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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.
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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
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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.
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Affiliation(s)
- Josh Orpen-Palmer
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 0SF, UK
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Cha B, Noh JH, Ahn JY, Lee JS, Kim GH, Na HK, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Clinical Outcomes of Patients with Benign Peptic Ulcer Bleeding After an Emergency Endoscopy Based on Patient Location. Dig Dis Sci 2023; 68:1539-1550. [PMID: 36284035 DOI: 10.1007/s10620-022-07708-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/20/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS In the efforts toward reducing bleeding-related mortality, it is crucial to determine the risk factors for rebleeding after endoscopic hemostasis in benign peptic ulcer (BPU). METHODS Between 2013 and 2017, the medical records of 864 BPU patients were selected from 5076 who had undergone emergency endoscopy for suspected upper gastrointestinal bleeding. Patients who visited the emergency room or were hospitalized for other illnesses were selected. The primary end point was rebleeding within 30 days after initial endoscopy. The risk factors of rebleeding and subgroup analyses according to patient location were evaluated. RESULTS Among 864 BPU bleeding patients, rebleeding after completion of BPU bleeding occurred in 140 (16.2%). Initial indicators of hypotension (OR 1.878, p = 0.005) and Forrest classes Ia (OR 25.53, p < 0.001), Ib (OR 27.91, p = 0.005), IIa (OR 21.41, p < 0.001), and IIb (OR 23.74, p < 0.001) were independent risk factors of rebleeding compared to Forrest class III, and being inpatients (OR 1.75, p = 0.01). Compared to the outpatients, the inpatients showed significantly higher rebleeding rates (25.6% vs 13.8%, p < 0.001), predictive bleeding scores, red blood transfusion counts, proportion of Forrest classes Ia, Ib, and IIb (p < 0.001), and overall mortality rates (68.8% vs 34.0%, p < 0.001). CONCLUSIONS Patient location was a novel predictive factor of BPU rebleeding. Particularly, being an inpatient correlated with increased rebleeding. Furthermore, Forrest classes Ia, Ib, IIa, and IIb were predictive of rebleeding not only the included BPUs, but also in the inpatient or outpatient groups.
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Affiliation(s)
- Boram Cha
- Department of Internal Medicine, Digestive Disease Center, Inha University School of Medicine, Incheon, Republic of Korea
| | - Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Jun Su Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ga Hee Kim
- Department of Internal Medicine, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Marks I, Janmohamed IK, Malas S, Mavrou A, Banister T, Patel N, Ayaru L. Derivation and validation of a novel risk score to predict need for haemostatic intervention in acute upper gastrointestinal bleeding (London Haemostat Score). BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001008. [PMID: 36997237 PMCID: PMC10069503 DOI: 10.1136/bmjgast-2022-001008] [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] [Received: 08/08/2022] [Accepted: 02/09/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency, which takes up considerable healthcare resources. However, only approximately 20%-30% of bleeds require urgent haemostatic intervention. Current standard of care is for all patients admitted to hospital to undergo endoscopy within 24 hours for risk stratification, but this is difficult to achieve in practice, invasive and costly. AIM To develop a novel non-endoscopic risk stratification tool for AUGIB to predict the need for haemostatic intervention by endoscopic, radiological or surgical treatments. We compared this with the Glasgow-Blatchford Score (GBS). DESIGN Model development was carried out using a derivation (n=466) and prospectively collected validation cohort (n=404) of patients who were admitted with AUGIB to three large hospitals in London, UK (2015-2020). Univariable and multivariable logistic regression analysis was used to identify variables that were associated with increased or decreased chances of requiring haemostatic intervention. This model was converted into a risk scoring system, the London Haemostat Score (LHS). RESULTS The LHS was more accurate at predicting need for haemostatic intervention than the GBS, in the derivation cohort (area under the receiver operating curve (AUROC) 0.82; 95% CI 0.78 to 0.86 vs 0.72; 95% CI 0.67 to 0.77; p<0.001) and validation cohort (AUROC 0.80; 95% CI 0.75 to 0.85 vs 0.72; 95% CI 0.67 to 0.78; p<0.001). At cut-off scores at which LHS and GBS identified patients who required haemostatic intervention with 98% sensitivity, the specificity of the LHS was 41% vs 18% with the GBS (p<0.001). This could translate to 32% of inpatient endoscopies for AUGIB being avoided at a cost of only a 0.5% false negative rate. CONCLUSIONS The LHS is accurate at predicting the need for haemostatic intervention in AUGIB and could be used to identify a proportion of low-risk patients who can undergo delayed or outpatient endoscopy. Validation in other geographical settings is required before routine clinical use.
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Affiliation(s)
- Isobel Marks
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sadek Malas
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Athina Mavrou
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Thomas Banister
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
| | - Nisha Patel
- Surgery and Cancer, Imperial College London, London, UK
| | - Lakshmana Ayaru
- Gastroenterology, Imperial College Healthcare NHS Trust, London, UK
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Allo G, Bürger M, Gillessen J, Kasper P, Franklin J, Mück V, Nierhoff D, Steffen HM, Goeser T, Schramm C. Comparison of Pre-Endoscopic C-WATCH Score with Established Risk Assessment Tools in Patients with Upper Gastrointestinal Bleeding. Dig Dis 2022; 40:826-834. [PMID: 35073555 PMCID: PMC9808639 DOI: 10.1159/000522121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/18/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Use of risk scores for early assessment of patients with upper gastrointestinal bleeding (UGIB) is recommended by various guidelines. We compared Cologne-WATCH (C-WATCH) score with Glasgow-Blatchford score (GBS), Rockall score (RS), and pre-endoscopic RS (p-RS). METHODS Patients with UGIB between January and December 2017 were retrospectively analyzed for 30-day mortality and composite endpoints risk of complications and need for intervention using areas under the receiver-operating characteristics curve (AUROC). Subgroup analysis was conducted for patients with UGIB on admission and in-hospital UGIB. RESULTS A total of 252 patients were identified (67.5% men, mean age 63.8 ± 14.9 years). In-hospital UGIB occurred in 49.6%. AUROCs for 30-day mortality, risk of complications, and need for intervention (not applicable to RS) were 0.684 (95% confidence interval [CI]: 0.606-0.763), 0.665 (95% CI: 0.594-0.735), and 0.694 (95% CI: 0.612-0.775) for C-WATCH score, 0.724 (95% CI: 0.653-0.796) and 0.751 (95% CI: 0.687-0.815) for RS, 0.652 (95% CI: 0.57-0.735), 0.653 (95% CI: 0.579-0.727), and 0.673 (95% CI: 0.602-0.745) for p-RS and 0.652 (95% CI: 0.572-0.732), 0.663 (95% CI: 0.592-0.734), and 0.752 (95% CI: 0.683-0.821) for GBS. RS outperformed pre-endoscopic scores in predicting risk of complications, while there were no significant differences between pre-endoscopic scores except GBS outperforming p-RS in predicting need for intervention. The subgroup analysis obtained similar results. Positive predictive values for patients with estimated low risk for all three endpoints (C-WATCH score ≤1, RS ≤2, p-RS <1, and GBS ≤1) were 89%, 69%, 78%, and 92%. CONCLUSION C-WATCH score performed similar to the established pre-endoscopic risk scores in patients with UGIB regarding relevant patient-related endpoints with no significant differences between both the subgroups.
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Affiliation(s)
- Gabriel Allo
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany,*Gabriel Allo,
| | - Martin Bürger
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Johannes Gillessen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Philipp Kasper
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jeremy Franklin
- Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Vera Mück
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Dirk Nierhoff
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hans-Michael Steffen
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Schramm
- Clinic for Gastroenterology, Hepatology and Transplant Medicine, Essen University Hospital, Essen, Germany
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Orpen-Palmer J, Stanley AJ. Update on the management of upper gastrointestinal bleeding. BMJ MEDICINE 2022; 1:e000202. [PMID: 36936565 PMCID: PMC9951461 DOI: 10.1136/bmjmed-2022-000202] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/15/2022] [Indexed: 11/04/2022]
Abstract
Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.
