- 死亡率は3.9～8.8％ と上部消化管出血と比べると必ずしも高くない。しかし、患者の高齢化や既存症はさらなる死亡リスクであり 、注意が必要である。
|1:||Risk factors for mortality in lower intestinal bleeding.|
著者: Lisa L Strate, John Z Ayanian, Gregory Kotler, Sapna SyngalClin Gastroenterol Hepatol. 2008 Sep;6(9):1004-10; quiz･･･
雑誌名: Clin Gastroenterol Hepatol. 2008 Sep;6(9):1004-10; quiz 955-. doi: 10.1016/j.cgh.2008.03.021. Epub 2008 Jun 16.
Abstract/Text BACKGROUND & AIMS: Previous studies of lower intestinal bleeding (LIB) have limited power to study mortality. We sought to identify characteristics associated with in-hospital mortality in a large cohort of patients with LIB.
METHODS: We used the 2002 Healthcare Cost and Utilization Project Nationwide Inpatient Sample to study a cross-sectional cohort of 227,022 hospitalized patients with discharge diagnoses indicating LIB. Predictors of mortality were identified by using multiple logistic regression.
RESULTS: In 2002, an estimated 8737 patients with LIB (3.9%) died while hospitalized. Independent predictors of in-hospital mortality were age (age >70 vs <50 years; odds ratio [OR], 4.91; 95% confidence interval [CI], 2.45-9.87), intestinal ischemia (OR, 3.47; 95% CI, 2.57-4.68), comorbid illness (>or=2 vs 0 comorbidities, OR, 3.00; 95% CI, 2.25-3.98), bleeding while hospitalized for a separate process (OR, 2.35; 95% CI, 1.81-3.04), coagulation defects (OR, 2.34; 95% CI, 1.50-3.65), hypovolemia (OR, 2.22; 95% CI, 1.69-2.90), transfusion of packed red blood cells (OR, 1.60; 95% CI, 1.23-2.08), and male gender (OR, 1.52; 95% CI, 1.21-1.92). Colorectal polyps (OR, 0.26; 95% CI, 0.15-0.45), and hemorrhoids (OR, 0.42; 95% CI, 0.28-0.64) were associated with a lower risk of mortality, as was diagnostic testing for LIB when added to the multivariate model (OR, 0.37; 95% CI, 0.28-0.48). Hospital characteristics were not significantly related to mortality. Predictors of mortality were similar in an analysis restricted to patients with diverticular bleeding.
CONCLUSIONS: The all-cause in-hospital mortality rate in LIB was low (3.9%). Advanced age, intestinal ischemia, and comorbid illness were the strongest predictors of mortality.
|2:||Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice.|
著者: Angel Lanas, Luis A García-Rodríguez, Mónica Polo-Tomás, Marta Ponce, Inmaculada Alonso-Abreu, Maria Angeles Perez-Aisa, Javier Perez-Gisbert, Luis Bujanda, Manuel Castro, Maria Muñoz, Luis Rodrigo, Xavier Calvet, Dolores Del-Pino, Santiago GarciaAm J Gastroenterol. 2009 Jul;104(7):1633-41. doi: 10.10･･･
雑誌名: Am J Gastroenterol. 2009 Jul;104(7):1633-41. doi: 10.1038/ajg.2009.164. Epub 2009 May 5.
Abstract/Text OBJECTIVES: Changing patterns in medical practice may contribute to temporal changes in the incidence of upper and lower gastrointestinal (GI) complications. There are limited data on the incidence of lower GI complications in clinical practice and most studies that have been done have serious methodological limitations to inferring the actual burden of this problem. The aims of this study were to analyze time trends of hospitalizations resulting from GI complications originating both from the upper and lower GI tract in the general population, and to determine the risk factors, severity, and clinical impact of these GI events.
METHODS: This was a population-based study of patients hospitalized because of GI complications in 10 general hospitals between 1996 and 2005 in Spain. We report the age- and gender-specific rates, estimate the regression coefficients of the upper and lower GI event trends, and evaluate the severity and associated risk factors. GI hospitalization charts were validated by an independent review of large random samples of unspecific and specific codes distributed among all hospitals and study years.
