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Abstract
Acute gastrointestinal (GI) bleeding is a common surgical emergency requiring hospital admission and associated with high morbidity and mortality. Appropriate decision-making is essential to make a prompt diagnosis, accurate risk assessment, and proper resuscitation of patients with gastrointestinal bleeding. Despite multiple randomized trials and meta-analyses, there is still controversy on various management issues like appropriate risk stratification, the timing of endoscopy, choosing an appropriate endoscopic, and radiological intervention in these groups of patients. As the usage of nonsteroidal anti-inflammatory drugs, antiplatelet, and antithrombotic agents is common in patients with gastrointestinal bleeding, the physician is challenged with proper management of these drugs. The present review summarizes the current strategies for risk stratification, localization of bleeding source, endoscopic and radiological intervention in patients with acute nonvariceal upper GI, middle GI, and lower GI bleeding.
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Affiliation(s)
- Vikram Kate
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
| | - Sathasivam Sureshkumar
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Balakrishnan Gurushankari
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgery and Gastrointestinal Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
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Sachan A, Dhibar DP, Bhalla A, Prakash A, Taneja S, Sharma V. COMPARISON OF NON-ENDOSCOPIC SCORES FOR THE PREDICTION OF OUTCOMES IN PATIENTS OF UPPER GASTROINTESTINAL BLEED IN AN EMERGENCY OF A TERTIARY CARE REFERRAL HOSPITAL: A PROSPECTIVE COHORT STUDY. Arq Gastroenterol 2021; 58:534-540. [PMID: 34909862 DOI: 10.1590/s0004-2803.202100000-95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/29/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. OBJECTIVE This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. METHODS In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. RESULTS The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). CONCLUSION Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.
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Affiliation(s)
- Anurag Sachan
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
| | - Deba Prasad Dhibar
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Ashish Bhalla
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Ajay Prakash
- Post Graduate Institute of Medical Education and Research, Department of Pharmacology, Chandigarh, India
| | - Sunil Taneja
- Post Graduate Institute of Medical Education and Research, Department of Hepatology, Chandigarh, India
| | - Vishal Sharma
- Post Graduate Institute of Medical Education and Research, Department of Gastroenterology, Chandigarh, India
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Yue W, Liu Y, Jiang W, Huang J, Liu J. Prealbumin and D-dimer as Prognostic Indicators for Rebleeding in Patients with Nonvariceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2021; 66:1949-56. [PMID: 32583220 DOI: 10.1007/s10620-020-06420-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 06/14/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Determining the risk stratification of nonvariceal upper gastrointestinal bleeding (NVUGIB) plays a vital role in treating upper gastrointestinal bleeding (UGIB). Traditional scores like Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score have been widely utilized in UGIB practice, however exhibiting limited practical use due to relative lack of user-friendly characters. Prealbumin as a nutritional indicator and d-dimer as a fibrinolytic activity monitor, are generally used to evaluate the overall nutritional and fibrinolytic condition in UGIB patients. AIMS Here, we explored the predictive value of these two markers in NVUGIB for evaluating severity and prognosis including rebleeding and surgery intervention. METHODS One hundred and eighty-five patients suffering NVUGIB were enrolled. Their GBS, RS, and AIMS65 score, routine laboratory test results including prealbumin and d-dimer were determined after admission. Multivariate regression analysis was performed to define the independent predictors of rebleeding. ROC curves were generated to compare the suitability of prealbumin, d-dimer, and scores for rebleeding prediction. RESULTS The NVUGIB patients with rebleeding exhibited higher scores, white blood cell counts, d-dimer, CRP, proportion of surgery intervention, and longer hospital stay, but lower hematocrit, hemoglobin, calcium, prealbumin, and fibrinogen than those without rebleeding. The multivariate regression analysis demonstrated that prealbumin and d-dimer were independent predictors for rebleeding. Values of prealbumin and d-dimer were correlated with hospital stay, ulcer degrees, and surgery demand. The ROC curve analyses showed that prealbumin and d-dimer exhibited superior prediction value over the scoring systems. CONCLUSIONS Prealbumin and d-dimer are promising predictors for severity and prognosis in NVUGIB practice.