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Horibe M, Iwasaki E, Matsuzaki J, Bazerbachi F, Kaneko T, Minami K, Fukuhara S, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Kanai T. Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata. Gastroenterol Rep (Oxf) 2021; 9:543-551. [PMID: 34925851 PMCID: PMC8677506 DOI: 10.1093/gastro/goab042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/26/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS). METHODS Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed. RESULTS HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0-4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5-19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09-0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16-0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001). CONCLUSIONS A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Mayo Clinic, MN, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare, St Cloud Hospital, MN, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan
- Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Shuai S, Zhifang Z, Yuming W, Hong J, Chao S, Kui J, Bangmao W. Clinical Scoring Systems in Predicting the Outcomes of Small Bowel Bleeding. THE TURKISH JOURNAL OF GASTROENTEROLOGY : THE OFFICIAL JOURNAL OF TURKISH SOCIETY OF GASTROENTEROLOGY 2021; 32:493-499. [PMID: 34405815 PMCID: PMC8975372 DOI: 10.5152/tjg.2020.19458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 11/19/2019] [Indexed: 06/13/2023]
Abstract
BACKGROUND The aim was to assess the clinical Glasgow-Blatchford score (GBS), Rockall score (CRS), and AIMS65 score in predicting outcomes (rebleeding, need for intervention, and length of stay) among patients with small bowel hemorrhage. METHODS We conducted a retrospective study of patients with small bowel bleeding (SBB). Rebleeding, need for intervention, and length of stay was investigated by 3 scoring systems. The area under the receiver operator characteristic curve was used to analyze the performance of 3 scoring systems. RESULTS Among 162 included patients, the scores of rebleeding, intervention, and length of stay ≥10 days groups were higher than no rebleeding, non-intervention, and length of stay <10 days groups, respectively (P < .05). The CRS, GBS, and AIMS65 scoring systems demonstrated statistically significant difference in predicting rebleeding (AUROC 0.693 vs. 0.790 vs. 0.740; all P < .01), intervention (AUROC: 0.726 vs. 0.825 vs. 0.773; all P < .01) and length of stay (AUROC 0.651 vs. 0.631 vs. 0.635; all P < .05). Higher cut-off scores achieved better sensitivity/specificity [rebleeding (CRS > 2, GBS > 7, AIMS65 > 0); need for intervention (CRS > 2, GBS > 7, AIMS65 > 0); length of stay (CRS > 0, GBS > 7, AIMS65 > 1)] in the risk stratification. CONCLUSIONS The GBS system is reliable to be recommended for routine use in predicting rebleeding and the need for intervention for early decision making in patients with SBB. The 3 scoring systems are poorly useful in predicting length of stay.
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Affiliation(s)
- Su Shuai
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Zhang Zhifang
- Department of Neurology, Tianjin Xiqing Hospital, Tianjin, People’s Republic of China
| | - Wang Yuming
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jin Hong
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Sun Chao
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Jiang Kui
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Wang Bangmao
- Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
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Horibe M, Iwasaki E, Bazerbachi F, Kaneko T, Matsuzaki J, Minami K, Masaoka T, Hosoe N, Ogura Y, Namiki S, Hosoda Y, Ogata H, Chan AT, Kanai T. Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding. Gastrointest Endosc 2020; 92:578-588.e4. [PMID: 32240682 DOI: 10.1016/j.gie.2020.03.3846] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although upper GI bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3-variable score (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure] ≥1, and blood urea nitrogen/creatinine ≥30 [urea/creatinine≥140]), the Horibe gAstRointestinal BleedING scoRe (HARBINGER), with the 8-variable Glasgow-Blatchford Score (GBS) and 5-variable AIMS65 to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy. METHODS Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. On presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata. RESULTS Of 1486 enrolled patients, 637 (43%) harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver operating characteristic curve (AUC) for the HARBINGER was .76 (95% confidence interval [CI], .72-.79), which was significantly superior to both the GBS (AUC, .68; 95% CI, .64-.71; P < .001) and the AIMS65 (AUC, .54; 95% CI, .50-.58; P < .001). When the HARBINGER cutoff value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively. CONCLUSIONS The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and AIMS65.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Fateh Bazerbachi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA; Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tetsuji Kaneko
- Department of Clinical Trial, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan; Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Juntaro Matsuzaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiro Masaoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shin Namiki
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasuo Hosoda
- Division of Gastroenterology, Department of Internal Medicine, National Hospital Organization Saitama National Hospital, Saitama, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University Hospital, Tokyo, Japan
| | - Andrew T Chan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Marmo R, Soncini M, Marmo C, Borbjerg Laursen S, Gralnek IM, Stanley AJ. Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study. Dig Liver Dis 2020; 52:561-565. [PMID: 32111388 DOI: 10.1016/j.dld.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding. AIMS To identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding. METHODS A retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward. PRIMARY OUTCOME 30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding. RESULTS Out of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01. CONCLUSION Survival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.
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Affiliation(s)
- Riccardo Marmo
- Gastroenterology Unit, L. Curto Hospital, Polla, SA, Italy.
| | - Marco Soncini
- Digestive Physiopathology Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | | | - Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ian Mark Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel; Rappaport Family Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
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Mujtaba S, Chawla S, Massaad JF. Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives. J Clin Med 2020; 9:402. [PMID: 32024301 PMCID: PMC7074258 DOI: 10.3390/jcm9020402] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/21/2020] [Accepted: 01/24/2020] [Indexed: 01/30/2023] Open
Abstract
Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.
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Affiliation(s)
| | | | - Julia Fayez Massaad
- Division of Digestive Diseases, Emory University, 1365 Clifton Road, Northeast, Building B, Suite 1200, Atlanta, GA 30322, USA; (S.M.); (S.C.)
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Hajiagha Mohammadi AA, Reza Azizi M. Prognostic factors in patients with active non-variceal upper gastrointestinal bleeding. Arab J Gastroenterol 2019; 20:23-27. [PMID: 30770260 DOI: 10.1016/j.ajg.2019.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/22/2018] [Accepted: 01/08/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND STUDY AIMS Acute upper gastrointestinal bleeding is one of the main causes of hospitalisation. The purpose of this study was to determine the prognostic factors in non-variceal upper gastrointestinal bleeding. PATIENTS AND METHODS Clinical outcomes, demographic and laboratory variables of the subjects were collected from the HIS software and national code with the SQL format from three hospitals in Qazvin. The data were linked to the database software designed by the author. Clinical and upper endoscopic findings of patients' records were collected through a questionnaire form in the designed software database. RESULTS In this study, 29.2% of patients with favourable outcome and 64.2% of patients with unfavourable clinical outcomes had a history of anticoagulant drug use before hospitalisation (p < 0.001). The prevalence of chronic cardiovascular disease, chronic liver disease, chronic lung disease, diabetes and dialysis was higher in subjects with poor clinical outcomes than those with a favourable clinical outcome. 53.1% of subjects with favourable clinical outcome and 90.5% of subjects with undesirable clinical outcomes received packed red blood cell transfusion (p < 0.001). 16.1% of subjects with desirable clinical outcome and 86.3% of subjects with undesirable clinical outcomes received endoscopic haemostatic treatment which was statistically significant (p < 0.001). CONCLUSION Undesirable clinical outcome in patients with acute non-variceal upper gastrointestinal bleeding has a significant statistical association with longer hospitalisation, chronic underlying disease, anticoagulant administration, packed red blood cell infusion, higher Forrest stage, low systolic blood pressure, higher age, low haemoglobin, low platelet count, high INR and high BUN at the onset of diagnosis.
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Affiliation(s)
- Ali Akbar Hajiagha Mohammadi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mohammad Reza Azizi
- Department of Internal Medicine, Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.
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13
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Fortinsky KJ, Barkun AN. Nonvariceal Upper Gastrointestinal Bleeding. CLINICAL GASTROINTESTINAL ENDOSCOPY 2019:153-170.e8. [DOI: 10.1016/b978-0-323-41509-5.00014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Jiménez-Rosales R, Valverde-López F, Vadillo-Calles F, Martínez-Cara JG, López de Hierro M, Redondo-Cerezo E. Inhospital and delayed mortality after upper gastrointestinal bleeding: an analysis of risk factors in a prospective series. Scand J Gastroenterol 2018; 53:714-720. [PMID: 29575962 DOI: 10.1080/00365521.2018.1454509] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Detailed analyses of mortality after upper gastrointestinal (GI) bleeding are lacking. Follow-up rarely extends beyond 30 days. AIMS Our aim was to analyze in-hospital and delayed 6-months mortality, identifying risk factors. METHODS This was a prospective study on patients with upper GI bleeding over 36 months. Clinical outcomes were in-hospital and delayed-6 month-mortality. RESULTS Four hundred and forty-none patients were included. Overall inpatient mortality was 9.8% but mortality directly related to bleeding was 5.1%. Patients who died presented lower systolic blood pressures, platelet recounts, prothrombin times and lower levels of hemoglobin, calcium, albumin, urea, creatinine and total proteins. Cirrhosis and neoplasms determined a higher in-hospital mortality. Albumin levels were protective, whereas creatinine and an active bleeding were risk factors for in-hospital death in multivariate analysis. Up to 12.6% of patients discharged died in the first 6 months. Neoplasms, chronic kidney disease, coronary disease and esophageal varices were related to delayed mortality. Coronary disease and neoplasms were independent risk factors for mortality, but albumin levels were protective in multivariate analysis. CONCLUSION Comorbidities were risk factors for delayed mortality, whereas albumin levels were a protective factor for in-hospital and delayed deaths. Six months mortality is proportionately as important as in-hospital mortality. Half of the delayed deaths might be preventable.
