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Frequency of Variceal Upper Gastrointestinal Bleeding (UGIB) in Patients with Established Varices
*M1767 Frequency of Variceal Upper Gastrointestinal Bleeding (UGIB) in Patients with Established Varices Kevin J. Peifer, Gary R. Zuckerman, Mauricio Lisker-Melman, Chandra Prakash
*M1769 Nasogastric Aspirates Frequently Lead to Erroneous Results and Delay of Therapy in Patients with Suspected UGI Bleeding Asyia Ahmad, Joseph M. Bruno, Robert Boynton, Carlos Leon, Zaid Alnoah, Norman Zitomer, James C. Reynolds
Older literature suggests that 53% of patients with known varices presenting with acute UGIB have a nonvariceal source; bleeding peptic ulcers and erosions account for almost 40% (Dagradi, Am J Gastroenterol 1970). These proportions may have changed with advances in endoscopic evaluation and overall management. Methods: All patients presenting with definitive acute UGIB and varices on upper endoscopy were eligible for inclusion. Inpatient charts were reviewed to confirm the source of acute UGIB and corroborate the diagnosis of portal hypertension. Variceal bleeding was diagnosed if active bleeding or red wale sign were visualized. Nonvariceal etiologies required the presence of stigmata of bleeding (active bleeding or adherent clot). Multiple bleeding presentations within a 30 day period were considered part of one bleeding episode. Results: Over a 2year period, varices were visualized on endoscopy in 143 consecutive patients (5561.1 yr, 50F:93M) presenting with 173 distinct episodes of acute UGIB. Bleeding presentation included hematemesis (bloody or coffee ground emesis) in 65 instances (37%), melena in 41 (24%) and both in 67 (39%). The source of UGIB was conclusively localized in 137 bleeding episodes (79%). A variceal source was identified in 115 instances (66%), 108 from esophageal varices, and 7 from gastric varices. Nonvariceal bleeding accounted for 22 bleeding episodes (13%), and included peptic ulcers and erosions (9 episodes, 5%), angioectasia including gastric antral vascular ectasia (9, 5%), Mallory-Weiss tear (1, 0.6%), oozing portal hypertensive gastropathy (1, 0.6%), and oro- and nasopharyngeal sources (2, 1%). The bleeding source could not be definitively identified in 36 instances (21%); endoscopic findings included Grade II or larger varices in 10 (4 underwent band ligation), peptic ulcers and erosions in 9, nonbleeding angioectasia in 4 (3 treated), esophagitis in 4 and Mallory Weiss tears in 2. All patients with angioectasia had melena but no hematemesis, and all patients with gastric variceal bleeding had bloody emesis. However, bleeding presentation did not predict source of UGIB (p=NS). Conclusions: Using strict criteria to establish the bleeding source, variceal bleeding accounts for as many as two-thirds of patients with known varices presenting with UGIB - a significant change from older reports. Peptic ulcers are uncommon sources of bleeding in this population in the present day. Bleeding presentation cannot be used to predict the most likely source of UGIB.