RESULTS: Upper GI complications fell from 87/100,000 persons in 1996 to 47/100,000 persons in 2005, whereas lower GI complications increased from 20/100,000 to 33/100,000. Overall, mortality rates decreased, but the case fatality remained constant over time. Lower GI events had a higher mortality rate (8.8 vs. 5.5%), a longer hospitalization (11.6+/-13.9 vs. 7.9+/-8.8 days), and higher resource utilization than did upper GI events. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) without concomitant proton pump inhibitor was more frequently recorded among upper GI complications than among lower GI complications. When comparing upper GI events with lower GI events, we found that male gender (adjusted odds ratio (OR): 1.94; 95% confidence interval (CI): 1.70-2.21), and recorded NSAID use (OR: 1.92; 95% CI: 1.60-2.30) were associated to a greater extent with upper GI events, whereas older age (OR: 0.83; 95% CI: 0.77-0.89), number of comorbidities (OR: 0.91; 95% CI: 0.86-0.96), and having a diagnosis in recent years (OR: 0.92; 95% CI: 0.90-0.94) were all associated to a greater extent with lower GI events than with upper GI events after adjusting for age, sex, hospitalization, and discharge year.
CONCLUSIONS: Over the past decade, there has been a progressive change in the overall picture of GI events leading to hospitalization, with a clear decreasing trend in upper GI events and a significant increase in lower GI events, causing the rates of these two GI complications to converge. Overall, mortality has also decreased, but the in-hospital case fatality of upper or lower GI complication events has remained constant. It will be a challenge to improve future care in this area unless we develop new strategies to reduce the number of events originating in the lower GI tract, as well as reducing their associated mortality.
|3:||The role of endoscopy in the patient with lower GI bleeding.|
著者: ASGE Standards of Practice Committee, Shabana F Pasha, Amandeep Shergill, Ruben D Acosta, Vinay Chandrasekhara, Krishnavel V Chathadi, Dayna Early, John A Evans, Deborah Fisher, Lisa Fonkalsrud, Joo Ha Hwang, Mouen A Khashab, Jenifer R Lightdale, V Raman Muthusamy, John R Saltzman, Brooks D CashGastrointest Endosc. 2014 Jun;79(6):875-85. doi: 10.101･･･
雑誌名: Gastrointest Endosc. 2014 Jun;79(6):875-85. doi: 10.1016/j.gie.2013.10.039. Epub 2014 Apr 2.
|4:||BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage.|
著者: M H Kollef, J D O'Brien, G R Zuckerman, W ShannonCrit Care Med. 1997 Jul;25(7):1125-32.
雑誌名: Crit Care Med. 1997 Jul;25(7):1125-32.
Abstract/Text OBJECTIVE: To develop an outcome prediction tool (BLEED: ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, unstable comorbid disease) for clinical use in patients with either acute upper or acute lower gastrointestinal (GI) hemorrhage.
DESIGN: A cohort study.
SETTING: Barnes Hospital and Jewish Hospital, two private university-affiliated teaching hospitals in St. Louis, MO.
PATIENTS: Four hundred sixty-five patients with either acute upper or acute lower GI hemorrhage admitted from the emergency department.
INTERVENTIONS: Admission of patients to the intensive care unit or hospital ward was determined by emergency department physicians, without use or knowledge of BLEED criteria. Patients meeting any BLEED criteria at their initial assessment in the emergency department were classified as "high-risk." All other patients were classified as "low-risk."
MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the occurrence of an inhospital complication, defined as recurrent GI hemorrhage, surgery to control the source of hemorrhage, and hospital mortality. Patients classified as high-risk had significantly greater rates of inhospital complications at both Barnes Hospital (relative risk, 2.47; 95% confidence interval, 1.38 to 4.44; p < .001) and Jewish Hospital (relative risk, 8.94; 95% confidence interval, 3.92 to 20.41; p < .001) compared with patients classified as low-risk. Patients classified as high-risk at either hospital were significantly more likely to develop additional organ system derangements, require a greater number of transfused units of packed red blood cells, and have longer hospital stays compared with patients classified as low-risk (p < .006). The BLEED classification also identified a greater frequency of intensive care admission for both low-risk (RR, 4.21; 95% Cl, 2.24 to 7.89) and high-risk (relative risk, 1.58; 95% confidence interval, 1.23 to 2.02) patients at Barnes Hospital compared with those patients at Jewish Hospital, although no beneficial effects on patient outcome were reported.
CONCLUSIONS: The BLEED classification, applied at initial emergency department evaluation and before admission, predicts hospital outcomes for patients with acute upper or lower GI hemorrhage. This outcome prediction tool also identified variations in intensive care utilization between two hospitals.
|5:||Early predictors of severity in acute lower intestinal tract bleeding.|
著者: Lisa L Strate, E John Orav, Sapna SyngalArch Intern Med. 2003 Apr 14;163(7):838-43. doi: 10.100･･･
雑誌名: Arch Intern Med. 2003 Apr 14;163(7):838-43. doi: 10.1001/archinte.163.7.838.