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Affiliation(s)
- Rita Jiménez-Rosales
- a Department of Gastroenterology , "Virgen de las Nieves" University Hospital , Granada , Spain
| | | | | | | | | | - Eduardo Redondo-Cerezo
- a Department of Gastroenterology , "Virgen de las Nieves" University Hospital , Granada , Spain
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Shrestha MP, Borgstrom M, Trowers EA. Elevated lactate level predicts intensive care unit admissions, endoscopies and transfusions in patients with acute gastrointestinal bleeding. Clin Exp Gastroenterol 2018; 11:185-192. [PMID: 29872331 PMCID: PMC5973428 DOI: 10.2147/ceg.s162703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background and aims Initial clinical management decision in patients with acute gastrointestinal bleeding (GIB) is often based on identifying high- and low-risk patients. Little is known about the role of lactate measurement in the triage of patients with acute GIB. We intended to assess if lactate on presentation is predictive of need for intervention in patients with acute GIB. Patients and methods We performed a single-center, retrospective, cross-sectional study including patients ≥18 years old presenting to emergency with acute GIB between January 2014 and December 2014. Intensive care unit (ICU) admission, inpatient endoscopy (upper endoscopy and/or colonoscopy), and packed red blood cell (PRBC) transfusion were assessed as outcomes. Analyses included univariate and multivariate logistic regression analyses. Results Of 1,237 patients with acute GIB, 468 (37.8%) had venous lactate on presentation. Of these patients, 165 (35.2%) had an elevated lactate level (>2.0 mmol/L). Patients with an elevated lactate level were more likely to be admitted to ICU than patients with a normal lactate level (adjusted odds ratio [AOR] 2.96, 95% confidence interval [CI] 1.74–5.01; p<0.001). Patients with an elevated lactate level were more likely to receive PRBC transfusion (AOR 3.65, 95% CI 1.76–7.55; p<0.001) and endoscopy (AOR 1.64, 95% CI 1.02–2.65; p=0.04) than patients with a normal lactate level. Conclusion Elevated lactate level predicts the need for ICU admissions, transfusions, and endoscopies in patients with acute GIB. Lactate measurement may be a useful adjunctive test in the triage of patients with acute GIB.
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Affiliation(s)
- Manish P Shrestha
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Mark Borgstrom
- Research Computing Group of University Information Technology Services, University of Arizona, Tucson, AZ, USA
| | - Eugene Abraham Trowers
- Division of Gastroenterology, University of Arizona College of Medicine, Tucson, AZ, USA
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Zamparini E, Ahmed P, Belhassan M, Horaist C, Bouguerba A, Ayed S, Barchasz J, Boukari M, Goldgran-Toledano D, Yaacoubi S, Bornstain C, Nahon S, Vincent F. Orientation des patients adultes consultant aux urgences pour hémorragie digestive (hors hypertension portale prouvée ou présumée) : intérêt des scores pronostiques. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1288-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Garg SK, Anugwom C, Campbell J, Wadhwa V, Gupta N, Lopez R, Shergill S, Sanaka MR. Early esophagogastroduodenoscopy is associated with better Outcomes in upper gastrointestinal bleeding: a nationwide study. Endosc Int Open 2017; 5:E376-E386. [PMID: 28512647 PMCID: PMC5432117 DOI: 10.1055/s-0042-121665] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and study aims We analyzed NIS (National Inpatient Sample) database from 2007 - 2013 to determine if early esophagogastroduodenoscopy (EGD) (24 hours) for upper gastrointestinal bleeding improved the outcomes in terms of mortality, length of stay and costs. Patients and methods Patients were classified as having upper gastrointestinal hemorrhage by querying all diagnostic codes for the ICD-9-CM codes corresponding to upper gastrointestinal bleeding. For these patients, performance of EGD during admission was determined by querying all procedural codes for the ICD-9-CM codes corresponding to EGD; early EGD was defined as having EGD performed within 24 hours of admission and late EGD was defined as having EGD performed after 24 hours of admission. Results A total of 1,789,532 subjects with UGIH were identified. Subjects who had an early EGD were less likely to have hypovolemia, acute renal failure and acute respiratory failure. On multivariable analysis, we found that subjects without EGD were 3 times more likely to die during the admission than those with early EGD. In addition, those with late EGD had 50 % higher odds of dying than those with an early EGD. Also, after adjusting for all factors in the model, hospital stay was on average 3 and 3.7 days longer for subjects with no or late EGD, respectively, then for subjects with early EGD. Conclusion Early EGD (within 24 hours) is associated with lower in-hospital mortality, morbidity, shorter length of stay and lower total hospital costs.
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Affiliation(s)
- Sushil K. Garg
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - Chimaobi Anugwom
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - James Campbell
- Department of Internal Medicine, University of Minnesota Twin Cities,
Minneapolis, Minnesota, United States
| | - Vaibhav Wadhwa
- Department of Internal Medicine, Fairview Hospital, Cleveland Clinic,
Cleveland, Ohio, United States
| | - Nancy Gupta
- Department of Gastroenterology, University of Iowa, Iowa City, Iowa, United
States
| | - Rocio Lopez
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, United
States
| | - Sukhman Shergill
- All India Institute of Medical Sciences, Medicine, New Delhi,
India
| | - Madhusudhan R. Sanaka
- Digestive Disease Institute, Department of Gastroenterology & Hepatology,
The Cleveland Clinic, Cleveland, Ohio, United States,Corresponding author Madhu Sanaka, MD, FACG, FASGE Director of Endoscopy ResearchDepartment of GastroenterologyDesk Q39500 Euclid AvenueCleveland, OH 44195+1-216-444-6283
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Ramaekers R, Mukarram M, Smith CAM, Thiruganasambandamoorthy V. The Predictive Value of Preendoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients With Upper Gastrointestinal Bleeding: A Systematic Review. Acad Emerg Med 2016; 23:1218-1227. [PMID: 27640399 DOI: 10.1111/acem.13101] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 07/28/2016] [Accepted: 09/02/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Risk stratification of emergency department (ED) patients with upper gastrointestinal bleeding (UGIB) using preendoscopic risk scores can aid ED physicians in disposition decision-making. We conducted a systematic review to assess the predictive value of preendoscopic risk scores for 30-day serious adverse events. METHODS We searched MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to March 2015. We included studies involving adult ED UGIB patients evaluating preendoscopic risk scores and excluded reviews, case reports, and animal studies. The composite outcome included 30-day mortality, recurrent bleeding, and need for intervention. In two phases (screening and full review), two reviewers independently screened articles for inclusion and extracted patient-level data. The consensus data were used for analysis. We reported sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios with 95% confidence intervals. RESULTS We identified 3,173 articles, of which 16 were included: three studied Glasgow Blatchford score (GBS); one studied clinical Rockall score (cRockall); two studied AIMS65; six compared GBS and cRockall; three compared GBS, a modification of the GBS, and cRockall; and one compared the GBS and AIMS65. Overall, the sensitivity and specificity of the GBS were 0.98 and 0.16, respectively; for the cRockall they were 0.93 and 0.24, respectively; and for the AIMS65 they were 0.79 and 0.61, respectively. The GBS with a cutoff point of 0 had a sensitivity of 0.99 and a specificity of 0.08. CONCLUSION The GBS with a cutoff point of 0 was superior over other cutoff points and risk scores for identifying low-risk patients but had a very low specificity. None of the risk scores identified by our systematic review were robust and, hence, cannot be recommended for use in clinical practice. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.
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Affiliation(s)
- Rosa Ramaekers
- Ottawa Hospital Research Institute; The Ottawa Hospital; University of Ottawa; Ottawa ON Canada
- School of Epidemiology, Public Health, and Preventive Medicine; University of Ottawa; Ottawa ON Canada
- Department of Emergency Medicine; University of Ottawa; Ottawa ON Canada
| | - Muhammad Mukarram
- Ottawa Hospital Research Institute; The Ottawa Hospital; University of Ottawa; Ottawa ON Canada
| | - Christine A. M. Smith
- School of Epidemiology, Public Health, and Preventive Medicine; University of Ottawa; Ottawa ON Canada
| | - Venkatesh Thiruganasambandamoorthy
- Ottawa Hospital Research Institute; The Ottawa Hospital; University of Ottawa; Ottawa ON Canada
- School of Epidemiology, Public Health, and Preventive Medicine; University of Ottawa; Ottawa ON Canada
- Department of Emergency Medicine; University of Ottawa; Ottawa ON Canada
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Martínez-Cara JG, Jiménez-Rosales R, Úbeda-Muñoz M, de Hierro ML, de Teresa J, Redondo-Cerezo E. Comparison of AIMS65, Glasgow-Blatchford score, and Rockall score in a European series of patients with upper gastrointestinal bleeding: performance when predicting in-hospital and delayed mortality. United European Gastroenterol J 2016; 4:371-379. [PMID: 27403303 PMCID: PMC4924428 DOI: 10.1177/2050640615604779] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 08/11/2015] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE AIMS65 is a score designed to predict in-hospital mortality, length of stay, and costs of gastrointestinal bleeding. Our aims were to revalidate AIMS65 as predictor of inpatient mortality and to compare AIMS65's performance with that of Glasgow-Blatchford (GBS) and Rockall scores (RS) with regard to mortality, and the secondary outcomes of a composite endpoint of severity, transfusion requirements, rebleeding, delayed (6-month) mortality, and length of stay. METHODS The study included 309 patients. Clinical and biochemical data, transfusion requirements, endoscopic, surgical, or radiological treatments, and outcomes for 6 months after admission were collected. Clinical outcomes were in-hospital mortality, delayed mortality, rebleeding, composite endpoint, blood transfusions, and length of stay. RESULTS In receiver-operating characteristic curve analyses, AIMS65, GBS, and RS were similar when predicting inpatient mortality (0.76 vs. 0.78 vs. 0.78). Regarding endoscopic intervention, AIMS65 and GBS were identical (0.62 vs. 0.62). AIMS65 was useless when predicting rebleeding compared to GBS or RS (0.56 vs. 0.70 vs. 0.71). GBS was better at predicting the need for transfusions. No patient with AIMS65 = 0, GBS ≤ 6, or RS ≤ 4 died. Considering the composite endpoint, an AIMS65 of 0 did not exclude high risk patients, but a GBS ≤ 1 or RS ≤ 2 did. The three scores were similar in predicting prolonged in-hospital stay. Delayed mortality was better predicted by AIMS65. CONCLUSION AIMS65 is comparable to GBS and RS in essential endpoints such as inpatient mortality, the need for endoscopic intervention and length of stay. GBS is a better score predicting rebleeding and the need for transfusion, but AIMS65 shows a better performance predicting delayed mortality.
