Utilidade clínica dos escores de risco no sangramento varicoso / Clinical utility of risk scores in variceal bleeding

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.

RESUMO CONTEXTO: O sangramento varicoso permanece como importante causa de sangramento gastrointestinal superior. Vários escores são utilizados na estratificação do risco para sangramento não varicoso. Sua utilidade em pacientes de sangramento varicoso não é clara. OBJETIVO: Este estudo tem como objetivo comparar a probabilidade desses escores em prever vários desfechos na mesma população. Estudar característica e validar o AIMS65, o Rockall, a Pontuação de Glasgow Blatchford (GBS), o escore Progetto Nazionale Emorragia Digestiva (PNED), na pontuação em hemorragia gastrointestinal varicosa superior (UGIB) em pacientes para prever vários resultados em nossa população. MÉTODOS: Um total de 300 indivíduos com UGIB foram rastreados prospectivamente. Destes, 141 pacientes com sangramento varicoso foram submetidos à avaliação clínica, hematológica e endoscopia tendo seus escores de risco calculados e comparados aos casos não-varicosos. Todos os casos foram acompanhados por 30 dias para mortalidade, necessidade de transfusão sanguínea por ressangramento ou de necessidade de intervenção radiológica ou cirúrgica. RESULTADOS: O sangramento varicoso (141) foi mais comum do que não varicoso (134) e em 25 teve endoscopia negativa. No grupo varicoso, a cirrose foi a etiologia mais comum (85%). A distribuição da idade e do sexo foi semelhante em ambos os grupos. Presença de vômito colorido em borra de café (P=0,002), sangramento indolor (P=0,001), edema (P=0,001), ascite (P=0,001), hemoglobina <7,5 GMS (P<0,001), pH <7,35 (P<0,001), nível de bicarbonato sérico <17,6 mmol/L (P<0,001), albumina sérica <2,75 GMS% (P<0,001), contagem plaquetária <1,2 Lacs/μL (P<0,001), INR elevada 1,35 (P<0,001), Bun >25 mmol/L (P<0,001) e estado ASA (P<0,001), lactato elevado >2,85 mmol/L (P=0,001) foram significativos. Entretanto, nenhum fator foi encontrado como significativo na análise multivariada. Rockall foi significativo em prever a mortalidade e ressangrar. O AIMS65 também foi significante na predição da mortalidade. O GBS foi significativo na predição de transfusão sanguínea e necessidade de intervenção. O escore de PNED foi significante em todos os eventos, exceto mortalidade. CONCLUSÃO: Todos os quatro escores apresentaram menor potencial preditivo na predição de eventos em sangramento varicoso. Entretanto, o AIMS65 e o escore de Rockall foram significantes na predição da mortalidade, enquanto o GBS na predição da necessidade de transfusão e intervenção. O escore de PNED foi significante em todos os eventos, exceto mortalidade.

Outcome of upper gastrointestinal hemorrhage according to the bleed risk classification: a two-year prospective survey

Upper gastrointestinal bleeding [UGIB] is a common and serious medical emergency. The aim of this study was to predict UGIB patients' outcome according to a risk scoring system, independent of endoscopic findings, introduced by Kollef et al [BLEED: ongoing bleeding, elevated prothrombin time, erratic mental status, and unstable co-morbid disease]. Prospective study. Sina university hospital. We studied all patients who presented with UGIB during 2000 to 2002. Patients meeting the BLEED criteria at their initial assessment were classified as high-risk [71] and all others were categorized as low-risk [50]. In-hospital complications were defined as recurrent UGIB, surgery to control the source of hemorrhage and hospital mortality. There were 101 patients, aged 55.7 +/- 20.8 years. Re-bleeding, surgery and death occurred in 21 [20.8%], 28 [27.7%] and 14 [13.9%] of the patients, respectively. Therapeutic and diagnostic upper gastrointestinal endoscopy were performed in 7 [7%] and 83 [82.2%] of patients, respectively. Seventy percent were categorized as high-risk. There was significant difference in development of in-hospital complications, and death when considered individually, between the high and low-risk patients, but not in the rate of re-bleeding, length of hospital stay and transfused units of packed red blood cells. High-risk patients needed surgery more often than the low-risk cases but the difference was borderline significant [p=0.051]. Low systolic blood pressure and elevated prothrombin time were independent predictors of in-hospital complications among BLEED criteria. BLEED classification was capable of predicting in-hospital complications, especially mortality. It is, therefore, a helpful triage tool in centers where urgent endoscopy is hardly available

Hemorragia digestiva baja: [revisión] / Low gastrointestinal bleeding: [review]

La hemorragia digestiva baja es una entidad que debe ser tratada por grupos multidisciplinarios interesados en esta patología, siguiendo algoritmos diagnósticos acordes a los centros donde actúan. En esta revisión se describen los aspectos fisiopatológicos de las patologías más frecuentes, como la enfermedad diverticular y las angiodisplasias. Se han revisado las ventajas y desventajas de cada uno de los procedimientos utilizados para el diagnóstico, tomando en cuenta la bibliografía nacional e internacional disponible. La parte final del trabajo pretende transmitir una visión práctica de la conducta a seguir en estos pacientes, especialmente en algunos aspectos relacionados al tratamiento quirúrgico.

