J Korean Med Sci.  2016 Oct;31(10):1611-1616. 10.3346/jkms.2016.31.10.1611.

The Clinical Outcomes of Lower Gastrointestinal Bleeding Are Not Better than Those of Upper Gastrointestinal Bleeding

• Kwak MS
• Cha JM
• Han YJ
• Yoon JY
• Jeon JW
• Shin HP
• Joo KR
• Lee JI

• KMID: 2468252
• DOI: http://doi.org/10.3346/jkms.2016.31.10.1611

Abstract

The incidence of lower gastrointestinal bleeding (LGIB) is increasing; however, predictors of outcomes for patients with LGIB are not as well defined as those for patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to identify the clinical outcomes and the predictors of poor outcomes for patients with LGIB, compared to outcomes for patients with UGIB. We identified patients with LGIB or UGIB who underwent endoscopic procedures between July 2006 and February 2013. Propensity score matching was used to improve comparability between LGIB and UGIB groups. The clinical outcomes and predictors of 30-day rebleeding and mortality rate were analyzed between the two groups. In total, 601 patients with UGIB (n = 500) or LGIB (n = 101) were included in the study, and 202 patients with UGIB and 101 patients with LGIB were analyzed after 2:1 propensity score matching. The 30-day rebleeding and mortality rates were 9.9% and 4.5% for the UGIB group, and 16.8% and 5.0% for LGIB group, respectively. After logistic regression analysis, the Rockall score (P = 0.013) and C-reactive protein (CRP; P = 0.047) levels were significant predictors of 30-day mortality in patients with LGIB; however, we could not identify any predictors of rebleeding in patients with LGIB. The clinical outcomes for patients with LGIB are not better than clinical outcomes for patients with UGIB. The clinical Rockall score and serum CRP levels may be used to predict 30-day mortality in patients with LGIB.

Keyword

Gastrointestinal Bleeding; Colonoscopy; Hematochezia; Mortality; Prognosis

MeSH Terms

Adult
Aged
C-Reactive Protein/analysis
Endoscopy, Digestive System
Female
Gastrointestinal Hemorrhage/mortality/*pathology
Humans
Length of Stay
Male
Middle Aged
Odds Ratio
Propensity Score
Retrospective Studies
Risk Factors
Survival Rate
C-Reactive Protein

Reference

1. Fallah MA, Prakash C, Edmundowicz S. Acute gastrointestinal bleeding. Med Clin North Am. 2000; 84:1183–1208.

2. Thibault GE, Mulley AG, Barnett GO, Goldstein RL, Reder VA, Sherman EL, Skinner ER. Medical intensive care: indications, interventions, and outcomes. N Engl J Med. 1980; 302:938–942.

3. Mäkelä JT, Kiviniemi H, Laitinen S, Kairaluoma MI. Diagnosis and treatment of acute lower gastrointestinal bleeding. Scand J Gastroenterol. 1993; 28:1062–1066.

4. Lanas A, García-Rodríguez LA, Polo-Tomás M, Ponce M, Alonso-Abreu I, Perez-Aisa MA, Perez-Gisbert J, Bujanda L, Castro M, Muñoz M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol. 2009; 104:1633–1641.

5. Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1997; 92:419–424.

6. Arroja B, Cremers I, Ramos R, Cardoso C, Rego AC, Caldeira A, Eliseu L, Silva JD, Glória L, Rosa I, et al. Acute lower gastrointestinal bleeding management in Portugal: a multicentric prospective 1-year survey. Eur J Gastroenterol Hepatol. 2011; 23:317–322.

7. Marmo R, Koch M, Cipolletta L, Bianco MA, Grossi E, Rotondano G. PNED 1 and PNED 2 Investigators. Predicting mortality in patients with in-hospital nonvariceal upper GI bleeding: a prospective, multicenter database study. Gastrointest Endosc. 2014; 79:741–749.e1.