Abstract/Text BACKGROUND: Identification of high-risk patients with lower intestinal tract bleeding (LIB) is challenging, and prognostic factors have not been clearly defined. The aim of this study was to determine risk factors for severe acute LIB.
METHODS: A total of 252 consecutive patients admitted with acute LIB were identified. Data were collected on 24 clinical factors available in the first 4 hours of evaluation. The outcome was severe bleeding, which was defined as continued bleeding within the first 24 hours of hospitalization (transfusion of > or = 2 units of blood and/or hematocrit decrease of > or = 20%) and/or recurrent bleeding after 24 hours of stability (additional transfusions, further hematocrit decrease of > or = 20%, or readmission for LIB within 1 week of discharge).
RESULTS: Severe LIB occurred in 123 patients (49%). Independent correlates of severe bleeding were as follows: heart rate, > or = 100/min (odds ratio [OR], 3.67; 95% confidence interval [CI], 1.78-7.57); systolic blood pressure, < or = 115 mm Hg (OR, 3.45; 95% CI, 1.54-7.72); syncope (OR, 2.82; 95% CI, 1.06-7.46); nontender abdominal examination (OR, 2.43; 95% CI, 1.22-4.85); bleeding per rectum during the first 4 hours of evaluation (OR, 2.32; 95% CI, 1.28-4.20); aspirin use (OR, 2.07; 95% CI, 1.12-3.82); and more than 2 active comorbid conditions (OR, 1.93; 95% CI, 1.08-3.44).
CONCLUSION: Clinical data available on initial evaluation can be used to identify patients at risk for severe LIB, who may benefit most from urgent intervention.
|6:||Validation of a clinical prediction rule for severe acute lower intestinal bleeding.|
著者: Lisa L Strate, John R Saltzman, Rie Ookubo, Muthoka L Mutinga, Sapna SyngalAm J Gastroenterol. 2005 Aug;100(8):1821-7. doi: 10.111･･･
雑誌名: Am J Gastroenterol. 2005 Aug;100(8):1821-7. doi: 10.1111/j.1572-0241.2005.41755.x.
Abstract/Text OBJECTIVES: Acute lower intestinal bleeding is a heterogeneous disorder and identification of high-risk patients is challenging. We previously retrospectively identified predictors of severity in patients with acute lower intestinal bleeding. The aim of this study was to prospectively validate a clinical prediction rule for severe acute lower intestinal bleeding.
METHODS: This was a prospective, observational cohort study of consecutive patients admitted to an academic, tertiary care or a community-based teaching hospital for management of acute lower intestinal bleeding. Data were collected on seven previously identified predictors of severe bleeding: heart rate > or = 100/min, systolic blood pressure < or = 115 mmHg, syncope, nontender abdominal exam, rectal bleeding in the first 4 h of evaluation, aspirin use, and >2 comorbid conditions. Severe bleeding was defined as transfusion of > or =2 units of red blood cells, and/or a decrease in hematocrit of > or =20% in the first 24 h, and/or recurrent rectal bleeding after 24 h of stability (accompanied by a further decrease in hematocrit of > or =20%, and/or additional blood transfusions, and/or readmission for acute lower intestinal bleeding within 1 wk of discharge). Patients were stratified into 3 risk groups according to the previously developed prediction rule: low (no risk factors), moderate (1-3 risk factors), and high (>3 risk factors).
RESULTS: A total of 275 patients with acute lower intestinal bleeding were identified. The risk of severe bleeding in each risk category was similar in the validation and derivation cohorts (p values >0.05): low risk 6%versus 9%, moderate risk 43%versus 43%, and high risk 79%versus 84%. The area under the receiver operating characteristic curve was 0.754 for the validation cohort and 0.761 for the derivation cohort. The magnitude of the risk score was significantly correlated with major clinical outcomes including surgery, death, blood transfusions, and length of stay.
