Acute Lower Gastrointestinal Bleeding in an Emergency Department and Performance of the SHA2PE Score: A Retrospective Observational Study

Which scoring systems are useful for predicting the prognosis of lower gastrointestinal bleeding? Old and new

BACKGROUND

The incidence of lower gastrointestinal bleeding is on the rise, prompting the creation of various scoring systems to forecast patient's outcomes. But there is no single unified scoring system and these scoring systems clinical data are small and not worldwide.

AIMS

To evaluate how different scoring systems predict mortality and prolonged hospital stay (≥ 10 days).

METHODS

A retrospective review was conducted on the medical records of 4417 patients who presented with hematochezia at the emergency department from January 2016 to December 2022. We evaluated the predictive accuracy of various scoring systems for 30-day mortality and prolonged hospital stay (≥ 10 days) by analyzing the areas under the receiver-operating characteristic curves, taking into account factors such as patient age, laboratory findings, and comorbidities (ABC); AIMS 65; Glasgow-Blatchford; Oakland; Rockall(pre-endoscopy); SHA2PE; and CHAMPS scores.

RESULTS

We analyzed data from 1000 patients (mean age 66 years, 56.1% men, mean hospital stay 9.4 days) with lower gastrointestinal bleeding confirmed by any other means including DRE, colonoscopy and CT. The 30-day mortality rate was 3.7%. The primary etiologies of lower gastrointestinal bleeding were identified as ischemic colitis and diverticular bleeding, accounting for 18.8% and 18.5% of cases, respectively. In terms of forecasting 30-day mortality, the AIMS 65, CHAMPS, and ABC scoring systems demonstrated superior performance (p < 0.001). For predicting prolonged hospital stay, the SHA2PE score exhibited the highest accuracy among all evaluated systems (p < 0.001).

CONCLUSIONS

The newly developed scoring systems demonstrated superior accuracy in forecasting outcomes for patients with lower gastrointestinal bleeding, and the results of this study demonstrate that these scoring systems can be applied in clinical practice.

External Validation of SHA2PE Score: A Score to Predict Low-Risk Lower Gastrointestinal Bleeding in the Emergency Department

Introduction: Lower gastrointestinal bleeding (LGIB) frequently leads to emergency department (ED) visits and hospitalizations, encompassing a spectrum of outcomes from spontaneous resolution to intrahospital mortality. Aim: The purpose of this study was to validate a scoring system designed to identify cases of low-risk LGIB, allowing for safe discharge from the ED. Methods: A retrospective analysis of all gastrointestinal bleeding cases presented at three EDs in 2020 was conducted, focusing specifically on patients with LGIB. The SHA2PE score incorporates factors such as systolic blood pressure, hemoglobin levels, use of antiplatelet or anticoagulant medications, pulse rate, and episodes of bright blood per rectum. Results: Out of 1112 patients presenting with LGIB to the ED, 55 were hospitalized, 20 required blood transfusions, 15 underwent colonoscopies, one underwent interventional radiology procedures, and two patients died. Employing a SHA2PE score with a cutoff value of 1 yielded a specificity of 78.5% (95% CI (confidence interval) [75.8-81.0]), sensitivity of 76.8% (95% CI [63.6-87.0]), positive predictive value (PPV) of 17.0% (95% CI [12.6-22.2]), and negative predictive value (NPV) of 98.3% (95% CI [97.2-99.1]) for predicting the need for hospitalization and intrahospital intervention. When considering return visits to the ED within 7 days with the same presentation, the score demonstrated a specificity of 78.8% (95% CI [76.0-81.3]), sensitivity of 68.6% (95% CI [56.4-79.1]), PPV of 19% (95% CI [14.3-24.4]), and NPV of 97.2% (95% CI [95.8-98.2]). Conclusions: The SHA2PE score demonstrates potential in predicting cases of low-risk LGIB, offering a high NPV for hospitalization, the need for intrahospital intervention, and return visits to the ED. However, these findings should be interpreted cautiously given the low prevalence of interventions and limitations in the study's population and design.

External validation of the SHA2PE score and its comparison to the Oakland score for the prediction of safe discharge in patients with lower gastrointestinal bleeding

BACKGROUND

The growing incidence of lower gastrointestinal bleeding (LGIB) is leading to a rise in-hospital admissions even though most LGIB episodes are self-limiting. The Oakland and SHA2PE scores were designed to identify patients best suited to outpatient care. Our aim is explore the validity of the SHA2PE score and compare both of these scores in terms of predictiveness of safe discharge.

METHODS

Retrospective observational study of LGIB patients admitted to a tertiary hospital between June 2014 and June 2019. Safe discharge was defined as the absence of all the following: blood transfusion, haemostatic intervention, re-bleeding, in-hospital death, and re-admission due to LGIB within 28 days after discharge.

