Emergency endoscopy for acute gastrointestinal bleeding: prognostic value of endoscopic hemostasis and the AIMS65 score in Japanese patients

Comparison of scoring systems for predicting clinical outcomes of acute lower gastrointestinal bleeding: A prospective cohort study

BACKGROUND

This study aimed to determine the performance of the Oakland, Glasgow-Blatchford, and AIMS65 scores in predicting the clinical outcomes of acute lower gastrointestinal bleeding (LGIB).

METHODS

This prospective cohort study was conducted from July 2020 to July 2021. Patients admitted with acute lower gastrointestinal bleeding were enrolled. The Oakland, Glasgow-Blatchford, and AIMS65 scores were calculated. The primary outcome was validating the performance of the scores in predicting severe LGIB; secondary outcomes were comparing the performance of the scores in predicting the need for blood transfusion, hemostatic interventions, in-hospital rebleeding, and mortality. Receiver operating characteristic curves were calculated for all outcomes. The associations between all three scores and the primary outcomes were calculated using multivariate logistic regression analysis.

RESULTS

Patients with acute LGIB (n = 150) were enrolled (88 [58.7%] men and mean age: 63.6 ± 17.3 years). The rates of severe LGIB, need for blood transfusion, hemostatic intervention, in-hospital rebleeding, and in-hospital mortality were 54.7%, 79.3%, 10.7%, and 3.3%, respectively. The Oakland and Glasgow-Blatchford scores had comparable performance in predicting severe LGIB, need for blood transfusion, and mortality, outperforming the AIMS65 score. All scores were suboptimal for predicting hemostatic interventions and rebleeding.

CONCLUSIONS

Our results demonstrate the predictive performances of the Oakland score and the GBS are excellent and comparable for severe LGIB, the need for blood transfusion, and in-hospital mortality in patients with acute LGIB. Thus, GBS could be considered as an alternative predictive score for stratification of the patients with acute LGIB.

Comparison and validation of the Japanese score and other scoring systems in patients with peptic ulcer bleeding: A retrospective study

Acute upper gastrointestinal bleeding (UGIB) is one of the most urgent medical conditions, with peptic ulcer bleeding (PUB) accounting for most gastrointestinal bleeding cases. The Japanese scoring system was developed to predict the probability of intervention in patients with UGIB, and it is more effective than other scoring systems, according to several studies. This study aimed to verify whether the Japanese scoring system is better than other scoring systems in predicting the probability of intervention when limited to PUB in patients with UGIB. We enrolled patients who presented with symptoms of UGIB and were diagnosed with peptic ulcers using endoscopy. The performances of the scoring systems in predicting patient outcomes were validated and compared using the receiver-operating characteristic curve analysis. Additionally, we used the chi-square test, Fisher exact test, and the t test to analyze the association between the patients characteristics and clinical outcomes. Of the 1228 patients diagnosed with peptic ulcers, 90.6% underwent endoscopy. rebleeding occurred in 12.5% of the patients, and 2.5% of the patients died within 30 days. The Japanese score was the most effective in predicting the need for endoscopic intervention for PUB. Sex, systolic blood pressure, hematemesis, syncope, blood urea nitrogen level, and the American Society of Anesthesiologists score were predictive factors for the probability of endoscopic intervention in patients with PUB. The Japanese score is an effective predictor of the probability of endoscopic intervention in patients with PUB.

External validation of Glasgow-Blatchford, modified Glasgow-Blatchford and CANUKA scores to identify low-risk patients with upper gastrointestinal bleeding in emergency departments: a retrospective cohort study

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a medical emergency with an approximate mortality of 10%, which results in a high hospitalisation rate. The Glasgow-Blatchford score (GBS) is recommended to identify low-risk patients who can be discharged from the emergency department (ED). A modified GBS (mGBS) and CANUKA score have recently been proposed but have not been well studied. The aim of this study was to assess whether the use of GBS, mGBS or CANUKA score could identify patients at low risk of death or need for intervention.

METHODS

A single-centre retrospective study was performed including patients with suspected UGIB visiting the ED of Saint-Antoine hospital (Paris, France) from January 2016 to December 2018. Demographic and medical data needed to calculate GBS and CANUKA were collected, as well as outcomes data. Need for intervention was defined as the need for blood transfusion, endoscopic haemostasis or rebleeding within 7 days. In-hospital mortality was also collected. Sensitivity, specificity and predictive values were measured for the score thresholds of interest.

RESULTS

A total of 386 patients were included. Median age was 60 years (38-78), 65.3% (n=252) were male and 60% (n=233) were hospitalised. A GBS≤1, mGBS=0 and CANUKA≤2 categorised 24.9%, 18.2% and 18.9% of patients as low risk, respectively. There was a need for intervention in 2.2%, 4.6% and 0% of those patients categorised as low risk by GBS, mGBS and CANUKA, respectively. No deaths occurred in the patients identified as low risk, regardless of the score used. All scores had a high sensitivity and negative predictive value.

CONCLUSIONS

In patients with UGIB, the use of a GBS≤1 or CANUKA score ≤2 appears to be safe for identifying patients at low risk of death or need for intervention.

Comparative study between histochemical mucus volume, histopathological findings, and endocytoscopic scores in patients with ulcerative colitis

Ulcerative colitis (UC) causes a reduction in goblet cells. However, there have been few reports on the relationship between endoscopic and pathological findings and mucus volume. In this study, we quantitatively evaluated histochemical colonic mucus volume by fixing biopsied tissue sections taken from patients with UC in Carnoy's solution and compared it with endoscopic and pathological findings to determine whether there is a correlation between them. Observational study. A single-center, university hospital in Japan. Twenty-seven patients with UC (male/female, 16/11; mean age, 48.4 years; disease median duration, 9 years) were included in the study. The colonic mucosa of the most inflamed area and the surrounding less inflamed area were evaluated separately by local MES and endocytoscopic (EC) classification. Two biopsies were taken from each area; one was fixed with formalin for histopathological evaluation, and the other was fixed with Carnoy's solution for the quantitative evaluation of mucus via histochemical Periodic Acid Schiff and Alcian Blue staining. The relative mucus volume was significantly reduced in the local MES 1-3 groups, with worsening findings in EC-A/B/C and in groups with severe mucosal inflammation, crypt abscess, and severe reduction in goblet cells. The severity of inflammatory findings in UC by EC classification correlated with the relative mucus volume suggesting functional mucosal healing. We found a correlation between the colonic mucus volume and endoscopic and histopathological findings in patients with UC, and a stepwise correlation with disease severity, particularly in EC classification.