CONCLUSION: We have developed and prospectively validated a clinical prediction rule for acute severe lower intestinal bleeding. This prediction rule could improve the triage of patients to appropriate levels of care and interventions, and guide a more standardized approach to acute lower intestinal bleeding.
|7:||Early predictors of severe lower gastrointestinal bleeding and adverse outcomes: a prospective study.|
著者: Fernando S Velayos, Ann Williamson, Karen H Sousa, Edward Lung, Alan Bostrom, Ellen J Weber, James W Ostroff, Jonathan P TerdimanClin Gastroenterol Hepatol. 2004 Jun;2(6):485-90.
雑誌名: Clin Gastroenterol Hepatol. 2004 Jun;2(6):485-90.
Abstract/Text BACKGROUND & AIMS: Unlike in upper tract bleeding, prognostic factors for ongoing or recurrent bleeding from the lower gastrointestinal tract have not been well-defined. The aim of this study was to identify risk factors for severe lower gastrointestinal bleeding and for significant adverse outcomes.
METHODS: All patients seeking attention at a university emergency department for gastrointestinal bleeding were prospectively identified during a 3-year period. Ninety-four of 448 (21%) admitted patients had lower gastrointestinal bleeding. Clinical predictors available in the first hour of evaluation were recorded. The primary outcome, severe lower gastrointestinal bleeding, was defined as gross blood per rectum after leaving the emergency department associated with either abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) or more than a 2-unit blood transfusion during the hospitalization. Significant adverse outcomes, including death, were tabulated.
RESULTS: Thirty-seven patients (39%) had severe lower gastrointestinal bleeding. Independent risk factors for severe lower gastrointestinal bleeding were initial hematocrit =35% (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.2-16.7); presence of abnormal vital signs (systolic blood pressure < 100 mm Hg or heart rate > 100/min) 1 hour after initial medical evaluation (OR, 4.3; 95% CI, 1.4-12.5); and gross blood on initial rectal examination (OR, 3.9; 95% CI, 1.2-13.2). Nineteen patients (20%) experienced a significant adverse outcome, including 3 deaths. The main independent predictor of adverse outcomes was severe lower gastrointestinal bleeding (OR, 5.3; 95% CI, 1.7-16.5).
CONCLUSIONS: Risk factors are available in the first hour of evaluation in the emergency department to identify patients at risk for severe lower gastrointestinal bleeding. Severe lower gastrointestinal bleeding is a significant risk factor for global adverse outcomes.
|8:||Outcome predictors in acute surgical admissions for lower gastrointestinal bleeding.|
著者: J Newman, J E F Fitzgerald, S Gupta, A C von Roon, H H Sigurdsson, T G Allen-MershColorectal Dis. 2012 Aug;14(8):1020-6. doi: 10.1111/j.1･･･
雑誌名: Colorectal Dis. 2012 Aug;14(8):1020-6. doi: 10.1111/j.1463-1318.2011.02824.x.
Abstract/Text AIM: The BLEED criterion is a triaging model for lower gastrointestinal bleeding (LGIB), which was developed and validated in the USA. We assessed the BLEED criteria in a UK population and aimed to elucidate factors that can be implemented for early risk stratification.
METHOD: Patients were identified from a prospectively maintained surgical admission database at a central London teaching hospital. Data were collected on 26 clinical factors available on initial presentation. The primary-outcome end-points included severe bleeding (persistent bleeding within the first 24 h, blood transfusion, a decrease in haematocrit of ≥ 20% or recurrent bleeding after ≥ 24 hours of stability) and adverse outcome (emergency surgery to control bleeding, intensive care unit [ITU] admission or death).
RESULTS: One hundred and eighty-four clinical episodes were identified, representing 3% of all surgical referrals. Twelve patients with upper gastrointestinal bleeding were excluded. Severe bleeding occurred in 110 (64%) patients. An adverse outcome was recorded in 20 (11.6%) patients, and 10 (5.4%) patients died during admission. The commonest aetiologies were diverticular disease, haemorrhoids and malignancy. Four prognosticators of adverse outcome were identified, these being: creatinine > 150 μm (P = 0.002); age > 60 years (P = 0.001); abnormal haemodynamic parameters on presentation (P = 0.05); persistent bleeding within the first 24 h (P = 0.05); and area under the receiver-operating characteristics curve (AUC) = 0.79. The BLEED criteria were shown to be nonpredictive (AUC = 0.60).
CONCLUSION: The BLEED criterion was not shown to have any predictive value in this patient cohort. Our study has determined an independent set of prognostic factors that could be incorporated into initial triaging of patients presenting with LGIB. This may facilitate the early identification of patients requiring more aggressive resuscitation, admission to a monitored bed and consideration for early radiological or surgical intervention.
© 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.