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Affiliation(s)
| | | | | | | | | | - Eduardo Redondo-Cerezo
- Department of Gastroenterology and Hepatology, “Virgen de las Nieves” University Hospital, Granada, Spain
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Palmer AJ, Moroni F, Mcleish S, Campbell G, Bardgett J, Round J, McMullan C, Rashid M, Clark R, De Las Heras D, Vincent C. Risk assessment in acute non-variceal upper GI bleeding: the AIMS65 score in comparison with the Glasgow-Blatchford score in a Scottish population. Frontline Gastroenterol 2016; 7:90-96. [PMID: 28839841 PMCID: PMC5369468 DOI: 10.1136/flgastro-2015-100594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/05/2015] [Accepted: 05/05/2015] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The early use of risk stratification scores is recommended for patients presenting with acute non-variceal upper gastrointestinal (GI) bleeds (ANVGIB). AIMS65 is a novel, recently derived scoring system, which has been proposed as an alternative to the more established Glasgow-Blatchford score (GBS). OBJECTIVE To validate the AIMS65 scoring system in a predominantly Caucasian population from Scotland and compare it with the GBS. DESIGN Retrospective study of patients presenting to a district general hospital in Scotland with a suspected diagnosis of ANVGIB who underwent inpatient upper GI endoscopy between March 2008 and March 2013. OUTCOMES The primary outcome measure was 30-day mortality. Secondary outcome measures were requirement for endoscopic intervention, endoscopy refractory bleeding, blood transfusion, rebleeding and admission to high dependency unit (HDU) and intensive care unit (ICU). The area under the receiver operating characteristic (AUROC) curve was calculated for each score. RESULTS 328 patients were included. Of these 65.9% (n=216) were men and 34.1% (n=112) women. The mean age was 65.2 years and 30-day mortality 5.2%. AIMS65 was superior to the GBS in predicting mortality, with an AUROC of 0.87 versus 0.70 (p<0.05). The GBS was superior for blood transfusion (AUROC 0.84 vs 0.62, p<0.05) and admission to HDU (AUROC 0.73 vs 0.62, p<0.05). There were no significant differences between the scores with respect to requirement for endoscopic intervention, endoscopy refractory bleeding, rebleeding and admission to ICU. CONCLUSIONS AIMS65 accurately predicted mortality in a Scottish population of patients with ANVGIB. Large prospective studies are now required to establish the exact role of AIMS65 in triaging patients with ANVGIB.
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Affiliation(s)
- Andrew J Palmer
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Francesca Moroni
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Sally Mcleish
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Geraldine Campbell
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Jonathan Bardgett
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Joanna Round
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Conor McMullan
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Majid Rashid
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Robert Clark
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Dara De Las Heras
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
| | - Claire Vincent
- Departments of Acute Medicine & Gastroenterology, Raigmore Hospital, Inverness, Scotland
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Monteiro S, Gonçalves TC, Magalhães J, Cotter J. Upper gastrointestinal bleeding risk scores: Who, when and why? World J Gastrointest Pathophysiol 2016; 7:86-96. [PMID: 26909231 PMCID: PMC4753192 DOI: 10.4291/wjgp.v7.i1.86] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/02/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.
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Abstract
BACKGROUND AND AIMS Improved medical decisions by using a score at the initial patient triage level may lead to improvements in patient management, outcomes, and resource utilization. There is no validated score for management of lower gastrointestinal bleeding (LGIB) unlike for upper gastrointestinal bleeding. The aim of our study was to compare the accuracies of 3 different prognostic scores [Center for Ulcer Research and Education Hemostasis prognosis score, Charlson index, and American Society of Anesthesiologists (ASA) score] for the prediction of 30-day rebleeding, surgery, and death in severe LGIB. METHODS Data on consecutive patients hospitalized with severe gastrointestinal bleeding from January 2006 to October 2011 in our 2 tertiary academic referral centers were prospectively collected. Sensitivities, specificities, accuracies, and area under the receiver operator characteristic curve were computed for 3 scores for predictions of rebleeding, surgery, and mortality at 30 days. RESULTS Two hundred thirty-five consecutive patients with LGIB were included between 2006 and 2011. Twenty-three percent of patients rebled, 6% had surgery, and 7.7% of patients died. The accuracies of each score never reached 70% for predicting rebleeding or surgery in either. The ASA score had a highest accuracy for predicting mortality within 30 days (83.5%), whereas the Center for Ulcer Research and Education Hemostasis prognosis score and the Charlson index both had accuracies <75% for the prediction of death within 30 days. CONCLUSIONS ASA score could be useful to predict death within 30 days. However, a new score is still warranted to predict all 30 days outcomes (rebleeding, surgery, and death) in LGIB.
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Biecker E. Diagnosis and therapy of non-variceal upper gastrointestinal bleeding. World J Gastrointest Pharmacol Ther 2015; 6:172-182. [PMID: 26558151 PMCID: PMC4635157 DOI: 10.4292/wjgpt.v6.i4.172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 05/06/2015] [Accepted: 10/09/2015] [Indexed: 02/06/2023] Open
Abstract
Non-variceal upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions, erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor (PPI) therapy. These drugs are highly effective but the best route of application (oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal anti-inflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased.
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Hoffmann V, Neubauer H, Heinzler J, Smarczyk A, Hellmich M, Bowe A, Kuetting F, Demir M, Pelc A, Schulte S, Toex U, Nierhoff D, Steffen HM. A Novel Easy-to-Use Prediction Scheme for Upper Gastrointestinal Bleeding: Cologne-WATCH (C-WATCH) Risk Score. Medicine (Baltimore) 2015; 94:e1614. [PMID: 26402828 PMCID: PMC4635768 DOI: 10.1097/md.0000000000001614] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Acute upper gastrointestinal bleeding (UGIB) is the leading indication for emergency endoscopy. Scoring schemes have been developed for immediate risk stratification. However, most of these scores include endoscopic findings and are based on data from patients with nonvariceal bleeding. The aim of our study was to design a pre-endoscopic score for acute UGIB--including variceal bleeding--in order to identify high-risk patients requiring urgent clinical management. The scoring system was developed using a data set consisting of 586 patients with acute UGIB. These patients were identified from the emergency department as well as all inpatient services at the University Hospital of Cologne within a 2-year period (01/2007-12/2008). Further data from a cohort of 322 patients who presented to our endoscopy unit with acute UGIB in 2009 served for external/temporal validation.Clinical, laboratory, and endoscopic parameters, as well as further data on medical history and medication were retrospectively collected from the electronic clinical documentation system. A multivariable logistic regression was fitted to the development set to obtain a risk score using recurrent bleeding, need for intervention (angiography, surgery), or death within 30 days as a composite endpoint. Finally, the obtained risk score was evaluated on the validation set. Only C-reactive protein, white blood cells, alanine-aminotransferase, thrombocytes, creatinine, and hemoglobin were identified as significant predictors for the composite endpoint. Based on the regression coefficients of these variables, an easy-to-use point scoring scheme (C-WATCH) was derived to estimate the risk of complications from 3% to 86% with an area under the curve (AUC) of 0.723 in the development set and 0.704 in the validation set. In the validation set, no patient in the identified low-risk group (0-1 points), but 38.7% of patients in the high-risk group (≥ 2 points) reached the composite endpoint. Our easy-to-use scoring scheme is able to distinguish high-risk patients requiring urgent endoscopy, from low-risk cases who are suitable candidates for outpatient management or in whom endoscopy may be postponed. Based on our findings, a prospective validation of the C-WATCH score in different patient populations outside the university hospital setting seems warranted.