8. El-Tawil AM. Trends on gastrointestinal bleeding and mortality: where are we standing? World J Gastroenterol. 2012; 18:1154–1158.

9. Blatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ. 1997; 315:510–514.

10. Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ. 1995; 311:222–226.

11. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012; 107:345–360.

12. Banerjee S, Cash BD, Dominitz JA, Baron TH, Anderson MA, Ben-Menachem T, Fisher L, Fukami N, Harrison ME, Ikenberry SO, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010; 71:663–668.

13. Pasha SF, Shergill A, Acosta RD, Chandrasekhara V, Chathadi KV, Early D, Evans JA, Fisher D, Fonkalsrud L, Hwang JH, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointest Endosc. 2014; 79:875–885.

14. Raju GS, Gerson L, Das A, Lewis B; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007; 133:1697–1717.

15. Ell C, May A. Mid-gastrointestinal bleeding: capsule endoscopy and push-and-pull enteroscopy give rise to a new medical term. Endoscopy. 2006; 38:73–75.

16. Lee HH, Park JM, Lee SW, Kang SH, Lim CH, Cho YK, Lee BI, Lee IS, Kim SW, Choi MG. C-reactive protein as a prognostic indicator for rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Dig Liver Dis. 2015; 47:378–383.

17. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996; 38:316–321.

18. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000; 356:1318–1321.

19. Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a review of current management, controversies and advances. Int J Colorectal Dis. 2016; 31:175–188.

20. Strate LL, Ayanian JZ, Kotler G, Syngal S. Risk factors for mortality in lower intestinal bleeding. Clin Gastroenterol Hepatol. 2008; 6:1004–1010.

21. Das A, Ben-Menachem T, Cooper GS, Chak A, Sivak MV Jr, Gonet JA, Wong RC. Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model. Lancet. 2003; 362:1261–1266.

22. Hreinsson JP, Gumundsson S, Kalaitzakis E, Björnsson ES. Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol. 2013; 25:37–43.

23. Aoki T, Nagata N, Niikura R, Shimbo T, Tanaka S, Sekine K, Kishida Y, Watanabe K, Sakurai T, Yokoi C, et al. Recurrence and mortality among patients hospitalized for acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2015; 13:488–494.e1.

24. Green BT, Rockey DC, Portwood G, Tarnasky PR, Guarisco S, Branch MS, Leung J, Jowell P. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005; 100:2395–2402.

25. Sung JJ, Tsoi KK, Ma TK, Yung MY, Lau JY, Chiu PW. Causes of mortality in patients with peptic ulcer bleeding: a prospective cohort study of 10,428 cases. Am J Gastroenterol. 2010; 105:84–89.

26. Ríos A, Montoya MJ, Rodríguez JM, Serrano A, Molina J, Ramírez P, Parrilla P. Severe acute lower gastrointestinal bleeding: risk factors for morbidity and mortality. Langenbecks Arch Surg. 2007; 392:165–171.

27. Velayos FS, Williamson A, Sousa KH, Lung E, Bostrom A, Weber EJ, Ostroff JW, Terdiman JP. Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study. Clin Gastroenterol Hepatol. 2004; 2:485–490.

28. Kollef MH, O’Brien JD, Zuckerman GR, Shannon W. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med. 1997; 25:1125–1132.

29. Rockall TA, Logan RF, Devlin HB, Northfield TC; National Audit of Acute Upper Gastrointestinal Haemorrhage. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet. 1996; 347:1138–1140.

30. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, Wei J, Lontos S, Angus P, Vaughan R. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score to the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016; 83:1151–1160.

31. Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med. 2003; 163:838–843.

32. Koseoglu Z, Ozkan OV, Semerci E, Aslan A, Yetim I, Ucar E, Kuvandik G, Temiz M, Borazan A. The relationship between mortality and inflammation in patients with gastrointestinal bleeding. J Int Med Res. 2009; 37:1508–1514.