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Predictors of mortality in patients aged ≥80 years admitted to hospital for upper gastrointestinal hemorrhage
STOMACH AND DUODENUM~ COLON AND RECTUM
~289
291
P R E D I C T O R S OF M O R T A L I T Y IN P A T I E N T S A G E D -->80 Y E A R S ~J)MITTED T O H O S P I T A L F O R U P P E R GASTROI N T E S T I N A L HEMORRHAGE. J. Zimmerman, E. Tsvang.
D. Wengrower, V. Shohat, R. Safadi. Gastro Unit Hadassah Univ. Hospital, Jerusalem, Israel. In patients with upper gastrointestinal (UGI) hemorrhage, age >_ 80 is associated with an increased risk of mortality. The aim of this work was to define the prognostic factors associated with UGI hemorrhage in this age group. Methods: A prospective, longitudinal study of 115 consecutive patients aged >_80 admitted to hospital during 1988-94. Items of the past medical history, physical status on admission, laboratory and endoscopic data and the hospital course were analyzed by multiple stepwise logistic regression to define the factors independently associated with mortality. Two models were evaluated: The first based on the data at presentation (history, physical status, initial laboratory workup) and the seconc based on the first, plus the endoscopic and follow up data. Age was incorporated into these models as a potential confounder. Results: The mean age was 84--+0.4 years (SEM). The main causes of bleeding were duodenal ulcer (30%); esophagitis (21%); gastric ulcer (20%) and gastritis (6%). The overall mortality was 13%. A multivariate analysis indicated two independent predictors of mortality: Af presentation- a systolic blood pressure <_ 90 mm Hg (adjusted odds ratio 4.6; 95% CI I .I18.2; p= 0.03). The overall predictor of mortality was a persistent or recurrent bleeding (adjusted odds ratio 35.9; 95% CI 7-193; p(0.0001). Conclusions: In patients aged >_80 admitted to hospital for acute UGI bleeding: I : Continuous bleeding was the most important prognostic factor. 2: Increasing age and the causes of bleeding were of no prognostic significance.
#292
"I"290 U P P E R G A S T R O I N T E S T I N A L H E M O R R H A G E (UGIH) ELDERLY: DISTINCTCLINICAL FEATURES.
IN T H E
J. Zimmerman, V. Shohat, E. Tsvang, D Wengrower, R Safadi. Gastro Unit, Hadassah University Hospital, Jerusalem, Israel. The purpose of this study was to characterize patients aged !80 admitted to hospital for UGIH. Methods: This case-control study encompassed 642 consecutive cases admitted during 1988-94. We analyzed the background, clinical and endoscopic features in patients aged ~80 (n=115) and compared them to those of patients aged 60-69 (n=133). Results: In patients aged !80, there was a female preponderance (48 vs 26%), and a significantly higher prevalence of atherosclerotie cardiovascular disease (ASCVD, 55 vs 33%). By contrast, smoking, alcohol consumption, diabetes and liver disease were significantly less prevalent in the elderly with respect to patients aged 60-69. Use of aspirin, NSAIDs, anticoagulants and corticosteroids was reported in a similar proportion in the two age groups. Esophagitis (due to reflux in >90%) was the cause of bleeding in 21.1% of the patients aged !80 compared to 3.3% in those aged 60-69 (p=0.0003). A multivariate analysis revealed that the relative risk for esophagitis in age !80 was increased and was independent of gender, smoking, alcohol intake, use of NSAIDs, aspirin or corticosteroids, diabetes, ASCVD and lives disease (adjusted odds ratio 18.1; 95% CI 4.178.8; p=0.0002). The rates of persistent or recurrent bleeding and emergency surgery were similar in the two age groups. The mortality in patients aged !80 was 13% compared to 6.1% in the younger patients (p=0.09). Conclusions: In patients aged k80 admitted to hospital for UGIH: I: Age is an independent determinant for esophagitis; 2: The increased mortality rate is nos due to a difference in the course or severity of bleeding.
