APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer

Broadening of the red blood cell distribution width is associated with increased severity of illness in patients with sepsis

Background:

Sepsis is a pro-inflammatory state caused by systemic infection. As sepsis progresses, multiple organ systems become affected with subsequent increase in mortality. Elevated red cell distribution width (RDW) has been seen with changes of other inflammatory markers and thus could potentially serve as a means of assessing sepsis severity. In this study, we examine the association of RDW with APACHE II score and in-hospital mortality.

Meterials and Methods:

We conducted a retrospective study involving a cohort of patients with sepsis. The study period spanned 2 years with a cohort of 349 patients. Data were collected to determine if RDW is associated with APACHE II scores and in-hospital mortality in this cohort.

Results:

RDW correlated weakly (r_s = 0.27), but significantly (P < 0.0001) with APACHE II scores; coefficient of determination (r² = 0.09). The odds ratios for the association of RDW with APACHE II were calculated over the RDW range 12-20% at a dichotomized level of APACHE II, i.e., <15 and ≥15. At a RDW ≥16%, multivariate analysis including all potential confounders indicated that RDW was independently associated with an APACHE II score of ≥15. Similarly, mortality was associated with RDW ≥16%.

Conclusion:

A prognostic biomarker for sepsis in the form of a routine blood test may be of considerable clinical utility. The results of our study suggest that RDW may have value in differentiating between more severe and less severe cases of sepsis. Future studies with larger samples are needed to confirm these findings.

What if endoscopic hemostasis fails?: Alternative treatment strategies: surgery

Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.

The surgical management of acute upper gastrointestinal bleeding: a 12-year experience

INTRODUCTION

Acute upper gastrointestinal bleeding (AUGIB) is a common reason for admission to gastroenterologists, with only 2% of patients requiring surgical intervention. The aim of this study was to review the surgical management of patients with non-variceal AUGIB in a single institution over a 12-year period and compare practice with recognised regional and national standards.

MATERIALS AND METHODS

Data was collected retrospectively for all patients undergoing surgery for AUGIB between September 1995 and September 2007. Audit standards included the local hospital protocol, British Society of Gastroenterology Endoscopy Committee guidelines and the UK Comparative Audit of AUGIB and the Use of Blood.

RESULTS

53 patients were identified, of which 41 case notes were available. Mean (range) age of the patients was 75.8 (45-92) years. 56% had pre-existing cardiorespiratory comorbidity and 63% were taking anti-inflammatory drugs. Pre-operative Rockall score was >or=7 in 46% and ASA score was >or=3 in 65% of patients. 56% of operations were performed by the registrar, compared with 20% reported nationally. All cases after 2004 were performed by the consultant. No operations were performed after midnight beyond 1999. 23 (56%) patients suffered post-operative complications compared with 55% reported nationally; cardiorespiratory (n = 16), wound infection (n = 7) and rebleed (n = 6). 37% required intensive care support and median length of hospital stay was 13 days. In-hospital mortality rate was 10%, compared with 30% reported nationally and this increased with rising Rockall, Blatchford, APACHE-2, P-POSSUM and Charlson scores.

CONCLUSIONS

These findings highlight the high rate of morbidity and mortality associated with surgical treatment for AUGIB. The small volume of cases and reduction in registrar operating raises training issues. An integrated approach with greater use of interventional radiology is likely to play a greater role in the future.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

OBJECTIVE

Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies.

MATERIAL AND METHODS

Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated.

RESULTS

The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 +/- 16.1 versus 61.9 +/- 14.1 years; P = 0.043), APACHE II score (17.0 +/- 5.1 versus 12.8 +/- 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score >or= 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group.

CONCLUSIONS

TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

Predicting poor outcome from acute upper gastrointestinal hemorrhage

In conclusion, numerous prediction models identified pre-endoscopic and endoscopic risk factors for adverse clinical outcomes in patients with acute upper GI hemorrhage. The risk factors for mortality are different from those of rebleeding. Predictors for rebleeding are usually related to the severity of the bleeding and characteristics of the ulcer, whereas advanced age, physical status of the patient, and comorbidities are important predictors for mortality in addition to those for rebleeding. Future studies should focus on validation of these predictors in a prospective cohort and application of these prediction models to guide clinical management in patients with acute upper GI hemorrhage.