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Abstract
OBJECTIVES Acute variceal bleeding (AVB) results from rupture of esophageal or gastric varices. It is a life-threatening complication of portal hypertension. Nevertheless, it remains unclear how to predict adverse outcomes and identify high-risk patients. In variceal hemorrhage, high Child-Turcotte-Pugh (Child) and Model for End-stage Liver Disease (MELD) scores are associated with a worse prognosis. The Rockall system (Rockall), Glasgow-Blatchford (Blatchford), and AIMS65 scores have been validated for risk stratification for nonvariceal upper gastrointestinal bleeding; however, their use is controversial in AVB. The aim of this study was to compare the performance of Child, MELD, Rockall, Blatchford, and AIMS65 scores in risk stratification for rebleeding and/or mortality associated with AVB. METHODS This retrospective study was conducted at a tertiary care hospital over 42 months. The outcomes were 6-week rebleeding and mortality. The AUROC was calculated for each score (1-0.9, 0.9-0.8, and 0.8-0.7, indicating excellent, good, and acceptable predictive power, respectively). RESULTS In total, 222 patients were included. Six-week rebleeding and mortality rates were 14% and 18.5%, respectively. No score was useful for discriminating patients at a higher risk of rebleeding. The AUROCs were 0.59, 0.57, 0.61, 0.63, and 0.56 for Rockall, Blatchford, AIMS65, Child, and MELD scores, respectively. Prediction of 6-week mortality based on Rockall (AUROC 0.65), Blatchford (AUROC=0.60), and AIMS65 (AUROC=0.67) scores were also not considered acceptable. The AUROCs for predicting mortality were acceptable for Child and MELD scores (0.72 and 0.74, respectively). CONCLUSION Rockall, Blatchford, and AIMS65 scores are not useful for predicting 6-week rebleeding or mortality in patients with AVB. Child and MELD scores can identify patients at higher risk for 6-week mortality but not for 6-week rebleeding.
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Chandnani S, Rathi P, Udgirkar SS, Sonthalia N, Contractor Q, Jain S. CLINICAL UTILITY OF RISK SCORES IN VARICEAL BLEEDING. Arq Gastroenterol 2019; 56:286-293. [PMID: 31633727 DOI: 10.1590/s0004-2803.201900000-54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/17/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Variceal bleeding remains important cause of upper gastrointestinal bleed. Various risk scores are used in risk stratification for non-variceal bleed. Their utility in variceal bleeding patients is not clear. This study aims to compare probability of these scores in predicting various outcomes in same population. OBJECTIVE This study aims to compare probability of these scores in predicting various outcomes in same population. To study characteristics and validate AIMS65, Rockall, Glasgow Blatchford score(GBS), Progetto Nazionale Emorragia Digestiva (PNED) score in variceal Upper Gastrointestinal Bleed (UGIB) patients for predicting various outcomes in our population. METHODS Three hundred subjects with UGIB were screened prospectively. Of these 141 patients with variceal bleeding were assessed with clinical, blood investigations and endoscopy and risk scores were calculated and compared to non-variceal cases. All cases were followed up for 30 days for mortality, rebleeding, requirement of blood transfusion and need of radiological or surgical intervention. RESULTS Variceal bleeding (141) was more common than non variceal (134) and 25 had negative endoscopy. In variceal group, cirrhosis (85%) was most common etiology. Distribution of age and sex were similar in both groups. Presence of coffee coloured vomitus (P=0.002), painless bleed (P=0.001), edema (P=0.001), ascites (P=0.001), hemoglobin <7.5 gms (P<0.001), pH<7.35 (P<0.001), serum bicarbonate level <17.6 mmol/L (P<0.001), serum albumin<2.75 gms% (P<0.001), platelet count <1.2 lacs/µL (P<0.001), high INR 1.35 (P<0.001), BUN >25mmol/L (P<0.001), and ASA status (P<0.001), high lactate >2.85 mmol/L (P=0.001) were significant. However, no factor was found significant on multivariate analysis. Rockall was found to be significant in predicting mortality and rebleed. AIMS65 was also significant in predicting mortality. GBS was significant in predicting blood transfusion and need of intervention. PNED score was significant in all events except mortality. CONCLUSION All four scores had lower predictive potential in predicting events in variceal bleed. However, AIMS65 & Rockall score were significant in predicting mortality, while GBS in predicting need of transfusion and intervention. PNED score was significant in all events except mortality.
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Affiliation(s)
- Sanjay Chandnani
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Pravin Rathi
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | | | - Nikhil Sonthalia
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Qais Contractor
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
| | - Samit Jain
- TNMC & BYL Nair Charitable Hospital, Department of Gastroenterology, Mumbai, Maharashtra, India
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Rout G, Sharma S, Gunjan D, Kedia S, Nayak B, Shalimar. Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study. Indian J Gastroenterol 2019; 38:158-66. [PMID: 30830583 DOI: 10.1007/s12664-018-0928-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/19/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Various prognostic scores like Glasgow-Blatchford bleeding score (GBS), modified Glasgow-Blatchford bleeding score (mGBS), full Rockall score (FRS) including endoscopic findings, clinical Rockall score (CRS), and albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 (AIMS65) are used for risk stratification in patients with upper gastrointestinal bleeding (UGIB). The utility of these scores in variceal UGIB (VUGIB) is not well defined. In this prospective study, we aimed to assess the performance of these scores in patients with non-variceal (NVUGIB) and VUGIB. METHODS We included 1011 patients (during March 2017 and August 2018) including 439 with NVUGIB and 572 VUGIB. Performance of GBS, mGBS, FRS, CRS, and AIMS65 for various outcome measures was analyzed using the area under receiver operator characteristic curve (AUROC). RESULTS The accuracy of prognostic scores in predicting the composite outcome including the need of hospital-based intervention and 42-day mortality was higher in NVUGIB as compared with VUGIB, AUROC: CRS: 0.641 vs. 0.537; FRS: 0.669 vs. 0.625; GBS: 0.719 vs. 0.587; mGBS: 0.711 vs. 0.594; AIMS65: 0.567 vs. 0.548. GBS and mGBS at a cut-off score of 1 had the highest negative predictive value, 91.7% and 91.3%, respectively, for predicting composite outcome in NVUGIB. Similarly, these scores had better accuracy for predicting 42-day rebleeding in NVUGIB as compared to VUGIB, AUROC: CRS: 0.680 vs. 0.537; FRS: 0.698 vs. 0.565; GBS: 0.661 vs. 0.543; mGBS: 0.627 vs. 0.540; AIMS65: 0.695 vs. 0.606. CONCLUSION The prognostic scores such as CRS, FRS, GBS, mGBS, and AIMS65 predict the need for hospital-based management, rebleeding, and mortality better among patients with NVUGIB than VUGIB.