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Affiliation(s)
- Vera Hoffmann
- From the Clinic for Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Str. 62, Köln, Germany (HV, NH, HJ, SA, BA, KF, DM, PA, SS, TU, ND, SHM); Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Kerpener Str. 62, Köln, Germany (HM)
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Prospective multicenter validation of the Glasgow Blatchford bleeding score in the management of patients with upper gastrointestinal hemorrhage presenting at an emergency department. Eur J Gastroenterol Hepatol 2015; 27:1011-6. [PMID: 26049709 DOI: 10.1097/meg.0000000000000402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS The Glasgow Blatchford Bleeding Score (GBS) has been developed to assess the need for treatment in patients with acute upper gastrointestinal hemorrhage (UGIH) presenting at emergency departments (EDs). We aimed (a) to determine the validity of the GBS and Rockall scoring systems for prediction of need for treatment and (b) to identify the optimal cut-off value of the GBS. METHODS We carried out a population-based, prospective multicenter study of 520 consecutive patients presenting with acute UGIH at EDs of three hospitals. The accuracy of GBS and Rockall scores in predicting the need for treatment (i.e. endoscopic, surgical, or radiological intervention and blood transfusion) was analyzed using receiver operating characteristic curves. RESULTS Receiver operating characteristic curve analysis showed that the GBS had a good discriminative ability to determine the need for treatment in patients with acute UGIH (area under the curve: 0.88; 95% confidence interval: 0.85-0.91). The GBS was superior to both the clinical Rockall and the full Rockall score in predicting the need for treatment (area under the curve: 0.86 vs. 0.70 vs. 0.77). At a cut-off value of up to 2, the GBS had the optimal combination of sensitivity (99.4%) and specificity (42.4%). CONCLUSION The GBS is superior compared with both Rockall scores in predicting the need for treatment in patients with suspected acute UGIH presenting at EDs in the Netherlands. Patients with a GBS of 2 or less form a subgroup of low-risk patients. These low-risk patients are eligible for outpatient management, which might reduce hospital admissions and healthcare costs.
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Simon TG, Travis AC, Saltzman JR. Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2015; 25:429-42. [PMID: 26142029 DOI: 10.1016/j.giec.2015.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.
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Affiliation(s)
- Tracey G Simon
- Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA
| | - Anne C Travis
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Khamaysi I, Gralnek IM. Nonvariceal Upper Gastrointestinal Bleeding: Timing of Endoscopy and Ways to Improve Endoscopic Visualization. Gastrointest Endosc Clin N Am 2015; 25:443-8. [PMID: 26142030 DOI: 10.1016/j.giec.2015.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Upper gastrointestinal (UGI) endoscopy is the cornerstone of diagnosis and management of patients presenting with acute UGI bleeding. Once hemodynamically resuscitated, early endoscopy (performed within 24 hours of patient presentation) ensures accurate identification of the bleeding source, facilitates risk stratification based on endoscopic stigmata, and allows endotherapy to be delivered where indicated. Moreover, the preendoscopy use of a prokinetic agent (eg, i.v. erythromycin), especially in patients with a suspected high probability of having blood or clots in the stomach before undergoing endoscopy, may result in improved endoscopic visualization, a higher diagnostic yield, and less need for repeat endoscopy.
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Affiliation(s)
- Iyad Khamaysi
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel; Interventional Endoscopy Unit, Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Ian M Gralnek
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Israel; The Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel.
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Ruggeri M, Manca A, Coretti S, Codella P, Iacopino V, Romano F, Mascia D, Orlando V, Cicchetti A. Investigating the Generalizability of Economic Evaluations Conducted in Italy: A Critical Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:709-720. [PMID: 26297100 DOI: 10.1016/j.jval.2015.03.1795] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 02/27/2015] [Accepted: 03/29/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess the methodological quality of Italian health economic evaluations and their generalizability or transferability to different settings. METHODS A literature search was performed on the PubMed search engine to identify trial-based, nonexperimental prospective studies or model-based full economic evaluations carried out in Italy from 1995 to 2013. The studies were randomly assigned to four reviewers who applied a detailed checklist to assess the generalizability and quality of reporting. The review process followed a three-step blinded procedure. The reviewers who carried out the data extraction were blind as to the name of the author(s) of each study. Second, after the first review, articles were reassigned through a second blind randomization to a second reviewer. Finally, any disagreement between the first two reviewers was solved by a senior researcher. RESULTS One hundred fifty-one economic evaluations eventually met the inclusion criteria. Over time, we observed an increasing transparency in methods and a greater generalizability of results, along with a wider and more representative sample in trials and a larger adoption of transition-Markov models. However, often context-specific economic evaluations are carried out and not enough effort is made to ensure the transferability of their results to other contexts. In recent studies, cost-effectiveness analyses and the use of incremental cost-effectiveness ratio were preferred. CONCLUSIONS Despite a quite positive temporal trend, generalizability of results still appears as an unsolved question, even if some indication of improvement within Italian studies has been observed.
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Affiliation(s)
- Matteo Ruggeri
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Silvia Coretti
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Paola Codella
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Iacopino
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Romano
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniele Mascia
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valentina Orlando
- Inter-departmental Research Centre of PharmacoEconomics and Drug utilization (CIRFF), Center of Pharmacoeconomics, Federico II University of Naples, Naples, Italy
| | - Americo Cicchetti
- Director of Post-Graduate School of Health Economics and Management (ALTEMS), Università Cattolica del Sacro Cuore, Rome, Italy
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Chaikitamnuaychok R, Patumanond J. Gastrointestinal Hemorrhage Severity Triage: Locally Derived Score May Outperform Existing Scoring Systems. Gastroenterology Res 2015; 8:186-192. [PMID: 27785294 PMCID: PMC5051144 DOI: 10.14740/gr652w] [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] [Accepted: 04/24/2015] [Indexed: 12/03/2022] Open
Abstract
Background Scoring tools to predict need for intervention, re-bleeding and mortality of upper gastrointestinal hemorrhage (UGIH) have been developed. It is inconclusive whether these tools are also appropriate for UGIH severity and/or urgency triage. The objective of the study was to compare the performances of the Blatchford score, the Rockall score, and the UGIH score on UGIH severity triage. Methods Retrospective 3-year data of UGIH patients (2009 - 2011) were collected. Patients were assigned to each of the three scoring systems based on their clinical characteristics required for the scoring systems. The score ranges of each scoring system were transformed into the same scale from 0 to 100. The score performances were compared by diagnostic indices, graphically presented with area under receiver operating curve (AuROC), discrimination curves, and statistically tested with Chi-squared tests. Results When focusing on the diagnostic indices, the local UGIH had similar sensitivity to, but better specificity than the Blatchford score in detecting mild UGIH. The sensitivity was better than and the specificity was less than the Blatchford score in detecting severe UGIH. The local UGIH score was better than the pre-endoscopic Rockall in almost all diagnostic indices. Focusing overall performances, the local UGIH score classified patients non-significantly better than the Blatchford: 89.3% vs. 87.9% for mild (P = 0.243), 87.2% vs. 85.0% for severe (P = 0.092), but significantly classified better than the pre-endoscopic Rockall score: 89.3% vs. 76.4% for mild (P < 0.001), and 87.2% vs. 81.2% for severe (P < 0.001). When exploring the discrimination curves, the Blatchford score classified more patients into the mild categories, and less into the severe categories than the local UGIH score. In contrast, the pre-endoscopic Rockall score classified less patients into the mild, but more into the severe than the local UGIH score. Conclusion Triaging UGIH patients into three severity levels in order to decide or set for endoscopy should apply the scoring system specifically developed for that purpose. Adopting other scores developed for other purposes may result in under- and/or over-estimations. The local UGIH score classified patients into three severity levels to help indicate endoscopy more efficiently than the Blatchford score and the pre-endoscopic Rockall score which was developed for different purposes.
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Affiliation(s)
| | - Jayanton Patumanond
- Department of Clinical Epidemiology and Clinical Statistics, Faculty of Medicine; Center of Excellence in Applied Epidemiology, Thammasat University, Pathum Thani 12120, Thailand
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Muguruma N, Kitamura S, Kimura T, Miyamoto H, Takayama T. Endoscopic management of nonvariceal upper gastrointestinal bleeding: state of the art. Clin Endosc 2015; 48:96-101. [PMID: 25844335 PMCID: PMC4381152 DOI: 10.5946/ce.2015.48.2.96] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/17/2015] [Indexed: 12/16/2022] Open
Abstract
Nonvariceal upper gastrointestinal (GI) bleeding is one of the most common reasons for hospitalization and a major cause of morbidity and mortality worldwide. Recently developed endoscopic devices and supporting apparatuses can achieve endoscopic hemostasis with greater safety and efficiency. With these advancements in technology and technique, gastroenterologists should have no concerns regarding the management of acute upper GI bleeding, provided that they are well prepared and trained. However, when endoscopic hemostasis fails, endoscopy should not be continued. Rather, endoscopists should refer patients to radiologists and surgeons without any delay for evaluation regarding the appropriateness of emergency interventional radiology or surgery.
