今日の臨床サポート

血便(潜血便を除く 含む血便を合併する下痢症)

著者: 柴﨑俊一 ひたちなか総合病院 救急・総合内科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正/監修レビュー済:2021/06/16
参考ガイドライン:
  1. 米国消化器病学会(ACG):AGC clinical guideline:management of patients with acute lower gastrointestinal bleeding
患者向け説明資料

概要・推奨   

  1. 下部消化管出血疑いでは循環動態、予後不良因子を確認することが推奨される(推奨度1循環動態が不安定、予後不良因子が複数ある場合は、迅速な専門家へのコンサルが推奨される(推奨度2)
  1. 循環動態が不安定な消化管出血では、血便でも上部消化管出血も積極的に疑うことが推奨される(推奨度2
  1. 循環動態が安定しており、予後不良因子がほとんどない下部消化管出血疑いでは、後日、大腸内視鏡または専門家への紹介が推奨される(推奨度2)
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
柴﨑俊一 : 特に申告事項無し[2021年]
監修:山中克郎 : 未申告[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疫学情報・病態・注意事項  
疫学情報:
  1. 下部消化管出血は、消化管出血全体の20%程度とされる[1]。その割合は、上部消化管出血が減少傾向に比して、下部消化管出血は増加傾向である。
  1. 米国・英国では年間100,000人あたり20~33人の発症率である。
  1. 死亡率は3.9~8.8%[2][3]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[2]、注意が必要である。
 
病態:
  1. 出血の量とで臨床的には大きく2つに分類できる。
  1. ①肉眼的に明らかな血便(Overt)=急性の出血
  1. ②顕微鏡的な血便(occult)=肉眼ではわからず、便潜血検査で初めてみつかる血便=慢性的な出血で、鉄欠乏としてみつかる[4]
  1. 本章は、急性下部消化管出血について取り扱う。
  1. 便の色調で、出血部位を類推することができる。ただし、絶対的なものではく、循環動態が不安定などリスクの高い症例では過信しすぎないことが肝要である。
  1. ①黒色便・タール便:食道~小腸
  1. ②栗色・褐色の便:下部小腸~右半結腸
  1. ③鮮やかな血便:左半結腸~肛門
問診・診察のポイント  
  1. 急性下部消化管出血の診療で大事なポイントは以下の3つである[5]
  1. ①重症度・リスクの評価
  1. ②出血部位の推定
  1. ③病態・疾患の推定
  1. 具体的な問診、診察については下記に記載した。

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文献 

著者: G F Longstreth
雑誌名: Am J Gastroenterol. 1997 Mar;92(3):419-24.
Abstract/Text OBJECTIVES: Population-based data on the epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage (ALGIH) are lacking. This survey of the incidence, etiology, therapy, and long-term outcome of patients with ALGIH was conducted in a defined population.
METHODS: In a large health maintenance organization, discharge data and colonoscopy records were used to identify adults hospitalized with ALGIH from 1990 to 1993. Data were collected by record review and telephone calls.
RESULTS: Two hundred nineteen patients had 235 hospitalizations, yielding an estimated annual incidence rate of 20.5 patients/100,000 (24.2 in males versus 17.2 in females, p < .001). The rate increased > 200-fold from the third to the ninth decades of life. Diagnoses were: colonic diverticulosis, 91 (41.6%); colorectal malignancy, 20 (9.1%); ischemic colitis, 19 (8.7%); miscellaneous, 63 (28.8%); and unknown, 26 (11.9%). Eight (3.6%) patients died in the hospital (5 of 206 (2.4%) with hemorrhage before admission versus 3 of 13 (23.1%) with hemorrhage after admission, p < .001). Follow-up of 210 of 211 (99.5%) survivors was 34.0 +/- 1.1 months. In the 83 diverticulosis patients without definitive therapy, the hemorrhage recurrence rate (Kaplan-Meier method) was 9% at 1 year, 10% at 2 years, 19% at 3 years, and 25% at 4 years. In the 89 diverticulosis patients who survived hospitalization, all-cause mortality rates (none from hemorrhage) were 11% at 1 year, 15% at 2 years, 18% at 3 years, and 20% at 4 years.
CONCLUSIONS: Hospitalization with ALGIH is related to age and male gender. After hemorrhage from colonic diverticulosis, the leading cause, rates of ALGIH recurrence and unrelated death are similar during the next 4 years.

PMID 9068461  Am J Gastroenterol. 1997 Mar;92(3):419-24.
著者: Lisa L Strate, John Z Ayanian, Gregory Kotler, Sapna Syngal
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.

PMID 18558513  Clin Gastroenterol Hepatol. 2008 Sep;6(9):1004-10; quiz・・・
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 Garcia
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.