Usefulness of prognostic indices in upper gastrointestinal bleeding

Upper gastrointestinal haemorrhage remains a significant cause of hospital admission, with mortality rates up to 14%. In order to standardise and improve care, various scoring systems (e.g. Rockall, Blatchford and Baylor) have been developed to identify those individuals at high risk of requiring treatment (transfusion, endoscopic or surgical intervention) or of re-bleeding or death. There is also increasing interest in the utilisation of scoring systems to identify individuals at low risk of complications, as these may be discharged early, possibly with outpatient endoscopy. Most scoring systems are developed to predict outcomes in non-variceal bleeding. However, several indices are used to predict the outcome of advanced liver disease, including Child-Pugh and the Model of End-Stage Liver Disease (MELD). This chapter reviews all these aspects of the various scoring systems.

Therapeutic decision-making in endoscopically unmanageable nonvariceal upper gastrointestinal hemorrhage

The purpose of this study was to identify endoscopic and clinical parameters influencing the decision-making in salvage of endoscopically unmanageable, nonvariceal upper gastrointestinal hemorrhage (UGIH) and to report the outcome of selected therapy. We retrospectively retrieved all cases of surgery and arteriography for arrest of endoscopically unmanageable UGIH. Only patients with overt bleeding on endoscopy within the previous 24 h were included. Patients with preceding nonendoscopic hemostatic interventions, portal hypertension, malignancy, and transpapillar bleeding were excluded. Potential clinical and endoscopic predictors of allocation to either surgery or arteriography were tested using statistical models. Outcome and survival were regressed on the choice of rescue and clinical variables. Forty-six arteriographed and 51 operated patients met the inclusion criteria. Univariate analysis revealed a higher number of patients with a coagulation disorder in the catheterization group (41.4%, versus 20.4% in the laparotomy group; p = 0.044). With multivariate analysis, the identification of a bleeding peptic ulcer at endoscopy significantly steered decision-making toward surgical rescue (OR = 5.2; p = 0.021). Taking into account reinterventions, hemostasis was achieved in nearly 90% of cases in both groups. Overall therapy failure (no survivors), rebleeding within 3 days (OR = 3.7; p = 0.042), and corticosteroid use (OR = 5.2; p = 0.017) had a significant negative impact on survival. The odds of dying were not different for embolotherapy or surgery. In conclusion, decision-making was endoscopy-based, with bleeding peptic ulcer significantly directing the choice of rescue toward surgery. Unsuccessful hemostasis and corticosteroid use, but not the choice of rescue, negatively affected outcome.

[Transcatheter embolization for endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage]

OBJECTIVES

Evaluate the efficacy of endovascular embolization for patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage as well as the factors that may influence mortality. MATERIALS AND METHODS. Retrospective study over a 4-year period including a historical cohort of 37 consecutive patients (22 men), with a mean age of 69.2 years (range, 22-93 years). In most cases (54%), the hemorrhage stemmed from a gastrointestinal ulcer. Technical, primary clinical, and secondary clinical success rates, as well as complication rates, were calculated. Several clinical and angiographic parameters were compared to the early mortality rate using Kruskal-Wallis or Fisher tests.

RESULTS

Technical, primary clinical, secondary clinical success rates, and complication rates were, respectively, 89.2%, 83.8%, 88.9%, and 10.8%. The early mortality rate was 32.4%. The APACHE II and IGS II scores were strongly correlated with mortality (p=0.001 and p=0.003, respectively).

CONCLUSION

Endovascular embolization in patients with endoscopically unmanageable acute nonvariceal upper gastrointestinal hemorrhage is effective. However, the mortality rate remains high because of the changes in the clinical condition of these patients.

Perioperative Vasopressors Are Associated with an Increased Risk of Gastrointestinal Anastomotic Leakage

BACKGROUND

The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown.

PATIENTS AND METHODS

Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications

RESULTS

A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002).

CONCLUSIONS

Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.

Surgical therapy of peptic ulcers in the 21st century: more common than you think

BACKGROUND

The frequency of surgery for peptic ulcer disease (PUD) has decreased dramatically during the last 3 decades. The purpose of this study was to characterize the Veteran patients undergoing surgery for peptic ulcer disease in a modern series and to examine the effect of H. pylori status on surgical outcome and recurrence of PUD.

METHODS

An Institutional Review Board-approved retrospective review of all patients undergoing operations for peptic ulcer disease during a 66-month period at a single Veterans Administration medical center was performed. Patient records were examined for demographics, medication use, Helicobacter pylori status, operative details, and surgical outcomes.