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Affiliation(s)
- Naoki Muguruma
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Shinji Kitamura
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Tetsuo Kimura
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Hiroshi Miyamoto
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Tetsuji Takayama
- Department of Gastroenterology and Oncology, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
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Laursen SB, Dalton HR, Murray IA, Michell N, Johnston MR, Schultz M, Hansen JM, Schaffalitzky de Muckadell OB, Blatchford O, Stanley AJ. Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2015; 13:115-21.e2. [PMID: 25058843 DOI: 10.1016/j.cgh.2014.07.023] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/11/2014] [Accepted: 07/01/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification. METHODS We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk. RESULTS There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%). CONCLUSIONS A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.
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Affiliation(s)
- Stig B Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark.
| | - Harry R Dalton
- Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, United Kingdom
| | - Iain A Murray
- Gastrointestinal Unit, Dunedin Public Hospital, Dunedin, New Zealand
| | - Nick Michell
- Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, United Kingdom
| | - Matt R Johnston
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Michael Schultz
- Department of Medicine, University of Otago, Dunedin, New Zealand
| | - Jane M Hansen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | | | - Oliver Blatchford
- Public Health Department, University of Glasgow, Glasgow, United Kingdom
| | - Adrian J Stanley
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom
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Rotondano G. Epidemiology and diagnosis of acute nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin North Am 2014; 43:643-63. [PMID: 25440917 DOI: 10.1016/j.gtc.2014.08.001] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is a common gastroenterological emergency. A vast majority of these bleeds have nonvariceal causes, in particular gastroduodenal peptic ulcers. Nonsteroidal antiinflammatory drugs, low-dose aspirin use, and Helicobacter pylori infection are the main risk factors for UGIB. Current epidemiologic data suggest that patients most affected are older with medical comorbidit. Widespread use of potentially gastroerosive medications underscores the importance of adopting gastroprotective pharamacologic strategies. Endoscopy is the mainstay for diagnosis and treatment of acute UGIB. It should be performed within 24 hours of presentation by skilled operators in adequately equipped settings, using a multidisciplinary team approach.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology & Digestive Endoscopy, Hospital Maresca, ASLNA3sud, Via Montedoro, Torre del Greco 80059, Italy.
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Lu Y, Chen YI, Barkun A. Endoscopic management of acute peptic ulcer bleeding. Gastroenterol Clin North Am 2014; 43:677-705. [PMID: 25440919 DOI: 10.1016/j.gtc.2014.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This review discusses the indications, technical aspects, and comparative effectiveness of the endoscopic treatment of upper gastrointestinal bleeding caused by peptic ulcer. Pre-endoscopic considerations, such as the use of prokinetics and timing of endoscopy, are reviewed. In addition, this article examines aspects of postendoscopic care such as the effectiveness, dosing, and duration of postendoscopic proton-pump inhibitors, Helicobacter pylori testing, and benefits of treatment in terms of preventing rebleeding; and the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, and oral anticoagulants, including direct thrombin and Xa inhibitors, following acute peptic ulcer bleeding.
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Affiliation(s)
- Yidan Lu
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Yen-I Chen
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, 1650 Cedar Avenue, Montréal H3G 1A4, Canada; Division of Clinical Epidemiology, McGill University Health Center, McGill University, 687 Pine Avenue West, Montréal H3A 1A1, Canada.
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Abstract
Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.
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Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014; 9:45. [PMID: 25114715 PMCID: PMC4127969 DOI: 10.1186/1749-7922-9-45] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/26/2014] [Indexed: 12/11/2022] Open
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Di Saverio S, Bassi M, Smerieri N, Masetti M, Ferrara F, Fabbri C, Ansaloni L, Ghersi S, Serenari M, Coccolini F, Naidoo N, Sartelli M, Tugnoli G, Catena F, Cennamo V, Jovine E. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014. [PMID: 25114715 DOI: 10.1186/1749-7922-9-451749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salomone Di Saverio
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Marco Bassi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy.,Liver and Multivisceral Transplantation Unit, University of Modena&Reggio Emilia - Policlinico Hospital, Modena, Italy
| | - Michele Masetti
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Carlo Fabbri
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Stefania Ghersi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Matteo Serenari
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Federico Coccolini
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Noel Naidoo
- Port Shepstone Regional Hospital, Port Shepstone, South Africa - Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gregorio Tugnoli
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Dept., Maggiore Hospital of Parma, Parma, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Elio Jovine
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
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Girardin M, Bertolini D, Ditisheim S, Frossard JL, Giostra E, Goossens N, Morard I, Nguyen-Tang T, Spahr L, Vonlaufen A, Hadengue A, Dumonceau JM. Use of glasgow-blatchford bleeding score reduces hospital stay duration and costs for patients with low-risk upper GI bleeding. Endosc Int Open 2014; 2:E74-9. [PMID: 26135264 PMCID: PMC4423275 DOI: 10.1055/s-0034-1365542] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 01/23/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Upper gastrointestinal (UGI) bleeding is a frequent cause of hospitalization. Its severity may be assessed before endoscopy using the Glasgow-Blatchford Bleeding Score (GBS), a score validated to identify patients requiring clinical intervention. The aim of this study was to assess whether the GBS was effective for shortening hospital stay and reducing costs in patients with an UGI bleeding predicted at low risk of requiring clinical intervention. PATIENTS AND METHODS Consecutive outpatients presenting with UGI bleeding at our hospital were prospectively included. In the observational study phase, UGI endoscopy was performed in all patients according to routine clinical practice. In the interventional study phase, patients with a GBS of 0 were discharged with an appointment for an outpatient UGI endoscopy. All patients had follow-up at 7 and 30 days. Need for clinical intervention was defined as performance of endoscopic hemostasis, blood transfusion or surgery. Results Two-hundred and eight patients were included, 104 in each study phase; complete follow-up was obtained in 201 patients. GBS varied from 0 to 18, with 15 (14 %) and 11 (11 %) patients having a GBS of 0 in the observational and interventional study phase, respectively. For patients with a GBS of 0, hospital stay was shorter (6 versus 19 h, P < 0.01), and costs were lower (845 EUR versus 1272 EUR, P = 0.002) in the interventional versus the observational study phase. For patients with a GBS > 0, hospital stay duration did not significantly differ between study phases (189 versus 207 h, P = 0.726). No adverse event was observed in the patients sent home with a GBS of 0 during the interventional study phase. Conclusions Implementing the GBS as a tool for triage of hospital outpatients who present with UGI bleeding allowed us to identify those who could safely be discharged for ambulatory management. Implementing this change in the hospital strategy significantly shortened hospital stay and decreased management costs.
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Affiliation(s)
- Marc Girardin
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland,Corresponding author Marc Girardin, MD 4 Gabrielle-Perret Gentil Street1211 Geneva 14Switzerland
| | - David Bertolini
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Saskia Ditisheim
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Louis Frossard
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Emiliano Giostra
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Nicolas Goossens
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Isabelle Morard
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Thai Nguyen-Tang
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Laurent Spahr
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Alain Vonlaufen
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Antoine Hadengue
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Marc Dumonceau
- Division of Gastroenterology and Hepatology, Geneva University Hospital, Geneva, Switzerland
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Use of the Complete Rockall Score and the Forrest Classification to Assess Outcome in Patients with Non-variceal Upper Gastrointestinal Bleeding Subject to After-hours Endoscopy: A Retrospective Cohort Study. W INDIAN MED J 2014; 63:29-33. [PMID: 25303191 DOI: 10.7727/wimj.2012.316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/25/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To evaluate the usefulness of the Forrest classification and the complete Rockall score with customary cut-off values for assessing the risk of adverse events in patients with upper gastrointestinal bleeding (UGI-B) subject to after-hours emergency oesophago-gastro-duodenoscopy (E-EGD) within six hours after admission. METHODS The medical records of patients with non-variceal UGI-B proven by after-hours endoscopy were analysed. For 'high risk' situations (Forrest stage Ia-IIb/complete Rockall score > 2), univariate analysis was conducted to evaluate odds ratio for reaching the study endpoints (30-day and one-year mortality, re-bleeding, hospital stay ≥ 3 days). RESULTS During the study period (75 months), 86 cases (85 patients) met the inclusion criteria. Patients' age was 66.36 ± 14.38 years; 60.5% were male. Mean duration of hospital stay was 15.21 ± 19.24 days. Mortality rate was 16.7% (30 days) and 32.9% (one year); 14% of patients re-bled. Univariate analysis of post-endoscopic Rockall score ≥ 2 showed an odds ratio of 6.09 for death within 30 days (p = 0.04). No other significant correlations were found. CONCLUSION In patients with UGI-B subject to after-hours endoscopy, a 'high-risk' Rockall score permits an estimation of the risk of death within 30 days but not of re-bleeding. A 'high-risk' Forrest score is not significantly associated with the study endpoints.