Background: While a positive nasogastric aspirate (NGA) has been shown to correlate with the presence of a significant upper gastrointestinal bleed (UGIB), no prospective study has thoroughly investigated the significance of a negative NGA in ruling out a lesion requiring emergent endoscopy. Aim: To determine the ability of the NGA and 30 clinical and laboratory values to predict the presence of a highrisk lesion with stigmata of recent hemorrhage. Methods: Patients with a suspected UGIB and nasogastric tube placement were included in this prospective study. Upon entry, baseline characteristics, laboratory data, and color of NGA were recorded. Patients who had an upper endoscopy within 24 hours of nasogastric tube placement were allowed to complete this study. At endoscopy, the site and stigmata of the bleeding lesion was recorded. Results: Fifty patients completed the study and the site of bleeding was localized in 88%. Findings on endoscopy included 36% gastric ulcers/gastritis, 14% erosive esophagitis, 9% duodenal ulcers/duodenitis, 9% varices, 7% portal gastropathy, 11% normal and 14% other. At endoscopy, 20 patients were found to have a lesion with stigmata and all underwent therapeutic intervention. Patients with a positive NGA (bloody or coffee grounds) were 4 times more likely (p=0.045) to have a lesion with stigmata than patients with a negative NGA (clear or bilious). Although, patients with a negative NGA were less likely to have stigmata, 18% was falsely negative. Surprisingly, all the false negatives occurred in the bilious group. Furthermore, patients with a negative NGA were more likely to have a delay in endoscopy > 8 hours (p=0.02). Twenty-five percent of patients who had an endoscopy > 8 hrs after NGA were still found to have lesions requiring therapeutic intervention. The site of the bleed could not be predicted based on color of NGA. Platelet count < 150,000 (p<0.05) correlated with the finding of stigmata, although only 4% received platelet transfusions during the bleeding episode. Contrary to a prior study, Hgb > 8.0 (p<0.05), MCV > 80 (p<0.03) and a lower BUN/creatinine ratio correlated with stigmata. Age, concurrent illness, NSAIDS and other medications did not distinguish between the two groups. Conclusion: A negative NGA leads to a delay in endoscopies and fails to identify 18% of patients with stigmata of recent hemorrhage. Laboratory values such as platelets, hemoglobin and MCV may be useful in distinguishing patients who require EGD with therapeutic intervention.
*M1768 Utilisation of the Rockall Score in the Development of a Clinical Pathway for the Management of Non-Variceal Upper Gastrointestinal Bleeding Peter Bampton, Jayne Sandford, Gautam Ramnath, Graeme Young Background: The Rockall scoring system (based upon co-morbidities, haemodynamic stability and endoscopic appearances) has been validated to predict outcome from non-variceal upper GI bleeding. We believed that the postendoscopy Rockall score could be used to determine a length of stay recommended by a clinical pathway for non-variceal upper GI bleeding. Methods: Patients presenting with a upper GI bleeding were admitted to high dependency (HDU) or the gastroenterology ward depending upon their pre-endoscopy Rockall score. After endoscopy they were assigned a post-endoscopy Rockall score. Patients with a post-endoscopy Rockall score of greater than 7 (or who had required endoscopic therapy) were managed initially in HDU, with an expectation of discharge to the ward in 36 hours, those less than 7 were admitted to the ward with an aim for discharge within 48hrs. Endoscopic high risk lesions were treated with adrenalin injection +/- argon plasma coagulation followed by PPI infusion. Nonparametric, two-tailed Spearman coefficient calculation was used to determine the correlation between Rockall score and length of stay (total and HDU) and transfusion rates. Results: 165 patients (mean age 65.1, r:15-94 years) were entered over 10 months. Total length of stay, HDU stay and transfusion rates correlated with post-Rockall score (r=0.313, p<0.01:r=0.186, p<0.02:r=0.308, p<0.01). Patients with a post endoscopy Rockall score between 1-2 had a mean total length of stay of 2.8 days (and 0.92 units transfused), compared with 4.2 days (1.8 units) and 4.3 days (2.8 units) respectively for those with scores between 3-4 and greater than 5. Significant rebleeds (defined by a 20g/L fall in Hb) occured in 14 of all patients (8.4%), with 10 of these in the 45 (22%) patients with pepic ulcer disease. Three of the bleeding peptic ulcers (6%) proceeded to surgery, with one death (2.2%) due to an acute MI. There were 3 other deaths (2 due to presumed acute myocardial infarction (AMI) prior to endoscopyand 1 from sepsis) leading to an overall mortality of 2.4%. Discussion:We have demonstrated that the post endoscopy Rockall score predicts total and HDU legth of stay, as well as transfusion requirements.This enables us to predict expected length of stay in the patients clinical pathway immediately following their endoscopy for non-variceal upper GI bleeding. This will enable the easier detection of variance from the clinical pathway with respect to length of stay.