Low gastrointestinal bleeding should be treated by multidisciplinary teams interested in this pathology. Proper algorithms should be used according to each institution common practice. Pathogenesis of diverticular disease and angiodysplasia are described, and a classification of low gastrointestinal bleeding is proposed. Advantages and disadvantages of the procedures used for the diagnosis and treatment have been reviewed, taken into consideration the available national and international bibliography. Finally, an overview of some practical aspects of the surgical decision and treatment is given.

Predictors of non-significant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage.

OBJECTIVES: The objective of the present study was to determine pre-endoscopic predictive factors of nonsignificant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage (UGIH). MATERIAL AND METHOD: Medical records of 187 patients admitted with the primary diagnosis of UGIH were reviewed. Non-significant endoscopic findings were defined as "normal": "mild gastritis" or unspecified gastritis with a hospital stay of two days or less. Possible predictors of non-significant endoscopic findings included pertinent history, physical examination, nasogastric tube aspirate, routine laboratory findings, and units of infused packed red cells (PRC). Multiple logistic regression analysis was used to determine significant predictors. RESULTS: Predictors of non-significant endoscopic findings included the absence of comorbid diseases (OR: 6.4; 95%CI: 3.0-13.6), higher platelet count (OR. 1.7 per 100,000 increase; 95%CI: 1.1-2.5) and less PRC infusion (OR: 1.9 per unit decrease; 95%CI: 1.3-2.7). CONCLUSION: Patients with UGIH who may have a negative EGD can be identified prior to endoscopy.

Hemorragia digestiva baixa em criança / Lower digestive hemorrhage in childhood

A hemorragia digestiva baixa em crianças está relacionada a uma série de diagnósticos que variam de acordo com a faixa etária do paciente pediátrico. Os dados da história clínica, assim como a idade do paciente, tipo de sangramento e história dietética, são fundamentais para um diagnóstico correto. Os achados de exame físico e os exames complementares realizados de acordo com a suspeita clínica, geralmente levam à resolução do problema. Os autores propõem, através desta revisão de leitura, um roteiro diagnóstico para o sangramento gastrointestinal baixo em pediatria, discutindo ainda os principais diagnósticos diferenciais.

Factores de riesgo asociados a hemorragia digestiva alta, en sala común / Risk factors associated to upper gastrointestinal bleeding in non intensive care units

Upper gastrointestinal bleeding--UGB-, as a complication, is well studied at intensive care units (ICU), but is less known in non ICU settings. Objectives: To determine incidence and risk factors of this entity at clinical hospitalization. MATERIALS AND METHODS: A case-control study of patients with gastric ulcer disease diagnosed by endoscopy who presented with melena and hematemesis. Ten controls were taken for each case, matching sex, age and prophylaxis for gastric hemorrhage. Demographic data and other know risks factors were analyzed. RESULT: We found ten bleeding case among 35070 discharges (incidence: 2.8/10000 discharges). Mortality was not increased but the number of transfusion was higher in the bleeding group. We found an assocciation betwen UGB and systemic inflammatory response syndrome--SIRS-(OR: 9.22 IC 95% 2.98-28.17) and diabetes (OR: 7.8 IC 95% 2.3-26.8). The rest of the factors studied did not rich a statistical significance. CONCLUSIONS: UGB during clinical hospitalization is a rare complication that requires an increased staying at hospital and a great number of transfusions. It may be probably associated in a positive way with diabetes and SIRS.