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Reed EA, Dalton H, Blatchford O, Ashley D, Mowat C, Gaya DR, Cahill A, Warshow U, Hare N, Groome M, Forrest EH, Morris J, Stanley AJ. Is the Glasgow Blatchford score useful in the risk assessment of patients presenting with variceal haemorrhage? Eur J Gastroenterol Hepatol 2014; 26:432-437. [PMID: 24535596 DOI: 10.1097/meg.0000000000000051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Glasgow Blatchford score (GBS) is a pre-endoscopic risk assessment tool for patients presenting with upper gastrointestinal haemorrhage. There are few data regarding use in patients with variceal bleeding, who are generally accepted as being at high risk. AIM The aim of the study was to assess GBS in correctly identifying patients with subsequently proven variceal bleeding as 'high risk' and to compare GBS, admission and full Rockall scores in predicting clinical endpoints in this group. PATIENTS AND METHODS Data on consecutive patients with upper gastrointestinal haemorrhage presenting to four UK hospitals were collected. The GBS, admission and full Rockall scores were calculated and compared for the subgroup subsequently shown to have variceal bleeding. Area under the receiver operating curve (AUROC) was used to assess the scores ability to predict clinical endpoints within this variceal bleeding subgroup. RESULTS A total of 1432 patients presented during the study period. Seventy-one (5%) had a final diagnosis of variceal bleeding. At presentation, none of this group had GBS less than 2, but six had an admission Rockall score of 0. In predicting need for blood transfusion, AUROC scores for GBS, full and admission Rockall scores were 0.68, 0.65 and 0.68, respectively. For endoscopic/surgical intervention the scores were 0.34, 0.51 and 0.55, respectively, and for predicting death the scores were 0.56, 0.72 and 0.70, respectively. None of these AUROC score comparisons were significant. CONCLUSION At presentation, GBS correctly identifies patients with variceal bleeding as high risk and appears superior to the admission Rockall score. However, GBS and both Rockall scores are poor at predicting clinical outcome within this group.
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Affiliation(s)
- Elizabeth A Reed
- aGI Unit, Glasgow Royal Infirmary bHealth Protection Scotland, Glasgow cGastroenterology Department, Ninewells Hospital, Dundee, Scotland dGastroenterology Department, Royal Cornwall Hospital, Truro, Cornwall eGastroenterology Department, North Tees University Hospital, Stockton-on-Tees, Cleveland, UK
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Rotondano G, Cipolletta L, Koch M, Bianco MA, Grossi E, Marmo R. Predictors of favourable outcome in non-variceal upper gastrointestinal bleeding: implications for early discharge? Dig Liver Dis 2014; 46:231-236. [PMID: 24361122 DOI: 10.1016/j.dld.2013.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 09/25/2013] [Accepted: 10/28/2013] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is a lack of validated predictors on which to decide the timing of discharge in patients already hospitalized for upper nonvariceal bleeding. AIMS Identify factors that appear to protect nonvariceal bleeders from the development of negative outcome (rebleeding, surgery, death). METHODS Secondary analysis of two prospective multicenter studies. Multivariate analyses for each investigated outcome were performed; a single model was developed including all factors that were statistically significant in each sub-model. A final score was developed to predict favourable outcomes. Prognostic accuracy was tested with ROC curve analysis. RESULTS Out of 2398 patients, 211 (8.8%) developed one or more adverse outcomes: 87 (3.63%) had rebleeding, 46 (1.92%) needed surgery and 107 (4.46%) died. Predictors of favourable prognosis were: ASA score 1 or 2, absence of neoplasia, outpatient bleeding, use of low-dose aspirin, no need for transfusions, clean-based ulcer, age <70 years, no haemodynamic instability successful endoscopic diagnosis/therapy, no Dieulafoy's lesion at endoscopy, no hematemesis on presentation and no need for endoscopic treatment. Overall prognostic accuracy of the model was 83%. The final score accurately identified 20-30% of patients that eventually do not develop any negative outcome. CONCLUSIONS The "good luck score" may be a useful tool in deciding when to discharge a patient already hospitalized for acute non-variceal bleeding.
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Affiliation(s)
| | | | - Maurizio Koch
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Gastroenterology ACO San Filippo Neri, Roma, Italy
| | | | - Enzo Grossi
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Medical Department, Bracco, Milano, Italy
| | - Riccardo Marmo
- Gastroenterology Hospital Maresca, Torre del Greco, Italy; Gastroenterology Hospital Curto, Polla, Italy
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Wong SH, Sung JJY. Management of GI emergencies: peptic ulcer acute bleeding. Best Pract Res Clin Gastroenterol 2013; 27:639-47. [PMID: 24160924 DOI: 10.1016/j.bpg.2013.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 07/18/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Peptic ulcer bleeding is a common medical emergency. Management of acute ulcer bleeding requires prompt assessment for risk stratification, evaluation for early endoscopy, initiation of pharmacotherapy and treatment of co-morbid diseases. Tremendous advances in endoscopic technique and pharmacotherapy in the past few decades have reduced recurrent bleeding, the need for surgery and mortality of the disease. Strategies to minimize recurrence have been defined for various types of peptic ulcers. This article reviews the current management of acute peptic ulcer bleeding.
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Affiliation(s)
- Sunny H Wong
- Institute of Digestive Disease, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong; Department of Medicine and Therapeutics, Prince of Wales Hospital, Shatin, Hong Kong.
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Bryant RV, Kuo P, Williamson K, Yam C, Schoeman MN, Holloway RH, Nguyen NQ. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013; 78:576-83. [PMID: 23790755 DOI: 10.1016/j.gie.2013.05.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 05/06/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Data regarding the utility of the Glasgow-Blatchford bleeding score (GBS) in hospitalized patients with upper GI hemorrhage are limited. OBJECTIVE To evaluate the performance of the GBS in predicting clinical outcomes and the need for interventions in patients with upper GI hemorrhage. DESIGN Prospective observational study. SETTING Single, tertiary-care endoscopic center. PATIENTS Between July 2010 and July 2012, 888 consecutive hospitalized patients managed for upper GI hemorrhage were entered into the study. INTERVENTION GBS and Rockall scores. MAIN OUTCOME MEASUREMENTS GBS and Rockall scores were prospectively calculated. The performance of these scores to predict the need for interventions and outcomes was assessed by using a receiver operating characteristic curve. RESULTS Endoscopy was performed in 708 patients (80%). A total of 286 patients (40.3%) required endoscopic therapy, and 29 patients (3.8%) underwent surgery. GBS and post-endoscopy Rockall scores (post-E RS) were superior to pre-endoscopy Rockall scores in predicting the need for endoscopic therapy (area under the curve [AUC] 0.76 vs 0.76 vs 0.66, respectively) and rebleeding (AUC 0.71 vs 0.64 vs 0.57). The GBS was superior to Rockall scores in predicting the need for blood transfusion (AUC 0.81 vs 0.70 vs 0.68) and surgery (AUC 0.71 vs 0.64 vs 0.51). Patients with GBS scores ≤ 3 did not require intervention. LIMITATIONS Subjective decision making as to need for endoscopic therapy and blood transfusion. CONCLUSION Compared with post-E RS, the GBS was superior in predicting the need for blood transfusion and surgery in hospitalized patients with upper GI hemorrhage and was equivalent in predicting the need for endoscopic therapy, rebleeding, and death. There are potential cutoff GBS scores that allow risk stratification for upper GI hemorrhage, which warrant further evaluation.
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Affiliation(s)
- Robert V Bryant
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia
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Gado A, Ebeid B, Abdelmohsen A, Axon A. The management of low-risk acute upper gastrointestinal haemorrhage in the community in Egypt. ALEXANDRIA JOURNAL OF MEDICINE 2013. [DOI: 10.1016/j.ajme.2012.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Ahmed Gado
- Department of Medicine, Bolak Eldakror Hospital , Giza, Egypt
| | - Basel Ebeid
- Department of Tropical Medicine and Infectious Diseases, Banysweef University , Banysweef, Egypt
| | - Aida Abdelmohsen
- Department of Community Medicine, National Research Center , Giza, Egypt
| | - Anthony Axon
- Department of Gastroenterology, The General Infirmary at Leeds , Leeds, United Kingdom
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Ahn S, Lim KS, Lee YS, Lee JL. Blatchford score is a useful tool for predicting the need for intervention in cancer patients with upper gastrointestinal bleeding. J Gastroenterol Hepatol 2013; 28:1288-94. [PMID: 23432611 DOI: 10.1111/jgh.12179] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM The Blatchford score is based on clinical and laboratory variables to predict the need for clinical interventions in upper gastrointestinal bleeding (UGIB). The primary object was to evaluate the Blatchford score with clinical and full Rockall scores in patients with active cancer presenting to the emergency department with UGIB. The secondary object was to assess the accuracy of the Blatchford score at different source of UGIB; cancer bleeding versus non-malignant lesions. METHODS We reviewed and extracted data from electronic medical record on patients with active cancer presenting to the emergency department from January 2009 to December 2011. Clinical interventions included blood transfusion, therapeutic endoscopy, angiographic intervention, and surgery. RESULTS Of the 225 patients included, 197 (87.6%) received interventions. Comparing the area under receiver-operator curves, the Blatchford score (0.86, 95% confidence interval [CI] 0.77-0.95) was superior to clinical Rockall (0.67, 95% CI 0.55-0.79) and full Rockall score (0.72, 95% CI 0.61-0.83) in predicting interventions. When the score of 2 or less is counted as negative, sensitivity of 0.99 and specificity of 0.54 were calculated. When the patients were separated according to the source of UGIB, sensitivity and specificity were not changed. CONCLUSIONS The Blatchford score outperformed both Rockall scoring system in predicting intervention in patients with active cancer. The source of bleeding was not important factor in the score performance. The Blatchford score has a very good sensitivity. However, suboptimal specificity limits its role as sole means of decision making in cancer patient with UGIB.