VOLUME 43, NO. 4, 1996
ATTITUDES AhD ~ ABOUT COLORECTAL CANCER SCRE~IqlNG BY FLEXIBLE SI(~DIDOSCOPY (F.S.) APDNG URBAN HOSPITAL ~MPLOYEES. O.AJAH, D.NOWAK, M. HASAN, G.POSNER, F.MARSH. DIVISION OF ~ E N I I ~ D L O G Y , INIERFAITH F~DICAL CENTER, BI~0OKLYN. We recently surveyed our hospital employees for their ~owledge a~d attitudes toward the American Cancer Society (ACS) recor~endation regarding flexible si~nmidoscepy (F.S.) screening for colorectal cancer and compared the results with what r.hey know about ~qnr~ography. Method: 216 employees were served a questionnaire over a 10--~-~eriod, from 10/23-11/03/95. Results: There were 67 men (31%) and 149 w~men (697~) in the s - ~ - ~ end their ages ranged from 40-50 yrs(88 subjects), 50-60 yrs (100), 60-70 yrs (25), 70-80 (one subject). 174 (8170) were Blacks, 18 (87~ Whites, 12 (6%) Hispanics, II (57~ Asians, and one Native American. Three questions were asked (i) '~@hat is F.S.?", (ii) '%~at is the ACS recommendation regarding (F.S.)?, and (iii) '%4:~t is the official r e ~ n d a t i o n for n~m~mography?'. They were answered correctly from among five choices by 61%, 23% and 607~ respectively. Though virtually all of them had seen a physician within the precedin~ year, only 22% said a physician had mentioned F.S. to them and less than i07o had ~mdergone screening F.S. ever. Discussion: The incidence and mortality of colorectal cancer are higher a~ong blacks- but they could be reduced by screening flexible sigmoidoscopy as studies have shown. Compliance is, unfort~mately, low possibly due to ignorance of the official recommm%dation. Many more of our subjects knew of the reoommendations regarding mammography 60% V 237~ p<0.001. This may reflect the extensive media coverage given to breast cancer issues. Conclusion: Most of our subjects did not know .about the ACS recommendation. In order to reduce eolorectal cancer morbidity and mortality in this high risk group, our employees and the co~Sma~ity must be better educated.
EXPANDABLE METAL STENTS FOR TREATMENT OF COLONIC OBSTRUCTION "[Jd.J~l;l~&PA Dean, CR Shumate, RE Koehler, C Canon, Div. Gastroenterology, General Surgery, & Radiology. University of Alabama, Birmingham, AL Colonic obstruction carries a high morbidity and mortality, and usually requires a colostomy. We evaluated the feasibility of expandable metal stents to avoid colostomy. METHODS: 15 consecutive pts. with complete or near-cemplote colonic obstruction were treated with expandable metal stents for palliation (N=10) and preoperatively to avoid colostomy (N=5). Success was defined as ability to defecate or to adequately prep the colon for one-stage operation. RESULTS: Mean age 62 yrs. obstruction. ~t XRT, ;ornp. Tur, orlSite ite'nt mm " ilnteet 3utcome Duration Statu,= Rectum~ Jltraflex18 IPalliateSuccess 22 wks. ----Dead-I~fentqooe Rectum Iltrefiex 18 ~alliafe!Success 26 wks. Alive-patent ~lone Rect.um ~ltraflex 18 ~alliate Success 36 wks. ~Alive-patent' ~li~ration Sigmoid~ i/Vallstent10 =aUiate Success 8 wks. Oead-l~tent )erf. Rectum LIItraflex18 ~alliate Success 24 wks. )end-patent ~lone RectumQ Ecoil/Ultrafiexl~ ~alliate Success 2 wks. ,~_,ad-patent ~lone )vergrowtl~ Proximal Wallstent22 =alliate Success 17 wks. ~,live e-stentad descending~ #allstent 20 ~erl.N/A ~,liveRectosig. LJItraflex18 ~alliate Failure
;urger,/
Rectosig.~ Rectosig.
Wallstent16 ~allsfent22
F~alliate Failure ~alliate Failure
4wks. N/A
~lone )end
;'re-op Success 10 days live =re-op!Success 6 days ~tive
Rectosig.-
~re-op Success 3 wks. ~live
~allstent22
~eff.-
~urgery
Ultr~ex18 Transveree~ w/VaIIstent10
Rectum O.
~urgery
~lone qone ~ligration
.,b@nil~n Transverse~ i'Vallstent10 Transverse~ #allstent 10
;~re-op Failure Pre-op Failure
4 days ~live. 3 days ~,ad;urgery
Vligration Vligration
Overall success=67%:palliation 7/10;pre-op 3/5.Complications: 1 each of self-limited perforation, bacteramia; 4-migration; 2-major perforation (both dilated). Procedurer61ated mortality 1/15 (7%). Overgrowth in 1-successfully restented. CONCLUSIONS: 1) Successful colonic stenting is feasible using available endoprestheses 2) Changes in stent design are needed to prevent migration 3) Ditatation should be avoided during stent placement as perforation may result 4) Colonic stenting appears to be a viable alternative to surgery for palliation of malignant colorectal neoplasms given the availability and potential cost-effectiveness,
GASTROINTESTINAL ENDOSCOPY
363
~289
291
P R E D I C T O R S OF M O R T A L I T Y IN P A T I E N T S A G E D -->80 Y E A R S ~J)MITTED T O H O S P I T A L F O R U P P E R GASTROI N T E S T I N A L HEMORRHAGE. J. Zimmerman, E. Tsvang.
