bleeding (UGIB) is a frequent medical emergency and several scoring systems are developed to help risk-stratify patients. We aimed to investigate if elevated arterial lactate (AL) was associated with 30-day mortality, need for hospital-based intervention, or rebleeding. Furthermore, we compared the performance of AL with existing scoring systems and examined if incorporation of AL could improve their predictive ability. MATERIALS AND METHODS Retrospective cohort study of 331 consecutive patients admitted with UGIB during a one-year period. Multivariate analyses were performed to evaluate the association between AL and outcomes. Receiver operating characteristic curves were used to compare AL with existing scoring systems and to test if incorporation of AL could significantly increase their performance. RESULTS AL was significantly associated with mortality (p = .001), need for hospital-based intervention (p = .005), and rebleeding (p = .031). In predicting mortality and rebleeding, AL performed equally to existing scoring systems, however, inferior to all, in predicting need for intervention. Two of the scoring systems were marginally improved in predicting mortality if AL was included. CONCLUSIONS AL is associated with adverse outcomes in patients with UGIB, but has only similar or inferior ability to predict relevant clinical outcomes compared to existing scoring systems. Although AL could enhance performance of two scorings systems in predicting mortality, it does not have an apparent clinical significance. Thus, our data does not support routine measurement of AL in patients with UGIB.
Collapse
Affiliation(s)
- Line Aabel Stokbro
- a Department of Medical Gastroenterology S , Odense University Hospital , Odense , Denmark
| | | | - Stig Borbjerg Laursen
- a Department of Medical Gastroenterology S , Odense University Hospital , Odense , Denmark
| |
Collapse
|
|
48
|
Chatten K, Purssell H, Banerjee AK, Soteriadou S, Ang Y. Glasgow Blatchford Score and risk stratifications in acute upper gastrointestinal bleed: can we extend this to 2 for urgent outpatient management? Clin Med (Lond) 2018; 18:118-122. [PMID: 29626014 PMCID: PMC6303462 DOI: 10.7861/clinmedicine.18-2-118] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Upper gastrointestinal (GI) bleeds are a common presentation to emergency departments in the UK. The Glasgow Blatchford score (GBS) predicts the outcome of patients at presentation. Current UK and European guidelines recommend outpatient management for a GBS of 0. In the current study, our aim was to assess whether extending the GBS allows for early discharge while maintaining patient safety. We also analysed whether pathologies could be missed by discharging patients too early. Data were retrospectively collected on patients admitted with symptoms of an upper GI bleed between 1 October 2013 and 10 June 2016. The GBS was calculated and gastroscopy reports were obtained for each patient. In total, 399 patients were identified, 63 of whom required therapy. The negative predictive value (NPV) for excluding the need for endoscopic intervention with a GBS score up to 1 was 100%. Extending the score to 2 and 3 reduced the NPV to 98.53% and 98.77%, respectively. The NPV of GBS in excluding any diagnosis at 0 was 43.55%. Two patients died as a result of GI bleeding, with a GBS score of 3. Therefore, we can conclude that, for non-variceal bleeds, the GBS can be extended to 2 for safe outpatient management, thereby reducing the number of bed days and pressure for urgent endoscopies.