Safety and Efficacy of Sedation During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis

BACKGROUND AND AIM

This study aimed to compare patients with and without sedation during emergency endoscopy for upper gastrointestinal bleeding (UGIB) and to clarify the safety and efficacy of sedation in emergency endoscopy.

METHODS

We retrospectively collected 389 patients who underwent emergency endoscopy for UGIB at Ureshino Medical Center from 2016 to 2021. Patients were divided into two groups: sedation group during emergency endoscopy and nonsedation group. Clinical characteristics, patient status on admission, and UGIB etiology were evaluated. Treatment outcomes and adverse events were evaluated using propensity score matching (PSM), and risk factors for mortality from UGIB were investigated using Cox multivariate analysis.

RESULTS

The sedation group was significantly younger, composed of a higher proportion of males, and had chronic liver disease. Blood pressure and hemoglobin level on admission were significantly higher in the sedation group. The main cause of bleeding was peptic ulcer, which was significantly higher in the nonsedation group. PSM created 133 matched pairs. The success rate of endoscopic hemostasis was similar in both groups, and procedure time was significantly shorter in the sedation group than in the nonsedation group (17.6 ± 10.0 versus 20.2 ± 10.2 min, P = 0.04). There were no significant differences in adverse events between groups. Cox multivariate analyses revealed that red blood cell transfusion [hazard ratio (HR) 4.45, P < 0.02] and rebleeding (HR 3.30, P = 0.03) were associated with increased risk of 30-day mortality from UGIB.

CONCLUSIONS

Sedation reduced the procedure time during emergency endoscopy for UGIB. Sedation during emergency endoscopy for UGIB is acceptable for safe endoscopic procedures.

Usefulness of the CHAMPS score for risk stratification in lower gastrointestinal bleeding

We have recently developed a simple prediction score, the CHAMPS score, to predict in-hospital mortality in patients with upper gastrointestinal bleeding. In this study, the primary outcome of this study was the usefulness of the CHAMPS score for predicting in-hospital mortality with lower gastrointestinal bleeding (LGIB). Consecutive adult patients who were hospitalized with LGIB at two tertiary academic medical centers from 2015 to 2020 were retrospectively enrolled. The performance for predicting outcomes with CHAMPS score was assessed by a receiver operating characteristic curve analysis, and compared with four existing scores. In 387 patients enrolled in this study, 39 (10.1%) of whom died during the hospitalization. The CHAMPS score showed good performance in predicting in-hospital mortality in LGIB patients with an AUC (95% confidence interval) of 0.80 (0.73–0.87), which was significantly higher in comparison to the existing scores. The risk of in-hospital mortality as predicted by the CHAMPS score was shown: low risk (score ≤ 1), 1.8%; intermediate risk (score 2 or 3), 15.8%; and high risk (score ≥ 4), 37.1%. The CHAMPS score is useful for predicting in-hospital mortality in patients with LGIB.

Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases

OBJECTS

Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB.

METHODS

Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents.

RESULTS

Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti-thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non-users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%).

CONCLUSIONS

Although the usage of anti-thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti-thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti-thrombotic agents.

AIMS65 predicts prognosis of patients with duodenal ulcer bleeding; a comparison with other risk-scoring systems

BACKGROUND AND AIM

Duodenal ulcer bleeding has a higher risk of mortality than bleeding from other portions of the gastrointestinal tract. AIMS65 is an effective risk-scoring system to predict prognosis of upper gastrointestinal bleeding and can be easily calculated without endoscopic findings. In this study, we investigate the usefulness of AIMS65 to predict prognosis of patients with duodenal ulcer bleeding.

METHODS

Two hundred and fifty-five patients with endoscopically diagnosed duodenal ulcer bleeding at Kurashiki Central hospital from July 2007 to June 2017 were studied. We compared AIMS65, Glasgow Blatchford score (GBS), admission Rockall, and full Rockall scoring systems for predicting in-hospital mortality by calculating area under the receiver operating characteristic curve (AUROC).

RESULTS

In-hospital mortality due to duodenal ulcer bleeding occurred in 17 (6.7%). Scores of all scoring systems were significantly higher in patients with in-hospital mortality than in patients without it. AUROC values for predicting in-hospital mortality was 0.83 in AIMS65, 0.74 in GBS, 0.76 in admission Rockall score, and 0.82 in full Rockall score, a statistically insignificant difference among the systems. In AIMS65, score more than or equal to 2 was an optimal value to predict in-hospital mortality, with sensitivities of 88.2% and specificities of 59.7%, respectively.

CONCLUSIONS

AIMS65 predicted in-hospital mortality of patients with duodenal ulcer bleeding as accurately as did other scoring systems. Given its simplicity of calculation, AIMS65 may be a more clinically practical system in the management of bleeding duodenal ulcer patients.

Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study

BACKGROUND

Few studies have reported whether a biopsy in emergency gastroscopy (EG) increased the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) combined with suspected malignant gastric ulcer (SMGU). This study aims to conduct a multicenter retrospective cohort study using propensity score matching to verify whether a biopsy in EG increases the risk of rebleeding in patients diagnosed with Forrest I ANVUGIB combined with SMGU.

METHODS

Using the data for propensity-matched patients, logistic regression models were fitted using rebleeding as the dependent variable. Survival time was defined as the length of time the patient experienced from visiting the emergency department to rebleeding. We used the Kaplan-Meier (KM) method to analyze the 30-day survival of the patients with and without a biopsy after matching, and the log-rank test was performed to examine the differences in survival.