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Lee DH, Lee KM, Lee SM, Lee BK, Cho YS, Choi G, Yun SW. Performance of Three Scoring Systems in Predicting Massive Transfusion in Patients with Unstable Upper Gastrointestinal Hemorrhage. Yonsei Med J 2019; 60:368-374. [PMID: 30900423 PMCID: PMC6433562 DOI: 10.3349/ymj.2019.60.4.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/29/2019] [Accepted: 02/20/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE After trauma and surgery, upper gastrointestinal bleeding (UGIB) is the most common condition that can require massive transfusion (MT). The present study aimed to analyze and compare the prognostic performance of the Glasgow-Blatchford (GB), pre-endoscopy Rockall (PER), and modified early warning (MEW) scores for predicting MT in patients with unstable UGIB. MATERIALS AND METHODS This retrospective observational study included patients with UGIB from March 2016 to February 2018. Receiver operating characteristics analysis was performed to examine the prognostic performance of the GB, PER, and MEW scoring systems. Logistic regression analysis was used to identify independent risk factors for MT, after adjusting for relevant covariates. The primary outcome was MT. RESULTS Of the 484 included patients with unstable UGIB, 19 (3.9%) received an MT. The areas under the curves (AUCs) of the GB, PER, and MEW scores for MT were 0.577 [95% confidence interval (CI), 0.531-0.621], 0.570 (95% CI, 0.525-0.615), and 0.767 (95% CI, 0.727-0.804), respectively. The AUC of the MEW score was significantly different from those of the GB and PER scores. In multivariate analysis, MEW score was independently associated with MT in patients with unstable UGIB (odds ratio, 1.495; 95% CI, 1.100-2.033; p=0.010). CONCLUSION In unstable UGIB patients, MEW score had the best prognostic performance for MT among three scoring systems.
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Affiliation(s)
- Dong Hun Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Kyeung Mi Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Sung Min Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea.
| | - Byung Kook Lee
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Yong Soo Cho
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Goeun Choi
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Seong Woo Yun
- Department of Emergency Medical Technology, Namseoul University, Cheonan, Korea
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Chandnani S, Rathi P, Sonthalia N, Udgirkar S, Jain S, Contractor Q, Jain S, Singh AK. Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis. Indian J Gastroenterol 2019; 38:117-127. [PMID: 31124017 DOI: 10.1007/s12664-019-00951-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 02/28/2019] [Indexed: 02/04/2023]
Abstract
AIM To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB. METHODS Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30 days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated. RESULTS The mean age was 43.5 ± 17.2 years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7 gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3 mg/dL (p = 0.004), serum bicarbonate ≤ 15.7 mEq/L (p = 0.001), systolic blood pressure < 90 mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value. CONCLUSION Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.
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Affiliation(s)
- Sanjay Chandnani
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India.
| | - Pravin Rathi
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Nikhil Sonthalia
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Suhas Udgirkar
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Shubham Jain
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Qais Contractor
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Samit Jain
- Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr Anandrao Laxman Nair Marg, Mumbai, 400 008, India
| | - Anupam Kumar Singh
- Department of Medicine, Santosh Medical College, Ghaziabad, 201 009, India
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Abstract
PURPOSE OF REVIEW To review new advances in managing nonvariceal upper gastrointestinal hemorrhage. RECENT FINDINGS Implementation of various scoring systems in combination with video capsule endoscopy assists in stratifying and managing nonvariceal upper gastrointestinal bleeding. New techniques such as thermocoagulation and hemoclips are useful to treat bleeding. SUMMARY The advancement of methods and procedures in managing nonvariceal upper gastrointestinal bleeding has decreased mortality of patients presenting with this type of hemorrhage. In this chapter, we will be discussing various scores to stratify nonvariceal upper gastrointestinal bleeding and techniques to stop bleeding.
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