VOLUME 59, NO. 5, 2004
*M1770 The Blatchford Scoring System Do not Predict the Need for Intervention in Upper Gastrointestinal Haemorrhage Virginie Humbert-Sebbagh, Alain Attar, Philippe Le Toumelin, Kouroche Vahedi, Yoram Bouhnik, Groupe des Endoscopistes de garde a’ l’ AP-HP Blatchford et al. published a clinical and biological risk score [blood urea, hemoglobin, systolic blood pressure, pulse, melaena, syncope, hepatic disease and cardiac failure] ranged from 0 to 23, to predict the need for treatment in upper gastrointestinal hemorrhage*. To validate this score externally, we conducted a prospective study on patients with upper gastrointestinal hemorrhage hospitalized in AP-HP emergency units and for whom an upper gastrointestinal endoscopy was considered in emergency from 6:30 pm to 08:30 am every day and the weekend all-day. Methods : Over a 6 month period, all interventions needed for upper gastrointestinal hemorrhage in 13 emergency units, were recorded. Risk factors for the Blatchford score (BS) were recovered. We assessed the external validity of the scoring system by plotting a ROC curve. We used the following criteria to be relevant for an emergency intervention: active bleeding lesions, endoscopic hemostasis, death or surgery because of bleeding during the first 3 days. Actual diagnosis was retrospectively done at one month using data of control endoscopy or surgery. Results : 131 patients were recorded. Mean age was 60.5 y (range 23-97), 73.3% male, 65.6% non hospitalized patients when the hemorrhage occurred. Cirrhosis was present for 31.3% of patients. Whatever the score, 120 of 131 patients had had an emergency endoscopy. On the 11 patients who did not, 9 were considered to be in a non-severe situation. The mean BS was 11.7 (extr: 0-21). The area under the ROC curve was 0.672 with low values of sensitivity when false positive increased. There was no correlation between the need for emergency intervention and the BS : when the BS was $ 10, the numbers of patients who needed intervention or not were similar (53 and 46, respectively). Conclusion : No external validation of the Blatchford score was possible in this prospective trial, although tested in a clinically relevant situation. More evaluation is needed to help clinician in deciding which patient need emergency intervention in upper gastrointestinal hemorrhage. *Blatchford et al. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. Lancet. 2000 4;356:1318-21.
GASTROINTESTINAL ENDOSCOPY
P163
*M1769 Nasogastric Aspirates Frequently Lead to Erroneous Results and Delay of Therapy in Patients with Suspected UGI Bleeding Asyia Ahmad, Joseph M. Bruno, Robert Boynton, Carlos Leon, Zaid Alnoah, Norman Zitomer, James C. Reynolds
Older literature suggests that 53% of patients with known varices presenting with acute UGIB have a nonvariceal source; bleeding peptic ulcers and erosions account for almost 40% (Dagradi, Am J Gastroenterol 1970). These proportions may have changed with advances in endoscopic evaluation and overall management. Methods: All patients presenting with definitive acute UGIB and varices on upper endoscopy were eligible for inclusion. Inpatient charts were reviewed to confirm the source of acute UGIB and corroborate the diagnosis of portal hypertension. Variceal bleeding was diagnosed if active bleeding or red wale sign were visualized. Nonvariceal etiologies required the presence of stigmata of bleeding (active bleeding or adherent clot). Multiple bleeding presentations within a 30 day period were considered part of one bleeding episode. Results: Over a 2year period, varices were visualized on endoscopy in 143 consecutive patients (5561.1 yr, 50F:93M) presenting with 173 distinct episodes of acute UGIB. Bleeding presentation included hematemesis (bloody or coffee ground emesis) in 65 instances (37%), melena in 41 (24%) and both in 67 (39%). The source of UGIB was conclusively localized in 137 bleeding episodes (79%). A variceal source was identified in 115 instances (66%), 108 from esophageal varices, and 7 from gastric varices. Nonvariceal bleeding accounted for 22 bleeding episodes (13%), and included peptic ulcers and erosions (9 episodes, 5%), angioectasia including gastric antral vascular ectasia (9, 5%), Mallory-Weiss tear (1, 0.6%), oozing portal hypertensive gastropathy (1, 0.6%), and oro- and nasopharyngeal sources (2, 1%). The bleeding source could not be definitively identified in 36 instances (21%); endoscopic findings included Grade II or larger varices in 10 (4 underwent band ligation), peptic ulcers and erosions in 9, nonbleeding angioectasia in 4 (3 treated), esophagitis in 4 and Mallory Weiss tears in 2. All patients with angioectasia had melena but no hematemesis, and all patients with gastric variceal bleeding had bloody emesis. However, bleeding presentation did not predict source of UGIB (p=NS). Conclusions: Using strict criteria to establish the bleeding source, variceal bleeding accounts for as many as two-thirds of patients with known varices presenting with UGIB - a significant change from older reports. Peptic ulcers are uncommon sources of bleeding in this population in the present day. Bleeding presentation cannot be used to predict the most likely source of UGIB.