RESULTS

With the use of propensity score matching, 308 patients who underwent a biopsy in EG were matched with 308 patients who did not. In the five logistic regression models, there were no significant group differences in the risk of rebleeding in patients with Forrest I ANVUGIB combined with SMGU between the biopsy and no-biopsy groups. The probability of survival was not significantly different between the no-biopsy and biopsy groups.

CONCLUSIONS

In this multicenter, retrospective propensity score matching cohort study, compared with patients without a biopsy, patients with a biopsy during EG had no increased risk of rebleeding, and there was no significant difference in the rate of rebleeding.

Differences in emergency endoscopy outcomes according to gastrointestinal bleeding location

BACKGROUND AND AIM

With recent technological advances in the field of endoscopic hemostasis, the prognosis of patients with gastrointestinal (GI) bleeding has improved. However, few studies have reported on the clinical course of patients with GI bleeding. This study aimed to evaluate the differences in clinical outcomes of patients with lower GI bleeding (LGIB) compared with upper GI bleeding (UGIB) and the factors related to their prognosis.

METHODS

Patients who had undergone emergency endoscopy for GI bleeding were retrospectively reviewed. The severity of GI bleeding was evaluated using the Glasgow-Blatchford (GB), AIMS65, and NOBLADS scores. Patients in whom obvious GI bleeding relapsed and/or iron deficiency anemia persisted after emergency endoscopy were considered to exhibit rebleeding.

RESULTS

We reviewed 1697 consecutive patients and divided them into UGIB (1054 patients) and LGIB (643 patients) groups. The proportion of patients with rebleeding was significantly greater in the UGIB group than in the LGIB group; the mortality rate was significantly higher in the UGIB group than in the LGIB group. Multivariate analysis showed that a GB score ≥12 and an AIMS65 score ≥2 were significantly associated with rebleeding in the UGIB group, whereas a NOBLADS score ≥4 was significantly associated with rebleeding in the LGIB group. Notably, the influence of emergency endoscopy differed according to GI bleeding location.

CONCLUSIONS

The clinical course was significantly worse in patients with UGIB than in patients with LGIB. The influence of emergency endoscopy differed according to GI bleeding location.

Prospective Comparison of the AIMS65 Score, Glasgow-Blatchford Score, and Rockall Score for Predicting Clinical Outcomes in Patients with Variceal and Nonvariceal Upper Gastrointestinal Bleeding

Background/Aims

This study aimed to determine the performance of the AIMS65 score (AIMS65), Glasgow-Blatchford score (GBS), and Rockall score (RS) in predicting outcomes in patients with upper gastrointestinal bleeding (UGIB), and to compare the results between patients with nonvariceal UGIB (NVUGIB) and those with variceal UGIB (VUGIB).

Methods

We conducted a prospective observational study between March 2016 and December 2017. Receiver operating characteristic curve analysis was performed for all outcomes for comparison. The associations of all three scores with mortality were evaluated using multivariate logistic regression analysis.

Results

Of the total of 337 patients with UGIB, 267 patients (79.2%) had NVUGIB. AIMS65 was significantly associated (odds ratio [OR], 1.735; 95% confidence interval [CI], 1.148–2.620), RS was marginally associated (OR, 1.225; 95% CI, 0.973–1.543), but GBS was not associated (OR, 1.017; 95% CI, 0.890–1.163) with mortality risk in patients with UGIB. However, all three scores accurately predicted all other outcomes (all p<0.05) except rebleeding (p>0.05). Only AIMS65 precisely predicted mortality, the need for blood transfusion and the composite endpoint (all p<0.05) in patients with VUGIB.

Conclusions

AIMS65 is superior to GBS and RS in predicting mortality in patients with UGIB, and also precisely predicts the need for blood transfusion and the composite endpoint in patients with VUGIB. No scoring system could satisfactorily predict rebleeding in all patients with UGIB.

Validation of a new risk score system for non-variceal upper gastrointestinal bleeding

BACKGROUND

Recently, a new international bleeding score was developed to predict 30-day hospital mortality in patients with upper gastrointestinal bleeding (UGIB). However, the efficacy of this newly developed scoring system has not been extensively investigated. We aimed to validate a new scoring system for predicting 30-day mortality in patients with non-variceal UGIB and determine whether a higher score is associated with re-bleeding, length of hospital stay, and endoscopic failure.

METHODS

A retrospective study was performed on 905 patients with acute non-variceal UGIB who were examined in our hospital between January 2013 and December 2017. Baseline characteristics, endoscopic findings, re-bleeding, admission, and mortality were reviewed. The 30-day mortality rate of the new international bleeding risk score was calculated using the receiver operating characteristic curves and compared to the pre-endoscopy Rockall score, AIMS65, Glasgow Blatchford score, and Progetto Nazionale Emorragia Digestiva score. To verify the variable for the 30-day mortality of the new scoring system, we performed multivariate logistic regression using our data and further analyzed the score items.

RESULTS

The new international bleeding scoring system showed higher receiver operating characteristic (ROC) curve values in predicting mortality (area under ROC curve 0.958; [95% confidence interval (CI)]), compared with such as AIMS65 (AUROC, 0.832; 95%CI, 0.806-0.856; P < 0.001), PNED (AUROC, 0.865; 95%CI, 0.841-0.886; P < 0.001), Pre-RS (AUROC, 0.802; 95%CI, 0.774-0.827; P < 0.001), and GBS (AUROC, 0.765; 95%CI, 0.736-0.793; P < 0.001). Multivariate analysis was performed using our data and showed that the 30-day mortality rate was related to multiple comorbidities, blood urea nitrogen, creatinine, albumin, syncope at first visit, and endoscopic failure within 24 h during the first admission. In addition, in the high-score group, relatively long hospital stay, re-bleeding, and endoscopic failure were observed.