D. Wengrower, V. Shohat, R. Safadi. Gastro Unit Hadassah Univ. Hospital, Jerusalem, Israel. In patients with upper gastrointestinal (UGI) hemorrhage, age >_ 80 is associated with an increased risk of mortality. The aim of this work was to define the prognostic factors associated with UGI hemorrhage in this age group. Methods: A prospective, longitudinal study of 115 consecutive patients aged >_80 admitted to hospital during 1988-94. Items of the past medical history, physical status on admission, laboratory and endoscopic data and the hospital course were analyzed by multiple stepwise logistic regression to define the factors independently associated with mortality. Two models were evaluated: The first based on the data at presentation (history, physical status, initial laboratory workup) and the seconc based on the first, plus the endoscopic and follow up data. Age was incorporated into these models as a potential confounder. Results: The mean age was 84--+0.4 years (SEM). The main causes of bleeding were duodenal ulcer (30%); esophagitis (21%); gastric ulcer (20%) and gastritis (6%). The overall mortality was 13%. A multivariate analysis indicated two independent predictors of mortality: Af presentation- a systolic blood pressure <_ 90 mm Hg (adjusted odds ratio 4.6; 95% CI I .I18.2; p= 0.03). The overall predictor of mortality was a persistent or recurrent bleeding (adjusted odds ratio 35.9; 95% CI 7-193; p(0.0001). Conclusions: In patients aged >_80 admitted to hospital for acute UGI bleeding: I : Continuous bleeding was the most important prognostic factor. 2: Increasing age and the causes of bleeding were of no prognostic significance.
#292
"I"290 U P P E R G A S T R O I N T E S T I N A L H E M O R R H A G E (UGIH) ELDERLY: DISTINCTCLINICAL FEATURES.
IN T H E
J. Zimmerman, V. Shohat, E. Tsvang, D Wengrower, R Safadi. Gastro Unit, Hadassah University Hospital, Jerusalem, Israel. The purpose of this study was to characterize patients aged !80 admitted to hospital for UGIH. Methods: This case-control study encompassed 642 consecutive cases admitted during 1988-94. We analyzed the background, clinical and endoscopic features in patients aged ~80 (n=115) and compared them to those of patients aged 60-69 (n=133). Results: In patients aged !80, there was a female preponderance (48 vs 26%), and a significantly higher prevalence of atherosclerotie cardiovascular disease (ASCVD, 55 vs 33%). By contrast, smoking, alcohol consumption, diabetes and liver disease were significantly less prevalent in the elderly with respect to patients aged 60-69. Use of aspirin, NSAIDs, anticoagulants and corticosteroids was reported in a similar proportion in the two age groups. Esophagitis (due to reflux in >90%) was the cause of bleeding in 21.1% of the patients aged !80 compared to 3.3% in those aged 60-69 (p=0.0003). A multivariate analysis revealed that the relative risk for esophagitis in age !80 was increased and was independent of gender, smoking, alcohol intake, use of NSAIDs, aspirin or corticosteroids, diabetes, ASCVD and lives disease (adjusted odds ratio 18.1; 95% CI 4.178.8; p=0.0002). The rates of persistent or recurrent bleeding and emergency surgery were similar in the two age groups. The mortality in patients aged !80 was 13% compared to 6.1% in the younger patients (p=0.09). Conclusions: In patients aged k80 admitted to hospital for UGIH: I: Age is an independent determinant for esophagitis; 2: The increased mortality rate is nos due to a difference in the course or severity of bleeding.