Background: While a positive nasogastric aspirate (NGA) has been shown to correlate with the presence of a significant upper gastrointestinal bleed (UGIB), no prospective study has thoroughly investigated the significance of a negative NGA in ruling out a lesion requiring emergent endoscopy. Aim: To determine the ability of the NGA and 30 clinical and laboratory values to predict the presence of a highrisk lesion with stigmata of recent hemorrhage. Methods: Patients with a suspected UGIB and nasogastric tube placement were included in this prospective study. Upon entry, baseline characteristics, laboratory data, and color of NGA were recorded. Patients who had an upper endoscopy within 24 hours of nasogastric tube placement were allowed to complete this study. At endoscopy, the site and stigmata of the bleeding lesion was recorded. Results: Fifty patients completed the study and the site of bleeding was localized in 88%. Findings on endoscopy included 36% gastric ulcers/gastritis, 14% erosive esophagitis, 9% duodenal ulcers/duodenitis, 9% varices, 7% portal gastropathy, 11% normal and 14% other. At endoscopy, 20 patients were found to have a lesion with stigmata and all underwent therapeutic intervention. Patients with a positive NGA (bloody or coffee grounds) were 4 times more likely (p=0.045) to have a lesion with stigmata than patients with a negative NGA (clear or bilious). Although, patients with a negative NGA were less likely to have stigmata, 18% was falsely negative. Surprisingly, all the false negatives occurred in the bilious group. Furthermore, patients with a negative NGA were more likely to have a delay in endoscopy > 8 hours (p=0.02). Twenty-five percent of patients who had an endoscopy > 8 hrs after NGA were still found to have lesions requiring therapeutic intervention. The site of the bleed could not be predicted based on color of NGA. Platelet count < 150,000 (p<0.05) correlated with the finding of stigmata, although only 4% received platelet transfusions during the bleeding episode. Contrary to a prior study, Hgb > 8.0 (p<0.05), MCV > 80 (p<0.03) and a lower BUN/creatinine ratio correlated with stigmata. Age, concurrent illness, NSAIDS and other medications did not distinguish between the two groups. Conclusion: A negative NGA leads to a delay in endoscopies and fails to identify 18% of patients with stigmata of recent hemorrhage. Laboratory values such as platelets, hemoglobin and MCV may be useful in distinguishing patients who require EGD with therapeutic intervention.