CONCLUSION

This is a preliminary report of a new bleeding score which may predict 30-day mortality better than the other scoring systems. High-risk patients could be screened using this new scoring system to predict 30-day mortality. The use of this scoring system seemed to improve the outcomes of non-variceal UGIB patients in this study, through proper management and intervention.

[Optimization of surgical care for the hemorrhagic colorectal cancer]

AIM

To optimize surgical care for the hemorrhagic colorectal cancer.

MATERIAL AND METHODS

77 patients diagnosed with hemorrhagic colorectal cancer were reviewed: 9 patients of them were efficaciously treated with conservative therapy (I group); 47 - underwent successful endoscopic coagulation (I); 4 - arterial embolization (I), 2 - ligation of internal iliac arteries (I), 15 - acute resection (II group). 20 of 62 patients I group underwent plan surgery and radiation or chemotherapy during 7-10 days after hemostasis and normalization hemoglobin. The 3-year cumulative survival after resections (acute versus plan) was plotted on a Kaplan-Meier chart in 31 patients.

RESULTS

Complications and postoperative mortality was significantly higher after acute resection (II group) compared with plan resection (I): 33,3% vs 20%; 15% vs 5%, respectively. The survival rate was higher after plan than acute resections: 0,8882 and 0,3571, respectively.

CONCLUSION

Acute surgery for hemorrhagic colorectal cancer should only be carried out by appropriately trained surgeons in multi-specialty hospital. Endoscopy and arterial embolization are the most effective means of successfully controlling hemorrhage while minimizing potential complications. A bridging strategy may be a valid alternative in some of patients with hemorrhagic colorectal cancer, because a significantly lower postoperative mortality rate.

Comparison of clinical prediction tools and identification of risk factors for adverse outcomes in acute lower GI bleeding

BACKGROUND AND AIMS

Limited data exist on prediction of adverse outcomes in patients with acute lower GI bleeding (LGIB). The purpose of our study was to compare the ability of existing validated clinical risk scores to predict relevant outcomes in LGIB.

METHODS

We performed a prospective observational study of patients admitted with LGIB who underwent colonoscopy at a single center between April 2016 and September 2017. Seven risk scores were calculated at admission (Strate, NOBLADS, Sengupta, Oakland, Blatchford, AIMS65, and Charlson Comorbidity Index). The risk of severe LGIB was determined via univariable and multivariable logistic regression. Area under the receiver operating characteristic curve (AUC) analysis was used to compare the scores.

RESULTS

We included 170 patients admitted with LGIB requiring colonoscopy. Fifty-two percent (n = 89) fit criteria for severe bleeding. Patients with severe bleeding had lower admission hemoglobin levels (8.6 g/dL vs 11.1 g/dL; P = .0001), were more likely to have blood transfusions (85% vs 36%; P < .0001), intensive care unit stays (49% vs 19%; P < .0001), and had a longer length of stay (6 days vs 4 days; P = .0009). The Oakland score was best for prediction of severe bleeding (AUC, .74), Blatchford score for blood transfusion (AUC, .87), and Strate score for in-hospital recurrent bleeding (AUC, .66) and endoscopic intervention (AUC, .62). The strongest individual predictors of severe bleeding were low admission hemoglobin (odds ratio, 1.28 per 1-g/dL decrease; P = .0015; 95% confidence interval, 1.10-1.49) and low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02; 95% confidence interval, 1.16-5.56).

CONCLUSION

Admission albumin and hemoglobin levels were the strongest predictors of severe bleeding. No singular clinical risk tool had the best predictive ability across all outcomes.

Clinical features of acute lower gastrointestinal bleeding and its diagnostic strategy with emergency enteroscopy

AIM

To investigate the clinical features of acute lower gastrointestinal bleeding and its diagnostic strategy with emergency enteroscopy.

METHODS

Two hundred and ten patients with acute lower gastrointestinal bleeding at our hospital from January 2014 to December 2017 were selected, and the clinical features of acute lower gastrointestinal bleeding were analyzed. The patients were then divided into two groups based on the bowel preparation method used: a cleansing enema group (169 cases) and an oral cathartic group (41 cases). The influence of intestinal tract cleanliness on emergency enteroscopy diagnosis was then analyzed.

RESULTS

The ratio of males to females in 210 patients was 1.50:1. The elderly, middle-aged, and young patients accounted for 45.71% (96/210), 29.05% (61/210), and 25.24% (53/210), respectively. There were 10.48% of hidden blood loss and 89.52% of overt blood loss. The hemorrhage was mostly common with melena, bright red bloody stools, and dark red bloody stools. The bleeding was mostly caused by intestinal inflammation or infection (35.71%) and polyps of the rectum and colon (20.95%). Colorectal cancer, intestinal inflammation or infection, and polyps of the rectum and colon were main causes in the elderly group. Intestinal inflammation or infection, polyps of the rectum and colon, and colorectal cancer were main causes in the middle-aged group. Intestinal inflammation or infection, polyps of the rectum and colon, and vascular disease were main causes in the young group. The excellent rate of intestinal tract cleanliness in the cleansing enema group was lower than that of the oral cathartic group (P < 0.05). The diagnostic accuracy of enteroscopy with excellent, good, and poor cleanliness was 91.04% (61/67), 80.85% (38/47), and 52.42% (65/124), respectively. The diagnostic accordance rate of enteroscopy with excellent or good cleanliness was higher than that of enteroscopy with poor cleanliness (P < 0.05). There was no statistical difference in the diagnostic accordance rate between enteroscopy with excellent and good cleanliness (P > 0.05).

CONCLUSION

Acute lower gastrointestinal hemorrhage is common in males and the elderly population. Main causes are intestinal inflammation and polyps of the rectum and colon, and there is certain difference in the causes of bleeding in patients of different ages. Hemorrhage is mostly common with melena, bright red bloody stools, and dark red bloody stools. Good intestinal tract cleanliness can increase the diagnostic rate of emergency enteroscopy, and the intestinal tract cleanliness associated with oral cathartic is better than that of cleansing enema. Therefore, based on patient's hemodynamic stability, using bowel preparation with oral cathartic can improve the diagnostic accordance rate.

Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding

BACKGROUND AND AIMS

Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding.

METHODS

We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs.

RESULTS

A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p < .001, odds ratio [OR], 2.484) and prolonged prothrombin time-international normalized ratio (PT-INR) (p = .033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p = .043).

CONCLUSIONS

Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.

Is the AIMS 65 Score Useful in Prepdicting Clinical Outcomes in Korean Patients with Variceal and Nonvariceal Upper Gastrointestinal Bleeding?

Background/Aims

Various clinical scoring systems, including the Glasgow-Blatchford score (GBS), Rockall risk score (RS), and AIMS65 score (AIMS65), have been validated to predict the clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). We compared the performance of these three scoring systems in predicting clinical outcomes in patients with UGIB in Korea.

Methods

We retrospectively evaluated 286 patients with UGIB who visited emergency department. The primary outcome was the need for clinical intervention (endoscopic, radiologic, or surgical) and blood transfusion.

Results

The causes of UGIB were esophageal/gastric varices in 64 patients, peptic ulcer in 168, Mallory-Weiss tear in 32, malignancy of UGI tract in eight, and unknown in 14. One hundred seventy-four (61%) patients required blood transfusion, 166 (58%) required endoscopic intervention, and 10 (3.5%) required surgical intervention. The GBS outperformed the RS and AIMS65 in predicting the need for endoscopic intervention.

Conclusions

The GBS and RS were more accurate than AIMS65 in predicting the need for clinical interventions and transfusion patients with UGIB, regardless of variceal or nonvariceal bleeding. The AIMS65 may not be optimal for predicting clinical outcomes of UGIB in Korea.

Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes

Introduction

Although different scores have been suggested to predict outcomes in the setting of upper gastrointestinal bleeding (UGIB), few comparative studies between simplified versions of older scores and recent scores have been published. We aimed to evaluate the accuracy of pre- (PreRS) and postendoscopic Rockall scores (PostRS), the Glasgow-Blatchford score (GBS) and its simplified version (sGBS), as well as the AIMS65 score in predicting different clinical outcomes.

Methods

In this retrospective study, PreRS, PostRS, GBS, sGBS, and AIMS65 score were calculated, and then, areas under the receiver operating characteristic curve were used to evaluate the performance of each score to predict blood transfusion, endoscopic therapy, surgery, admission to intensive/intermediate care unit, length of hospital stay, as well as 30-day rebleeding or mortality.

Results

PreRS, PostRS, GBS, and sGBS were calculated for all the 433 included patients, but AIMS65 calculation was only possible for 315 patients. Only the PreRS and PostRS were able to fairly predict 30-day mortality. The GBS and sGBS were good in predicting blood transfusion and reasonable in predicting surgery. None of the studied scores were good in predicting the need for endoscopic therapy, admission to intensive/intermediate care unit, length of hospital stay, and 30-day rebleeding.

Conclusions

Owing to the identified limitations, none of the 5 studied scores could be singly used to predict all the clinically relevant outcomes in the setting of UGIB. The sGBS was as precise as the GBS in predicting blood transfusion and surgery. The PreRS and PostRS were the only scores that could predict 30-day mortality. An algorithm using the PreRS and the sGBS as an initial approach to patients with UGIB is presented and suggested.

[Urgent surgical care for patients with colon cancer complicated by hemorrhage]

AIM

To evaluate an effectiveness of various hemostatic methods in patients with colon and rectal cancer.

MATERIAL AND METHODS

77 urgent patients with colon and rectal cancer complicated by bleeding were enrolled. Medication was effective in 11 patients (group 1), endoscopic hemostasis in 47 patients (group 2), vascular embolization in 2 cases (group 3), internal iliac arteries ligation in 2 patients (group 4), 15 patients underwent emergency resection (group 5). Twenty out of 62 patients in groups 1-4 underwent elective radical procedures and radio- or chemotherapy in 7-10 days after hemostasis and normalization of hemoglobin. 3-year Kaplan-Meier survival was assessed after emergency (group 5) and elective surgery (groups 1-4) in 31 patients.

RESULTS

Effectiveness of various hemostatic methods was 14.3% in group 1, 79.7% in group 2, 28.6% in group 3 and 100% in groups 4 and 5. Postoperative morbidity and mortality were higher after emergency (group 5) compared with elective (groups 1-4) procedures: 33.3 and 20%; 15 and 5% respectively. 3-year survival was better after elective than emergency operations - 0.78 and 0.57, respectively.

CONCLUSION

Management of bleeding should be carried out by highly qualified specialist at multi-field emergency care hospital. Endoscopy and arterial embolization are the most effective methods of hemostasis with minimal risk of complications. In hemorrhage patients endoscopy and embolization ("bridge to surgery") are an alternative to conditionally radical operations, since they allow to reduce mortality.

Differences in the clinical course of 516 Japanese patients with upper gastrointestinal bleeding between weekday and weekend admissions

BACKGROUND AND AIMS

Patients suspected of having upper gastrointestinal bleeding (UGIB) admitted during the weekend tend to have a poor outcome in western countries. However, no Japanese studies have been reported on this matter. We aimed to evaluate differences in the clinical course of patients with UGIB between weekday and weekend admissions in Japan.

METHODS

Medical records of patients who had undergone emergency endoscopy for UGIB were retrospectively reviewed. The severity of UGIB was evaluated using the Glasgow-Blatchford (GB) and AIMS65 score. Patients in whom UGIB was stopped and showed improved iron deficiency anemia after admission were considered as having a good clinical course.

RESULTS

We reviewed 516 consecutive patients and divided them into two groups: Group A (daytime admission on a weekday: 234 patients) and Group B (nighttime or weekend admission: 282 patients). There was no significant difference in GB and AIM65 scores between the Groups. The proportions of patients with good clinical course were not significantly different between groups (A, 67.5% and B, 67.0%; p = .90). However, patients in Group B underwent hemostatic treatments more frequently compared with those in Group A (58.5% vs 47.4%, p = .012). Multivariate analysis showed that taking acid suppressants, no need for blood transfusions, use of hemostatic treatments, and GB score <12 were associated with a good clinical course.