VOLUME 43, NO. 4, 1996
ATTITUDES AhD ~ ABOUT COLORECTAL CANCER SCRE~IqlNG BY FLEXIBLE SI(~DIDOSCOPY (F.S.) APDNG URBAN HOSPITAL ~MPLOYEES. O.AJAH, D.NOWAK, M. HASAN, G.POSNER, F.MARSH. DIVISION OF ~ E N I I ~ D L O G Y , INIERFAITH F~DICAL CENTER, BI~0OKLYN. We recently surveyed our hospital employees for their ~owledge a~d attitudes toward the American Cancer Society (ACS) recor~endation regarding flexible si~nmidoscepy (F.S.) screening for colorectal cancer and compared the results with what r.hey know about ~qnr~ography. Method: 216 employees were served a questionnaire over a 10--~-~eriod, from 10/23-11/03/95. Results: There were 67 men (31%) and 149 w~men (697~) in the s - ~ - ~ end their ages ranged from 40-50 yrs(88 subjects), 50-60 yrs (100), 60-70 yrs (25), 70-80 (one subject). 174 (8170) were Blacks, 18 (87~ Whites, 12 (6%) Hispanics, II (57~ Asians, and one Native American. Three questions were asked (i) '~@hat is F.S.?", (ii) '%~at is the ACS recommendation regarding (F.S.)?, and (iii) '%4:~t is the official r e ~ n d a t i o n for n~m~mography?'. They were answered correctly from among five choices by 61%, 23% and 607~ respectively. Though virtually all of them had seen a physician within the precedin~ year, only 22% said a physician had mentioned F.S. to them and less than i07o had ~mdergone screening F.S. ever. Discussion: The incidence and mortality of colorectal cancer are higher a~ong blacks- but they could be reduced by screening flexible sigmoidoscopy as studies have shown. Compliance is, unfort~mately, low possibly due to ignorance of the official recommm%dation. Many more of our subjects knew of the reoommendations regarding mammography 60% V 237~ p<0.001. This may reflect the extensive media coverage given to breast cancer issues. Conclusion: Most of our subjects did not know .about the ACS recommendation. In order to reduce eolorectal cancer morbidity and mortality in this high risk group, our employees and the co~Sma~ity must be better educated.
EXPANDABLE METAL STENTS FOR TREATMENT OF COLONIC OBSTRUCTION "[Jd.J~l;l~&PA Dean, CR Shumate, RE Koehler, C Canon, Div. Gastroenterology, General Surgery, & Radiology. University of Alabama, Birmingham, AL Colonic obstruction carries a high morbidity and mortality, and usually requires a colostomy. We evaluated the feasibility of expandable metal stents to avoid colostomy. METHODS: 15 consecutive pts. with complete or near-cemplote colonic obstruction were treated with expandable metal stents for palliation (N=10) and preoperatively to avoid colostomy (N=5). Success was defined as ability to defecate or to adequately prep the colon for one-stage operation. RESULTS: Mean age 62 yrs. obstruction. ~t XRT, ;ornp. Tur, orlSite ite'nt mm " ilnteet 3utcome Duration Statu,= Rectum~ Jltraflex18 IPalliateSuccess 22 wks. ----Dead-I~fentqooe Rectum Iltrefiex 18 ~alliafe!Success 26 wks. Alive-patent ~lone Rect.um ~ltraflex 18 ~alliate Success 36 wks. ~Alive-patent' ~li~ration Sigmoid~ i/Vallstent10 =aUiate Success 8 wks. Oead-l~tent )erf. Rectum LIItraflex18 ~alliate Success 24 wks. )end-patent ~lone RectumQ Ecoil/Ultrafiexl~ ~alliate Success 2 wks. ,~_,ad-patent ~lone )vergrowtl~ Proximal Wallstent22 =alliate Success 17 wks. ~,live e-stentad descending~ #allstent 20 ~erl.N/A ~,liveRectosig. LJItraflex18 ~alliate Failure
;urger,/
Rectosig.~ Rectosig.
Wallstent16 ~allsfent22
F~alliate Failure ~alliate Failure
4wks. N/A
~lone )end
;'re-op Success 10 days live =re-op!Success 6 days ~tive
Rectosig.-
~re-op Success 3 wks. ~live
~allstent22
~eff.-
~urgery
Ultr~ex18 Transveree~ w/VaIIstent10
Rectum O.
~urgery
~lone qone ~ligration
.,b@nil~n Transverse~ i'Vallstent10 Transverse~ #allstent 10
;~re-op Failure Pre-op Failure
4 days ~live. 3 days ~,ad;urgery
Vligration Vligration
Overall success=67%:palliation 7/10;pre-op 3/5.Complications: 1 each of self-limited perforation, bacteramia; 4-migration; 2-major perforation (both dilated). Procedurer61ated mortality 1/15 (7%). Overgrowth in 1-successfully restented. CONCLUSIONS: 1) Successful colonic stenting is feasible using available endoprestheses 2) Changes in stent design are needed to prevent migration 3) Ditatation should be avoided during stent placement as perforation may result 4) Colonic stenting appears to be a viable alternative to surgery for palliation of malignant colorectal neoplasms given the availability and potential cost-effectiveness,
GASTROINTESTINAL ENDOSCOPY
363