*M1768 Utilisation of the Rockall Score in the Development of a Clinical Pathway for the Management of Non-Variceal Upper Gastrointestinal Bleeding Peter Bampton, Jayne Sandford, Gautam Ramnath, Graeme Young Background: The Rockall scoring system (based upon co-morbidities, haemodynamic stability and endoscopic appearances) has been validated to predict outcome from non-variceal upper GI bleeding. We believed that the postendoscopy Rockall score could be used to determine a length of stay recommended by a clinical pathway for non-variceal upper GI bleeding. Methods: Patients presenting with a upper GI bleeding were admitted to high dependency (HDU) or the gastroenterology ward depending upon their pre-endoscopy Rockall score. After endoscopy they were assigned a post-endoscopy Rockall score. Patients with a post-endoscopy Rockall score of greater than 7 (or who had required endoscopic therapy) were managed initially in HDU, with an expectation of discharge to the ward in 36 hours, those less than 7 were admitted to the ward with an aim for discharge within 48hrs. Endoscopic high risk lesions were treated with adrenalin injection +/- argon plasma coagulation followed by PPI infusion. Nonparametric, two-tailed Spearman coefficient calculation was used to determine the correlation between Rockall score and length of stay (total and HDU) and transfusion rates. Results: 165 patients (mean age 65.1, r:15-94 years) were entered over 10 months. Total length of stay, HDU stay and transfusion rates correlated with post-Rockall score (r=0.313, p<0.01:r=0.186, p<0.02:r=0.308, p<0.01). Patients with a post endoscopy Rockall score between 1-2 had a mean total length of stay of 2.8 days (and 0.92 units transfused), compared with 4.2 days (1.8 units) and 4.3 days (2.8 units) respectively for those with scores between 3-4 and greater than 5. Significant rebleeds (defined by a 20g/L fall in Hb) occured in 14 of all patients (8.4%), with 10 of these in the 45 (22%) patients with pepic ulcer disease. Three of the bleeding peptic ulcers (6%) proceeded to surgery, with one death (2.2%) due to an acute MI. There were 3 other deaths (2 due to presumed acute myocardial infarction (AMI) prior to endoscopyand 1 from sepsis) leading to an overall mortality of 2.4%. Discussion:We have demonstrated that the post endoscopy Rockall score predicts total and HDU legth of stay, as well as transfusion requirements.This enables us to predict expected length of stay in the patients clinical pathway immediately following their endoscopy for non-variceal upper GI bleeding. This will enable the easier detection of variance from the clinical pathway with respect to length of stay.
VOLUME 59, NO. 5, 2004
*M1770 The Blatchford Scoring System Do not Predict the Need for Intervention in Upper Gastrointestinal Haemorrhage Virginie Humbert-Sebbagh, Alain Attar, Philippe Le Toumelin, Kouroche Vahedi, Yoram Bouhnik, Groupe des Endoscopistes de garde a’ l’ AP-HP Blatchford et al. published a clinical and biological risk score [blood urea, hemoglobin, systolic blood pressure, pulse, melaena, syncope, hepatic disease and cardiac failure] ranged from 0 to 23, to predict the need for treatment in upper gastrointestinal hemorrhage*. To validate this score externally, we conducted a prospective study on patients with upper gastrointestinal hemorrhage hospitalized in AP-HP emergency units and for whom an upper gastrointestinal endoscopy was considered in emergency from 6:30 pm to 08:30 am every day and the weekend all-day. Methods : Over a 6 month period, all interventions needed for upper gastrointestinal hemorrhage in 13 emergency units, were recorded. Risk factors for the Blatchford score (BS) were recovered. We assessed the external validity of the scoring system by plotting a ROC curve. We used the following criteria to be relevant for an emergency intervention: active bleeding lesions, endoscopic hemostasis, death or surgery because of bleeding during the first 3 days. Actual diagnosis was retrospectively done at one month using data of control endoscopy or surgery. Results : 131 patients were recorded. Mean age was 60.5 y (range 23-97), 73.3% male, 65.6% non hospitalized patients when the hemorrhage occurred. Cirrhosis was present for 31.3% of patients. Whatever the score, 120 of 131 patients had had an emergency endoscopy. On the 11 patients who did not, 9 were considered to be in a non-severe situation. The mean BS was 11.7 (extr: 0-21). The area under the ROC curve was 0.672 with low values of sensitivity when false positive increased. There was no correlation between the need for emergency intervention and the BS : when the BS was $ 10, the numbers of patients who needed intervention or not were similar (53 and 46, respectively). Conclusion : No external validation of the Blatchford score was possible in this prospective trial, although tested in a clinically relevant situation. More evaluation is needed to help clinician in deciding which patient need emergency intervention in upper gastrointestinal hemorrhage. *Blatchford et al. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. Lancet. 2000 4;356:1318-21.
GASTROINTESTINAL ENDOSCOPY
P163