CONCLUSIONS

There were no significant differences in the clinical outcomes of patients with UGIB admitted during daytime on weekdays and those admitted at nighttime or weekends partly owing to the sufficient performance of endoscopic hemostatic treatments.

[Urgent surgical care for patients with colon cancer complicated by hemorrhage]

AIM

Comparative evaluation of the effectiveness of various hemostatic methods in patients with colon and rectal cancer complicated by bleeding.

MATERIAL AND METHODS

We examined 77 hospitalized patients with colon and rectal cancer complicated by bleeding. Conservative therapy was effective in 11 patients (group I), endoscopic hemostasis in 49 cases (group II), 17 patients underwent emergency surgery (bowel resection/ internal iliac arteries ligation) (group III). Vascular embolization was performed in 2 patients. 20 out of 77 patients in groups I-II underwent elective surgery and radiochemotherapy in 7-10 days after hemorrhage and normalization of hemoglobin. 3-year Kaplan-Meier survival was assessed after emergency (group III) and elective (I-II) interventions in 37 survivors.

RESULTS

The effectiveness of various methods of hemostasis was 14.3% in group I, 80.3% in group II and 100% in group III. Embolization was ineffective (patients underwent surgery). Complications were observed in 4.9% (II) and 29.4% (III), respectively. Mortality was significantly higher after conditionally radical surgery than after endoscopy: 17.6% vs. 0. 3-year survival was better after elective interventions compared with emergency surgery (0.79 vs. 0.64, respectively).

CONCLUSION

Endoscopy is the most effective method to stop colonic bleeding with minimal complications. It is a 'bridge to surgery' and alternative to conditionally radical operations in order to reduce mortality. Treatment of bleeding should be carried out in multi-field hospital by highly qualified specialists.

Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study

BACKGROUND

Acute lower gastrointestinal bleeding is a common reason for emergency hospital admission, and identification of patients at low risk of harm, who are therefore suitable for outpatient investigation, is a clinical and research priority. We aimed to develop and externally validate a simple risk score to identify patients with lower gastrointestinal bleeding who could safely avoid hospital admission.

METHODS

We undertook model development with data from the National Comparative Audit of Lower Gastrointestinal Bleeding from 143 hospitals in the UK in 2015. Multivariable logistic regression modelling was used to identify predictors of safe discharge, defined as the absence of rebleeding, blood transfusion, therapeutic intervention, 28 day readmission, or death. The model was converted into a simplified risk scoring system and was externally validated in 288 patients admitted with lower gastrointestinal bleeding (184 safely discharged) from two UK hospitals (Charing Cross Hospital, London, and Hammersmith Hospital, London) that had not contributed data to the development cohort. We calculated C statistics for the new model and did a comparative assessment with six previously developed risk scores.

FINDINGS

Of 2336 prospectively identified admissions in the development cohort, 1599 (68%) were safely discharged. Age, sex, previous admission for lower gastrointestinal bleeding, rectal examination findings, heart rate, systolic blood pressure, and haemoglobin concentration strongly discriminated safe discharge in the development cohort (C statistic 0·84, 95% CI 0·82-0·86) and in the validation cohort (0·79, 0·73-0·84). Calibration plots showed the new risk score to have good calibration in the validation cohort. The score was better than the Rockall, Blatchford, Strate, BLEED, AIMS65, and NOBLADS scores in predicting safe discharge. A score of 8 or less predicts a 95% probability of safe discharge.

INTERPRETATION

We developed and validated a novel clinical prediction model with good discriminative performance to identify patients with lower gastrointestinal bleeding who are suitable for safe outpatient management, which has important economic and resource implications.

FUNDING

Bowel Disease Research Foundation and National Health Service Blood and Transplant.

Comparison of three scoring systems in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding: a prospective observational study

OBJECTIVE

To compare the performances of the Glasgow-Blatchford score (GBS), modified GBS (mGBS) and AIMS65 in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding (AUGIB).

METHODS

This study enrolled 320 consecutive patients with AUGIB. Patients at high and low risks of developing adverse clinical outcomes (rebleeding, the need of clinical intervention and death) were categorized according to the GBS, mGBS and AIMS65 scoring systems. The outcome of the patients were the occurrences of adverse clinical outcomes. The areas under the receiver operating characteristics curve (AUROC) of three scoring systems were compared.

RESULTS

Irrespective of the systems used, the high-risk groups showed higher rates of rebleeding, intervention and death compared with the low-risk groups (P < 0.05). For the prediction of rebleeding, AIMS65 (AUROC 0.735, 95% CI 0.667-0.802) performed significantly better than GBS (AUROC 0.672, 95% CI 0.597-0.747; P < 0.01) and mGBS (AUROC 0.677, 95% CI 0.602-0.753; P < 0.01). For the prediction of interventions, there was no significant difference among the three systems (GBS: AUROC 0.769, 95% CI 0.668-0.870; mGBS: AUROC 0.745, 95% CI 0.643-0.847; AIMS65: AUROC 0.746, 95% CI 0.640-0.851). For the prediction of in-hospital mortality, there was no significant difference among the three systems (GBS: AUROC 0.796, 95% CI 0.694-0.898; mGBS: AUROC 0.803, 95% CI 0.703-0.904; AIMS65: AUROC 0.786, 95% CI 0.670-0.903).

CONCLUSIONS

The three scoring systems are reliable and accurate in predicting the rates of rebleeding, surgery and mortality in AUGIB. However, AIMS65 outperforms GBS and mGBS in predicting rebleeding.

Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients

BACKGROUND AND AIM

Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding.

METHODS

We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness.

RESULTS

Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m² , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]).

CONCLUSION

We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding.

Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems

BACKGROUND AND AIMS

The American College of Gastroenterology recommends early risk stratification in patients presenting with upper GI bleeding (UGIB). The AIMS65 score is a risk stratification score previously validated to predict inpatient mortality. The aim of this study was to validate the AIMS65 score as a predictor of inpatient mortality in patients with acute UGIB and to compare it with established pre- and postendoscopy risk scores.

METHODS

ICD-10 (International Classification of Diseases, Tenth Revision) codes identified patients presenting with UGIB requiring endoscopy. All patients were risk stratified by using the AIMS65, Glasgow-Blatchford score (GBS), pre-endoscopy Rockall, and full Rockall scores. The primary outcome was inpatient mortality. Secondary outcomes were a composite endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic, or surgical intervention; blood transfusion requirement; intensive care unit (ICU) admission; rebleeding; and hospital length of stay. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.

RESULTS

Of the 424 study patients, 18 (4.2%) died and 69 (16%) achieved the composite endpoint. The AIMS65 score was superior to both the GBS (AUROC, 0.80 vs 0.76, P < .027) and the pre-endoscopy Rockall score (0.74, P = .001) and equivalent to the full Rockall score (0.78, P = .18) in predicting inpatient mortality. The AIMS65 score was superior to all other scores in predicting the need for ICU admission and length of hospital stay. AIMS65, GBS, and full Rockall scores were equivalent (AUROCs, 0.63 vs 0.62 vs 0.63, respectively) and superior to pre-endoscopy Rockall (AUROC, 0.55) in predicting the composite endpoint. GBS was superior to all other scores for predicting blood transfusion.

CONCLUSION

The AIMS65 score is a simple risk stratification score for UGIB with accuracy superior to that of GBS and pre-endoscopy Rockall scores in predicting in-hospital mortality and the need for ICU admission.

Risk assessment in acute non-variceal upper GI bleeding: the AIMS65 score in comparison with the Glasgow-Blatchford score in a Scottish population

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.

Upper gastrointestinal bleeding risk scores: Who, when and why?

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.

The AIMS65 Score Is a Useful Predictor of Mortality in Patients with Nonvariceal Upper Gastrointestinal Bleeding: Urgent Endoscopy in Patients with High AIMS65 Scores

BACKGROUND/AIMS

To validate the AIMS65 score for predicting mortality of patients with nonvariceal upper gastrointestinal bleeding and to evaluate the effectiveness of urgent (<8 hours) endoscopic procedures in patients with high AIMS65 scores.

METHODS

This was a 5-year single-center, retrospective study. Nonvariceal, upper gastrointestinal bleeding was assessed by using the AIM65 and Rockall scores. Scores for mortality were assessed by calculating the area under the receiver-operating characteristic curve (AUROC). Patients with high AIMS65 scores (≥2) were allocated to either the urgent or non-urgent endoscopic procedure group. In-hospital mortality, success of endoscopic procedure, recurrence of bleeding, admission period, and dose of transfusion were compared between groups.

RESULTS

A total of 634 patients were analyzed. The AIMS65 score successfully predicted mortality (AUROC=0.943; 95% confidence interval [CI], 0.876 to 0.99) and was superior to the Rockall score (AUROC=0.856; 95% CI, 0.743 to 0.969) in predicting mortality. The group with high AIMS65 score included 200 patients. The urgent endoscopic procedure group had reduced hospitalization periods (p<0.05).

CONCLUSIONS

AIMS65 score may be useful in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding. Urgent endoscopic procedures in patients with high scores may be related to reduced hospitalization periods.

Time trends of the impact of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs on peptic ulcer bleeding in Japanese patients

BACKGROUND/AIMS

Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the main causes of peptic ulcers. The purpose of the present study was to elucidate the time trends of the impact of H. pylori infection and use of NSAIDs and/or antithrombotic agents on peptic ulcer bleeding (PUB) in Japanese patients.

METHODS

We retrospectively reviewed 719 patients who had received endoscopic hemostasis for PUB between 2002 and 2013. Subjects were divided into either the first-half group (2002-2007, n = 363) or the second-half group (2008-2013, n = 356). The clinical characteristics of the patients, including the prevalence of H. pylori infection and use of NSAIDs and antithrombotic agents, were compared between the two groups.

RESULTS

Compared to the first-half group, patients in the second-half group were characterized by older age (proportion of the patients above 60 years old, 63.9 vs. 76.7%, p = 0.0002), less frequent H. pylori infection (71.6 vs. 57.9%, p < 0.001) and more frequent NSAID intake (39.9 vs. 48.6%, p = 0.02). No significant difference was observed regarding the use of antithrombotic agents between the two groups (18.6 vs. 23.3%, p = 0.13). The prevalence of H. pylori infection and proportion of patients above 60 years old were significantly different between the two groups in a multivariate analysis.

CONCLUSION

The main cause of PUB has clearly shifted from H. pylori infection to the use of NSAIDs over the last decade.

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage

Background/Aims

To evaluate the ability of the recently proposed albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65) score to predict mortality in patients with acute upper gastrointestinal bleeding (UGIB).

Methods

AIMS65 scores were calculated in 251 consecutive patients presenting with acute UGIB by allotting 1 point each for albumin level <30 g/L, INR >1.5, alteration in mental status, systolic blood pressure ≤90 mm Hg, and age ≥65 years. Risk stratification was done during the initial 12 hours of hospital admission.

Results

Intensive care unit (ICU) admission, endoscopic therapy, or surgery were required in 51 patients (20.3%), 64 (25.5%), and 12 (4.8%), respectively. The predictive accuracy of AIMS65 scores ≥2 was high for blood transfusion (area under the receiver operator characteristic curve [AUROC], 0.59), ICU admission (AUROC, 0.61), and mortality (AUROC, 0.74). The overall mortality was 10.3% (n=26), and was 3%, 7.8%, 20%, 36%, and 40% for AIMS65 scores of 0, 1, 2, 3, and 4, respectively; these values were significantly higher in those with scores ≥2 (30.9%) than in those with scores <2 (4.5%, p<0.001).