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Affiliation(s)
- Shin Ahn
- Cancer Emergency Room, Department of Emergency Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea.
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Chaikitamnuaychok R, Patumanond J. Upper Gastrointestinal Hemorrhage: Validation of the Severity Score. Gastroenterology Res 2013; 6:56-62. [PMID: 27785227 PMCID: PMC5051158 DOI: 10.4021/gr540w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2013] [Indexed: 12/21/2022] Open
Abstract
Background A simple scoring system was developed earlier to classify patients presenting with upper gastrointestinal hemorrhage into mild, moderates and severe. To validate the derived simple UGIH severity scoring system to another set of data obtained from consecutive patients. Methods The score was developed earlier from data of patients with UGIH in 2009 - 2010. The same scoring system was assigned to another set of data from patients of the following year. Classification of patients into 3 urgency levels reflecting their severity was compared. Performance similarity of the score in the two sets of data was tested with a chi-squared test for homogeneity. The ability of the score to discriminate mild patients from moderate/severe, and to discriminate severe patients from mild/moderate was identified and compared with analysis of area under the receiver operating characteristic curve (AuROC). Results Patients from the validation data were similar to those from the development data in overall aspects. The severity of UGIH and the score distribution in the two sets were similar. The score successfully classified patients in the validation data into 3 severity levels similar to the development data (P = 0.381, chi-squared for homogeneity), and similarly discriminated mild patients from moderate/severe patients (P = 0.360, AuROC analysis), and similarly discriminated severe patients from mild/moderate patients (P = 0.589, AuROC analysis) Conclusion The simple scoring scheme developed earlier to classify UGIH patients into 3 severity/urgency levels performed similarly in the validation data obtained from patients in the following year. Advantages of the scoring scheme should be tested when applied to patient care to assure clinical adoption into routine practice.
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Affiliation(s)
| | - Jayanton Patumanond
- Clinical Epidemiology Unit, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
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Variability in the management of nonvariceal upper gastrointestinal bleeding in Europe: an observational study. Adv Ther 2012; 29:1026-36. [PMID: 23225523 DOI: 10.1007/s12325-012-0069-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Despite recent advances in endoscopic and pharmacological management, nonvariceal upper gastrointestinal bleeding (NVUGIB) is still associated with considerable mortality and morbidity that vary between countries. The European Survey of Nonvariceal Upper Gastrointestinal Bleeding (ENERGiB) reported clinical outcomes across Europe (Belgium, Greece, Italy, Norway, Portugal, Spain, and Turkey) and evaluated management strategies in a "real-world" European setting. This article presents the differences in clinical management strategies among countries participating in ENERGiB. METHODS Adult patients consecutively presenting with overt NVUGIB at 123 participating hospitals over a 2-month period were included. Data relevant to the initial NVUGIB episode and for up to 30 days afterwards were collected retrospectively from patient medical records. RESULTS The number of evaluable patients was 2,660; patient demographics and clinical characteristics were similar across countries. There was wide between-country variability in the area and speciality of the NVUGIB management team and unit transfer rates after the initial hospital assessment. The mean time from admission to endoscopy was <1 day only in Italy and Spain. Wide variation in the use of preendoscopy (35.0-88.7%) and relatively consistent (86.5-96.0%) postendoscopic pharmacological therapy rates were observed. There was substantial by-country variability in the rate of therapeutic procedures performed during endoscopy (24.9-47.6%). NVUGIB-related healthcare resource consumption was high and variable (days hospitalized, mean 5.4-8.7 days; number of endoscopies during hospitalization, mean 1.1-1.7). CONCLUSIONS ENERGiB demonstrates that there are substantial differences in the management of patients with acute NVUGIB episodes across Europe, and that in many cases the guideline recommendations for the management of NVUGIB are not being followed.
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Chaikitamnuaychok R, Patumanond J. Upper Gastrointestinal Hemorrhage: Development of the Severity Score. Gastroenterology Res 2012; 5:219-226. [PMID: 27785211 PMCID: PMC5074817 DOI: 10.4021/gr488w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/13/2012] [Indexed: 01/22/2023] Open
Abstract
Background Emergency endoscopy for every patient with upper gastrointestinal hemorrhage is not possible in many medical centers. Simple guidelines to select patients for emergency endoscopy are lacking. The aim of the present report is to develop a simple scoring system to classify upper gastrointestinal hemorrhage (UGIH) severity based on patient clinical profiles at the emergency departments. Methods Retrospective data of patients with UGIH in a university affiliated hospital were analyzed. Patients were criterion-classified into 3 severity levels: mild, moderate and severe. Clinical and laboratory information were compared among the 3 groups. Significant parameters were selected as indicators of severity. Coefficients of significant multivariable parameters were transformed into item scores, which added up as individual severity scores. The scores were used to classify patients into 3 urgency levels: non-urgent, urgent and emergent groups. Score-classification and criterion-classification were compared. Results Significant parameters in the model were age ≥ 60 years, pulse rate ≥ 100/min, systolic blood pressure < 100 mmHg, hemoglobin < 10 g/dL, blood urea nitrogen ≥ 35 mg/dL, presence of cirrhosis and hepatic failure. The score ranged from 0 to 27, and classifying patients into 3 urgency groups: non-urgent (score < 4, n = 215, 21.2%), urgent (score 4 - 16, n = 677, 66.9%) and emergent (score > 16, n = 121, 11.9%). The score correctly classified 81.4% of the patients into their original (criterion-classified) severity groups. Under-estimation (7.5%) and over-estimation (11.1%) were clinically acceptable. Conclusions Our UGIH severity scoring system classified patients into 3 urgency groups: non-urgent, urgent and emergent, with clinically acceptable small number of under- and over-estimations. Its discriminative ability and precision should be validated before adopting into clinical practice.
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Affiliation(s)
| | - Jayanton Patumanond
- Clinical Epidemiology Unit, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012; 10:1130-1135.e1. [PMID: 22801061 DOI: 10.1016/j.cgh.2012.06.022] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 06/18/2012] [Accepted: 06/18/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Risk scoring systems are used increasingly to assess patients with upper gastrointestinal hemorrhage (UGIH). There have been comparative studies to identify the best system, but most have been retrospective and included small sample sizes, few patients with severe bleeding and with low mortality. We aimed to identify the optimal scoring system. METHODS We performed a prospective study to compare the accuracy of the Glasgow Blatchford score (GBS), an age-extended GBS (EGBS), the Rockall score, the Baylor bleeding score, and the Cedars-Sinai Medical Center predictive index in predicting patients' (1) need for hospital-based intervention or 30-day mortality, (2) suitability for early discharge, (3) likelihood of rebleeding, and (4) mortality. We analyzed the area under receiver operating characteristic (AUROC) curve, sensitivity, specificity, and positive and negative predictive values for each system. The study included 831 consecutive patients admitted with UGIH during a 2-year period. RESULTS The GBS and EGBS better predicted patients' need for hospital-based intervention or 30-day mortality than the other systems (AUROC, 0.93; P < .001) and were also better in identifying low-risk patients (sensitivity values, 0.27-0.38; specificity values, 0.099-1). The EGBS identified a significantly higher proportion of low-risk patients than the GBS (P = .006). None of the systems accurately predicted which patients would have rebleeding or patients' 30-day mortality, on the basis of low AUROC and specificity values. CONCLUSIONS The GBS accurately identifies patients with UGIH most likely to need hospital-based intervention and also those best suited for outpatient care. The EGBS seems promising but must be validated externally. No scoring system seems to accurately predict patients' 30-day mortality or rebleeding. ClinicalTrials.gov number, NCT01589250.
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Affiliation(s)
- Stig Borbjerg Laursen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark.
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Stanley AJ. Update on risk scoring systems for patients with upper gastrointestinal haemorrhage. World J Gastroenterol 2012; 18:2739-2744. [PMID: 22719181 PMCID: PMC3374976 DOI: 10.3748/wjg.v18.i22.2739] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 02/20/2012] [Accepted: 04/21/2012] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.
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Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, Early DS, Evans JA, Fanelli RD, Foley K, Fukami N, Jain R, Jue TL, Khan KM, Lightdale J, Malpas PM, Maple JT, Pasha S, Saltzman J, Sharaf R, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012; 75:1132-8. [PMID: 22624808 DOI: 10.1016/j.gie.2012.02.033] [Citation(s) in RCA: 215] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 02/20/2012] [Indexed: 02/08/2023]
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