Collapse
Affiliation(s)
| | | | | | | | - Yeng Ang
- Salford Royal Foundation Trust, Salford, UK
| |
Collapse
|
|
49
|
Ko IG, Kim SE, Chang BS, Kwak MS, Yoon JY, Cha JM, Shin HP, Lee JI, Kim SH, Han JH, Jeon JW. Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding. BMC Gastroenterol 2017; 17:159. [PMID: 29233096 PMCID: PMC5727876 DOI: 10.1186/s12876-017-0716-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/28/2017] [Indexed: 12/14/2022] Open
Abstract
Background Risk scoring systems are used to evaluate patients with upper gastrointestinal bleeding (UGIB). We compared Glasgow-Blatchford score (GBS), modified GBS (mGBS), and Pre-endoscopy Rockall score (Pre-E RS) for immediate application without endoscopic findings in predicting the need of interventions and the 30-day mortality in patients with UGIB. Methods Patients who visited the emergency room with UGIB from January 2007 to June 2016 were included. GBS, mGBS, and Pre-E RS were obtained for all patients. The area under the receiver-operating characteristic curves (AUC) was used to assess the accuracy of the scoring systems to determine the need for interventions and 30-day mortality. Also, we investigated the potential cutoff scores for predicting 30-day mortality and the need for interventions. Results In predicting the need for interventions, GBS (AUC = 0.727) and mGBS (AUC = 0.733) outperformed Pre-E RS (AUC = 0.564, P < 0.0001). In predicting 30-day mortality, Pre-E RS (AUC = 0.929) outperformed GBS (AUC = 0.664, P < 0.0001) and mGBS (AUC = 0.652, P < 0.0001). Based on AUC analyses of sensitivities and specificities, the optimal cutoff mGBS and GBS for the need for interventions was 9 (70.71% sensitivity, 89.35% specificity) and 9 (73.57% sensitivity, 82.90% specificity) respectively, and optimal cutoff Pre-E RS for 30-day mortality was 4 (88.0% sensitivity, 97.52% specificity). Conclusions GBS and mGBS are considered to be moderately accurate in making an early decision about the need of interventions in patients with UGIB. Pre-E RS is considered to be highly accurate in early detection of patients at high risk for 30-day mortality without endoscopic findings. In addition, we suggested potential cutoff scores to predict the need of interventions for GBS and mGBS, and 30-day mortality for Pre-E RS. Further studies are needed to confirm the clinical applicability of results.
Collapse
Affiliation(s)
- Il-Gyu Ko
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, 02447, South Korea
| | - Sung-Eun Kim
- Department of Physiology, College of Medicine, Kyung Hee University, Seoul, 02447, South Korea
| | - Bok Soon Chang
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Min Seob Kwak
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Hyun Phil Shin
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Joung Il Lee
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Sang Hyun Kim
- Department of Surgery, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, Seoul, 05278, South Korea
| | - Jin Hee Han
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyung Hee University, Seoul, 02447, South Korea
| | - Jung Won Jeon
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, College of Medicine, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea.
| |
Collapse
|
|
50
|
Budimir I, Stojsavljević S, Baršić N, Bišćanin A, Mirošević G, Bohnec S, Kirigin LS, Pavić T, Ljubičić N. Scoring systems for peptic ulcer bleeding: Which one to use? World J Gastroenterol 2017; 23:7450-7458. [PMID: 29151699 PMCID: PMC5685851 DOI: 10.3748/wjg.v23.i41.7450] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/24/2017] [Accepted: 09/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the Glasgow-Blatchford score (GBS), Rockall score (RS) and Baylor bleeding score (BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012 consecutive patients admitted with peptic ulcer bleeding (PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores (RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics (AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated. RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome (AUROC 0.82 vs 0.67 vs 0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality (AUROC 0.84 vs 0.57 vs 0.64), rebleeding (AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion (AUROC 0.83 vs 0.63 vs 0.58) and surgical intervention (0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome (AUROC 0.82 vs 0.69, respectively). CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.
Collapse
Affiliation(s)
- Ivan Budimir
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| | - Sanja Stojsavljević
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| | - Neven Baršić
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| | - Alen Bišćanin
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| | - Gorana Mirošević
- Division of Endocrinology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Medical and Dental Faculty, University of Zagreb, Zagreb 10000, Croatia
| | - Sven Bohnec
- Gastronterologie, Allgemeine Innere Medizin und Geriatrie, Rems-Murr Klinik Winnenden, 71364 Winnenden, Germany
| | - Lora Stanka Kirigin
- Division of Endocrinology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Medical and Dental Faculty, University of Zagreb, Zagreb 10000, Croatia
| | - Tajana Pavić
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| | - Neven Ljubičić
- Division of Gastroenterology, Department of Internal Medicine, “Sestre Milosrdnice” University Hospital Center, Zagreb 10000, Croatia
| |
Collapse
|