La hemorragia digestiva alta durante la internación es una complicación estudiada en unidades de cuidados críticos, pero se sabe poco de esta complicación en sala común. Objetivos: determinar la incidencia y factores de riesgo de esta patología en sala común. Materiales y Métodos: Estudio casocontrol. Definimos casos, pacientes con endoscopía digestiva realizada por melena o hematemesis, con diagnóstico de enfermedad ulcerosa, se tomaron 10 controles por caso, controlando edad, sexo y uso de profilaxis ulcerosa. Se analizaron datos demográficos y factores de riesgo conocidos para esta patología y se determinó la incidencia en sala común. Resultados: Se produjeron 10 episodios de sangrado sobre 35070 altas (Incidencia 2.8110.000 altas). No hubo mayor mortalidad en los casos pero si requirieron mayor número de transfusiones (1.2 versus (vs) 0.07 paquetes de glóbulos rojos sedimentados en el grupo control. P=O.OOl) y tuvieron una mayor estadía hospitalaria (13.6 vs 6.8 días en el grupo control. P=O.OOl). Existió una asociación significativa entre hemorragia digestiva y presentar SIRS (aR: 9.22 IC95%: 2.9828.17) o Diabetes (aR: 7.8 IC95%: 2.326.8), el resto de los factores no alcanzaron significancia estadística. Conclusión: La hemorragia digestiva durante la internación es una entidad poco frecuente que requiere mayor estadía hospitalaria y necesidad de transfusiones. Asociada posiblemente en forma positiva al ingreso con SIRS, Diabetes, leucocitosis y taquicardia.

Sangramientos digestivos / Digestive bleeding

Se analizan desde un punto de vista general las principales causas de sangramiento digestivos, tratando de proponer un esquema de clasificación, basado, por lo menos inicialmente, en una minuciosa anamnesis que detalle las características del sangramiento y de su expresión clínica (anemia hipocroma, melena, colorragia o rectorragia)

Hemorragia digestiva alta / Upper digestive bleeding

Las últimas investigaciones llevadas a cabo en HDA dan importancia a la clasificación por categorías de riesgos, mediante la utilización de criterios predictivos, con el objeto de dirigir adecuadamente las medidas terapéuticas hacia el grupo de mayor riesgo. La hemostasia endoscópica ha demostrado su eficacia en la detención primaria y definitiva del sangrado. A pesar de las diferencias en metodología entre los ensayos, no existe ninguna diferencia real entre las varias modalidades del tratamiento disponible, que incluyen aparatos térmicos, láser, y terapia inyectable y por lo tanto la elección del método depende fundamentalmente de la disponibilidad y experiencia de cada grupo de trabajo. Aunque se están publicándo resultados aún mejores, mediante tratamientos relativamente nuevos como la trombina, fibrina, y los aparatos de hemostasia mecánicos prometedores, se esperan los resultados de los ensayos controlados. Datos confiables apoyan la utilidad del "second look" endoscópico y la importancia de la supresión del ácido ha quedado establecida, al utilizar medicamentos como el omeprazol y similares, pero, sin terapia endoscópica previa, no son capaces de detener una hemorragia activa. El valor de la erradicación del hélicobacter pylori para disminuir las recidivas hemorrágicas

Tratamiento quirúrgico de la hipertensión portal en enfermos en edad avanzada / Surgical treatment for hemorrhagic portal hypertension of elderly patients

Se valoraron los expedientes clínicos de 32 enfermos mayores de 65 años sometidos a tratamiento quirúrgico para hipertensión portal hemorrágica. La principal enfermedad asociada fue diabetes mellitus en 10 casos. El electrocardiograma fue normal en 20 casos y alteraciones diversas en los restantes, que no contraindicaban ningún procedimiento. Las pruebas de función respiratoria fueron normales en 12. Diecinueve se encontraban en clase funcional A de Child, cinco en clase B y los restantes en clase C. La cirugía fue realizada electivamente en 23 casos, realizándose 13 cirugías derivativas (12 de ellas selectivas), dos procedimientos completos de Sugiura (abdominal y torácico), cinco procedimientos abdominales de Sugiura y uno torácico; en los dos casos restantes, procedimientos de desvascularización esofagogástrica distintos a los de Sugiura. Los enfermos con clase funcional A-B de Child tuvieron una mortalidad operatoria del 10%. El seguimiento promedio fue de 11.3 meses. De acuerdo a la distribución no paramétrica de Kaplan y Meier la sobrevida calculada a los 12 meses fue de 83%, 77% a los 24 meses, 65% a los 48 meses y 59% a los 72 meses. Se encontró evidencia de resangrado en dos casos y encefalopatía clínica en cuatro. En nueve la cirugía realizada fue urgente. Cinco de los enfermos se encontraban en clase C de Child, tres en clase B y uno en clase A. Se realizaron dos operaciones de Sugiura completas, tres tiempos torácicos, uno abdominal y un procedimiento de desvascularización distinto al de Sugiura y dos procedimientos derivativos. La mortalidad operatoria fue de seis enfermos. Se concluye que los enfermos mayores de 65 años pueden ser manejados quirúrgicamente para control de hipertensión portal hemorrágica siempre que se encuentren en buena clasificación funcional de Child y en forma electiva.