RESULTS

From January 1999 to July 2004, 43 of 128 upper gastrointestinal operations were performed for PUD. Thirty-five operations (81%) were performed for bleeding or perforated ulcers, and 26 (60%) patients had no history of PUD. The mean age was 60 years, and 66% of patients were American Society of Anesthesiologists (ASA) class 3 or 4; 47% were Helicobacter pylori positive, and 54% used nonsteroidal anti-inflammatory (NSAID) medication. Hospital mortality was 23%. By univariate analysis, emergent surgery, higher ASA status, H. pylori status, and absence of a history of ulcer disease were risk factors for mortality (P <.05). Only 36% underwent definitive ulcer surgery. With a median follow-up of 18 months, there has been only 1 single recurrence (3%).

CONCLUSIONS

PUD still accounts for 33% of all gastroduodenal surgery performed in a Veterans Administration medical center. The majority of these operations are emergent operations in high-risk patients. In this era of effective acid suppression and H. pylori treatment, definitive ulcer surgery in the emergent setting may not be necessary.

Admission lactate level and the APACHE II score are the most useful predictors of prognosis following torso trauma

BACKGROUND

Markers of dysoxic metabolism and scoring systems for triage have been widely used in critically injured patients. However, so far, no model is sufficiently reliable to predict the outcome in trauma victims. The purposes of the present study, therefore, were to determine whether a correlation exits between the main trauma scoring systems and the markers of dysoxic metabolism. Moreover, to assess if any of the admission parameters can be used to indicate outcome.

METHODS

Sixty-four patients were included in this study. Admission data, including arterial lactate level, base deficit (BD), pH, revised trauma score (RTS), injury severity score (ISS), shock index (SI), and Acute Physiology and Chronic Health Evaluation (APACHE II), were collected and analysed by logistic regression analysis. Degree of association between continuous variables were calculated by either Pearson's or Spearman's correlation coefficient, where applicable. The dependence of lactate on two or more other variables was evaluated by multiple linear regression analysis.

RESULTS

Logistic regression analysis showed that the fatal outcome following major torso trauma was principally associated with the APACHE II score and lactate. The specificity and the sensitivity of this logistic regression model was 94.6 and 79.2%, respectively. According to standardised linear regression coefficients, BD was the best single predictor of lactate, and APACHE II added a small amount of predictive power. The proportion of total variation in lactate level explained by base deficit, APACHE II and age is R2=85.2%.

CONCLUSION

APACHE II score and the arterial lactate level are the most important determinants of clinical outcome in critically injured patients. A correlation exits between lactate and APACHE II and between lactate and base deficit.

Comparison of transcatheter arterial embolization and surgery for treatment of bleeding peptic ulcer after endoscopic treatment failure

PURPOSE

To compare the outcomes of embolotherapy and surgery as salvage therapy after therapeutic endoscopy failure in the treatment of upper gastrointestinal peptic ulcer bleeding.

MATERIALS AND METHODS

Retrospective analysis of 70 cases of refractory peptic upper gastrointestinal hemorrhage was performed. Thirty-one cases were managed with embolotherapy and 39 were managed surgically. Demographic variables, underlying conditions, clinical findings, endoscopic treatment, transfusion requirements before and after alternative therapeutic approach, length of hospital stay, and outcomes including recurrent bleeding, need for surgery after initial alternative treatment, and in-hospital death were recorded.

RESULTS

Patients who received embolotherapy were older (75.2 years +/- 10.9 vs 63.3 years +/- 14.5; P <.001) and had greater incidences of heart disease (67.7% vs 20.5%; P <.001) and previous anticoagulation treatment (25.8% vs 5.1%; P =.018). There were no differences in the rest of the pretreatment variables. No differences were found between the embolotherapy and surgery groups in the incidence of recurrent bleeding (29% vs 23.1%), need for additional surgery (16.1% vs 30.8%), or death (25.8% vs 20.5).

CONCLUSIONS

The lack of differences between these two treatment alternatives, despite the more advanced age and greater prevalence of heart disease in the embolotherapy group, provides support for future prospective randomized studies aimed to evaluate the role of embolotherapy in the management of refractory peptic ulcer bleeding.