RESULTS

From 595 hospital admissions for LGIB, 398 episodes were included. Fifty-four per cent met safe discharge criteria, with these cases being younger, with a lower score in the Charlson's index and significantly higher haemoglobin concentration upon arrival. The performance of both scores was good, with an AUC for the Oakland score of 0.85 (95% CI 0.82-0.89) and of 0.797 (95% CI 0.75-0.84) for the SHA2PE score. The Oakland score performed better in terms of prediction of safe discharge, with a positive predictive value and specificity of 100% when a cut-off value of ≤ 8 points was used; however, only a minority of patients might benefit from its implementation given its low sensitivity.

CONCLUSIONS

Almost half of the patients admitted for LGIB met criteria for safe discharge. However, the available indexes only allow for the identification of a small proportion of those patients candidates for outpatient care.

Emergency medicine updates: Lower gastrointestinal bleeding

INTRODUCTION

Lower gastrointestinal bleeding (LGIB) is a condition commonly seen in the emergency department. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning LGIB for the emergency clinician.

DISCUSSION

LGIB is most commonly due to diverticulosis or anorectal disease, though there are a variety of etiologies. The majority of cases resolve spontaneously, but patients can have severe bleeding resulting in hemodynamic instability. Initial evaluation should focus on patient hemodynamics, the severity of bleeding, and differentiating upper gastrointestinal bleeding from LGIB. Factors associated with LGIB include prior history of LGIB, age over 50 years, and presence of blood clots per rectum. Computed tomography angiography is the imaging modality of choice in those with severe bleeding to diagnose the source of bleeding and guide management when embolization is indicated. Among stable patients without severe bleeding, colonoscopy is the recommended modality for diagnosis and management. A transfusion threshold of 7 g/dL hemoglobin is recommended based on recent data and guidelines (8 g/dL in those with myocardial ischemia), though patients with severe bleeding and hemodynamic instability should undergo emergent transfusion. Anticoagulation reversal may be necessary. If bleeding does not resolve, embolization or endoscopic therapies are necessary. There are several risk scores that can predict the risk of adverse outcomes; however, these scores should not replace clinical judgment in determining patient disposition.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with LGIB.

Scoring systems for risk stratification in upper and lower gastrointestinal bleeding

Several scoring systems have been developed for both upper and lower GI bleeding to predict the bleeding severity and discriminate between low-risk patients, who may be suitable for outpatient management, and those who would likely need hospital-based interventions and are at high risk for adverse outcomes. Risk scores created to identify low-risk patients (namely the Glasgow Blatchford Score and the Oakland score) showed very good discriminative performances and their implementation has proven to be effective in reducing hospital admissions and healthcare burden. Conversely, the performances of risk scores in identifying specific adverse events to define high-risk patients are less accurate, and whether their integration into routine clinical practice has a tangible impact on patient management remains unproven. This review describes the existing risk score systems for GI bleeding, emphasizes key research findings, elucidates the circumstances in which their utilization can be beneficial, examines their constraints when considering routine clinical application, and discuss future development.

A comparative study of scoring systems that accurately predict the prognosis of lower gastrointestinal bleeding

PURPOSE

Lower gastrointestinal (GI) bleeding can be fatal; therefore, several scoring systems have been developed to predict its prognosis. We compared the mortality predictions and evaluated the usefulness of various scoring systems.

METHODS

The medical records of 3794 patients who visited the emergency department with hematochezia between January 2016 and December 2021 were retrospectively reviewed. We calculated the areas under the receiver operating characteristic curves for 30-day mortality and prolonged hospital stay (≥ 10 days) based on the age, blood tests, and comorbidities (ABC); AIMS65; Glasgow-Blatchford; Oakland; Rockall (pre-endoscopy); and SHA2PE scores and compared the predictive accuracy of each score.

RESULTS

Data for 963 patients (median age, 69 years; males, 54.5%; median hospital stay, 6 days) with colonoscopy-confirmed lower GI bleeding were analyzed. The 30-day mortality rate was 3.5%; the most common causes of lower GI bleeding were ischemic colitis and diverticulum bleeding in 19.3% and 19.2% of the cases, respectively. The AIMS65 and ABC scores were superior in predicting 30-day mortality (p < 0.001). The SHA2PE score was the most accurate predictor of prolonged hospital stay (p < 0.001). Through multivariate regression analysis, 30-day mortality was correlated with albumin level ≤ 3.0 g/dL, international normalized ratio > 1.5, blood urea nitrogen level ≥ 30 mg/dL, and systolic blood pressure (SBP) < 100 mmHg. A prolonged hospital stay was correlated with liver cirrhosis, hemoglobin ≤ 10 g/dL, albumin level ≤ 3.0 g/dL, and SBP < 100 mmHg.

CONCLUSION

The recently developed scoring systems accurately predict lower GI bleeding prognosis, and their usefulness in clinical decision-making was confirmed.

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.