Conclusions

AIMS65 is a simple, accurate, non-endoscopic risk score that can be applied early (within 12 hours of hospital admission) in patients with acute UGIB. AIMS65 scores ≥2 predict high in-hospital mortality.

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

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.

Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding

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.

Comparison of the Glasgow-Blatchford and AIMS65 scoring systems for risk stratification in upper gastrointestinal bleeding in the emergency department

OBJECTIVES

The aim of this study was to compare the performance of the Glasgow-Blatchford and the AIMS65 scoring systems as early risk assessment tools for accurately identifying patients with upper gastrointestinal (GI) bleeding who are at a low risk of requiring clinical interventions, including emergency endoscopy. The secondary objective was to compare their performance regarding relevant clinical outcomes.

METHODS

Data were collected prospectively over a 2-year period in the emergency department of a university hospital. Adult patients with upper GI bleeding from either variceal or nonvariceal sources were included. Composite clinical outcomes consisted of a need for surgical or endoscopic intervention, rebleeding, intensive care unit admission, or in-hospital mortality. Patients who required blood transfusions or suffered composite clinical outcomes were considered high-risk patients. Glasgow-Blatchford score (GBS) and AIMS65 score were calculated for each patient. The sensitivity and specificity of the scoring systems were calculated. The areas under the receiver-operating characteristic curve (AUC) of the scores were compared.

RESULTS

There were 254 patients in the study, of whom 163 (64.2%) were men. The median age was 61 years (interquartile range = 45 to 72 years). Among the patients, 211 (83.1%) underwent endoscopy, of whom 49 (19.3%) required endoscopic intervention to achieve hemostasis. Five (2%) patients required surgical intervention. Rebleeding was observed in 33 (13%) patients. A total of 143 (56.3%) patients received blood transfusions. A total of 152 (59.8%) were defined as high risk. Eighty-one (31.9%) experienced at least one component of the composite clinical outcomes, 18 (7.1%) of whom suffered in-hospital mortality. A GBS of 0 was observed in 16 patients (6.3%) in the study group. Two of these were high-risk patients. A total of 101 (39.8%) patients had AIMS65 scores of 0. Thirty-four of these were high-risk patients. A GBS of 0 had higher sensitivity than an AIMS65 score of 0 (98.68% vs. 77.6%). The negative predictive values of the GBS and AIMS65 of 0 were 87.5 and 66.3%, respectively. The GBS and AIMS65 were similar with regard to the composite outcome prediction, with AUCs of 0.795 (95% confidence interval [CI] = 0.74 to 0.843) and 0.746 (95% CI = 0.688 to 0.798), respectively (p = 0.137). The scores were also similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; p = 0.342). The GBS was superior to the AIMS65 in identifying high-risk patients, with AUCs of 0.896 (95% CI = 0.85 to 0.93) and 0.771 (95% CI = 0.714 to 0.821; p < 0.001), respectively. The GBS was also more accurate than the AIM65 in predicting the need for blood transfusions (AUCs of 0.904 vs. 0.796; p < 0.001) and interventions (AUCs of 0.727 vs. 0.647; p = 0.05).

CONCLUSIONS

These results suggest that the GBS has superior sensitivity relative to the AIMS65 in identifying patients who were not likely to require interventions, including emergency endoscopy. Additional work to determine the use in real-time decision making may be warranted and helpful in providing guidance to clinicians.

Prognostic Value of AIMS65 Score in Cirrhotic Patients with Upper Gastrointestinal Bleeding

Introduction. Unlike Rockall scoring system, AIMS65 is based only on clinical and laboratory features. In this study we investigated the correlation between the AIMS65 score and Endoscopic Rockall score, in cirrhotic and noncirrhotic patients. Methods. This is a retrospective study of patients admitted with overt UGIB and undergoing esophagogastroduodenoscopy (EGD). AIMS65 and Rockall scores were calculated at the time of admission. We investigated the correlation between both scores along with stigmata of bleed seen on endoscopy. Results. A total of 1255 patients were studied. 152 patients were cirrhotic while 1103 patients were noncirrhotic. There was significant correlation between AIMS65 and Total Rockall scores in patients of both groups. There was significant correlation between AIMS65 score and Endoscopic Rockall score in noncirrhotics but not cirrhotics. AIMS65 scores in both cirrhotic and noncirrhotic groups were significantly higher in patients who died from UGIB than in patients who did not. Conclusion. We observed statistically significant correlation between AIMS65 score and length of hospitalization and mortality in noncirrhotic patients. We found that AIMS65 score paralleled the endoscopic grading of lesion causing UGIB in noncirrhotics. AIMS65 score correlated only with mortality but not the length of hospitalization or endoscopic stigmata of bleed in cirrhotics.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

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.

[Upper gastrointestinal bleeding and haemorrhagic shock at the end of the holidays: pre-hospital and in-hospital management of a gastrointestinal emergency]

Upon returning from holidays, a 55-year-old patient presenting with melena and haemorrhagic shock was admitted to a University hospital after receiving first emergency medical care in a German InterCity train. In an interdisciplinary effort, haemodynamics were stabilised and the airway and respiratory function were secured. Under emergency care conditions the patient then underwent an emergency upper GI endoscopy where a spurting arterial upper gastrointestinal bleeding (Forrest 1a) was found. While the bleeding could not be controlled with endoscopic techniques, definitive haemostasis was achieved with a surgical laparotomy. While not commonly established for patients with severe GI bleeding, by spontaneous implementation of an interdisciplinary trauma room approach following established trauma algorithms the team was able to achieve stabilisation of vital functions and final control of bleeding in this highly unstable patient. Although the majority of upper gastrointestinal bleedings spontaneously cease, emergency care algorithms should be developed and implemented for patients with severe gastrointestinal bleedings in shock. Following the case vignette, we discuss a potential approach and develop an exemplary protocol for shock room management in this patient subgroup.