Investigation of the course of proinflammatory and anti-inflammatory cytokines after burn sepsis

Cytokines have been considered as important participants in the post-burn pathophysiological process. The aim of this study was to investigate the course of a proinflammatory cytokine interleukin-8 (IL-8) and an anti-inflammatory cytokine IL-10 in burned patients and whether there was a correlation between mortality and serum levels of these cytokines. Thirty-six acutely burned patients, admitted to Ankara Numune hospital burn unit, entered into the study. A series of serum samples were collected, and serum levels of IL-8 and IL-10 were determined using enzyme-linked immunosorbent assay kit. According to definition utilised, 21 patients developed septic shock and nine of them died. There was no mortality among the 17 non-septic patients. In all 36 patients, there was an increase in serum IL-8 levels, and a peak level was detected shortly after burn injury. The peak IL-8 value of the non-survivors was greater when compared with that of the others. On admission, a significant difference in serum IL-8 values was found between survivors and those who died. In all patients, a peak level of IL-10 was detected between 5 and 9 days of injury. In non-septic survivors, this peak level was less when compared with that of the others. After this peak level, in all patients, serum IL-10 levels showed a decrease, but in non-survivors, a second peak level was detected. A greater understanding of the pathology of the burn sepsis allows rationale use and assessment of current therapies. The results obtained in this study provide useful information on the formulation approaches to this task. Also, IL-8 and IL-10 are prognostic factors in burn sepsis.

Acute Lower Gastroenteric Bleeding Retrospective Analysis (The ALGEBRA Study): An Analysis of the Triage, Management and Outcomes of Patients with Acute Lower Gastrointestinal Bleeding

Many algorithms have been developed for patients with acute lower gastrointestinal hemorrhage (ALGIH). Their clinical usefulness is not readily apparent. It is important first to observe patterns in admission, triage, and management to formulate hypotheses as to how outcomes might be affected. We reviewed patient charts with the diagnosis of gastrointestinal hemorrhage from June 1998 to January 2001. Patients with ALGIH were entered into a database. We defined patients as having ALGIH if presentation included melena or hematochezia. Patients with hematemesis, bloody nasogastric aspirate, or occult fecal blood were excluded. Observations were made on 420 patients. Seventy-six per cent of patients were admitted to the medical service. Lower endoscopy was the first diagnostic method in 33 per cent. Medical management comprised 52 per cent of first management strategies. Surgeons used angiography (3% vs 1%) or surgery (25% vs 5%) more than other services. Fourteen per cent of patients managed with endoscopy, 16 per cent medically, 17 per cent with surgery, and 67 per cent with interventional radiology required two or more subsequent packed red blood cell transfusions. Mean admission Acute Physiology and Chronic Health Evaluation II score was 9.2 whereas that for those with mortality was 13.5. We conclude that the construction of a database will allow for formation and testing of hypotheses in managing ALGIH.

Physiology and organ-related pathology of the elderly: stomach ulcers

Peptic ulcer disease, particularly as a result of its complications, is a burden that is focused on the elderly through their higher Helicobacter pylori prevalence and use of non-steroidal anti-inflammatory drugs (NSAIDs). In these patients, senescence may further increase ulcer susceptibility, particularly in the stomach, by the loss of mucosal protection and repair mechanisms. Age is mainly a marker for the increased prevalence of other complicated ulcer risk factors such as previous ulcer history and use of anti-coagulants, steroids and aspirin. The development of selective cyclo-oxygenase inhibitors (coxibs) has reduced the specific risk of NSAID ulceration, but the residual incidence in high risk patients remains substantially higher than that in young patients without other risk factors. The argument for early surgery versus endoscopic therapy in high risk patients with bleeding ulcers has not been resolved, both having a high mortality. There is still potential for the development of new strategies to prevent primary and secondary ulcers, either by new drug development or by expanding existing co-prescription strategies.

Surgery in the acute management of bleeding peptic ulcer

The management of bleeding peptic ulcers is an increasing challenge in an ageing population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers, and ulcers that fail endoscopic therapy are often 'difficult' ulcers, highly demanding for most gastric surgeons. Mortality in patients requiring eventual salvage surgery is high. Planned urgent surgery is preferable to emergency surgery in elderly patients. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for early surgery. Such a logical approach has, however, not been supported by evidence in the literature. At surgery, an aggressive approach is recommended. Post-operative bleeding is more common after lesser surgery, and this complication is often fatal. When re-bleeding occurs, a selective approach is suggested as emergency surgery carries with it a substantial mortality. Large chronic ulcers with exigent bleeding are less likely to respond to endoscopic re-treatment. Expedient surgery is advised for these patients.