PMID 19574968  Am J Gastroenterol. 2009 Jul;104(7):1633-41. doi: 10.10・・・
著者: Kathy Bull-Henry, Firas H Al-Kawas
雑誌名: Am Fam Physician. 2013 Mar 15;87(6):430-6.
Abstract/Text Occult gastrointestinal bleeding is defined as gastrointestinal bleeding that is not visible to the patient or physician, resulting in either a positive fecal occult blood test, or iron deficiency anemia with or without a positive fecal occult blood test. A stepwise evaluation will identify the cause of bleeding in the majority of patients. Esophagogastroduodenoscopy (EGD) and colonoscopy will find the bleeding source in 48 to 71 percent of patients. In patients with recurrent bleeding, repeat EGD and colonoscopy may find missed lesions in 35 percent of those who had negative initial findings. If a cause is not found after EGD and colonoscopy have been performed, capsule endoscopy has a diagnostic yield of 61 to 74 percent. Deep enteroscopy reaches into the mid and distal small bowel to further investigate and treat lesions found during capsule endoscopy or computed tomographic enterography. Evaluation of a patient who has a positive fecal occult blood test without iron deficiency anemia should begin with colonoscopy; asymptomatic patients whose colonoscopic findings are negative do not require further study unless anemia develops. All men and postmenopausal women with iron deficiency anemia, and premenopausal women who have iron deficiency anemia that cannot be explained by heavy menses, should be evaluated for occult gastrointestinal bleeding. Physicians should not attribute a positive fecal occult blood test to low-dose aspirin or anticoagulant medications without further evaluation.

PMID 23547576  Am Fam Physician. 2013 Mar 15;87(6):430-6.
著者: Lisa L Strate, Ian M Gralnek
雑誌名: Am J Gastroenterol. 2016 May;111(5):755. doi: 10.1038/ajg.2016.155.
Abstract/Text
PMID 27151132  Am J Gastroenterol. 2016 May;111(5):755. doi: 10.1038/a・・・
著者: S McGee, W B Abernethy, D L Simel
雑誌名: JAMA. 1999 Mar 17;281(11):1022-9.
Abstract/Text OBJECTIVE: To review, systematically, the physical diagnosis of hypovolemia in adults.
METHODS: We searched MEDLINE (January 1966-November 1997), personal files, and bibliographies of textbooks on physical diagnosis and identified 10 studies investigating postural vital signs or the capillary refill time of healthy volunteers, some of whom underwent phlebotomy of up to 1150 mL of blood, and 4 studies of patients presenting to emergency departments with suspected hypovolemia, usually due to vomiting, diarrhea, or decreased oral intake.
RESULTS: When clinicians evaluate adults with suspected blood loss, the most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more. The presence of either finding has a sensitivity for moderate blood loss of only 22% (95% confidence interval [CI], 6%-48%) but a much greater sensitivity for large blood loss of 97% (95% CI, 91%-100%); the corresponding specificity is 98% (95% CI, 97%-99%). Supine hypotension and tachycardia are frequently absent, even after up to 1150 mL of blood loss (sensitivity, 33%; 95% CI, 21%-47%, for supine hypotension). The finding of mild postural dizziness has no proven value. In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue against it (negative likelihood ratio, 0.3; 95% CI, 0.1-0.6 for both findings). In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.
CONCLUSIONS: A large postural pulse change (> or =30 beats/min) or severe postural dizziness is required to clinically diagnose hypovolemia due to blood loss, although these findings are often absent after moderate amounts of blood loss. In patients with vomiting, diarrhea, or decreased oral intake, few findings have proven utility, and clinicians should measure serum electrolytes, serum blood urea nitrogen, and creatinine levels when diagnostic certainty is required.

PMID 10086438  JAMA. 1999 Mar 17;281(11):1022-9.
著者: Mitchell S Cappell, David Friedel
雑誌名: Med Clin North Am. 2008 May;92(3):491-509, xi. doi: 10.1016/j.mcna.2008.01.005.
Abstract/Text Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.

PMID 18387374  Med Clin North Am. 2008 May;92(3):491-509, xi. doi: 10.・・・
著者: Pablo Perel, Ian Roberts, Katharine Ker
雑誌名: Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567. doi: 10.1002/14651858.CD000567.pub6. Epub 2013 Feb 28.
Abstract/Text BACKGROUND: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid, and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids.
OBJECTIVES: To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients.
SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register (17 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library) (Issue 10, 2012), MEDLINE (Ovid) 1946 to October 2012, EMBASE (Ovid) 1980 to October 2012, ISI Web of Science: Science Citation Index Expanded (1970 to October 2012), ISI Web of Science: Conference Proceedings Citation Index-Science (1990 to October 2012), PubMed (October 2012), www.clinical trials.gov and www.controlled-trials.com. We also searched the bibliographies of relevant studies and review articles.
SELECTION CRITERIA: Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded cross-over trials and trials involving pregnant women and neonates.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and rated quality of allocation concealment. We analysed trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, separately. We stratified the analysis according to colloid type and quality of allocation concealment.
MAIN RESULTS: We identified 78 eligible trials; 70 of these presented mortality data.COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06).
AUTHORS' CONCLUSIONS: There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified.

PMID 23450531  Cochrane Database Syst Rev. 2013 Feb 28;(2):CD000567. d・・・
著者: F Douglas Srygley, Charles J Gerardo, Tony Tran, Deborah A Fisher
雑誌名: JAMA. 2012 Mar 14;307(10):1072-9. doi: 10.1001/jama.2012.253.
Abstract/Text CONTEXT: Emergency physicians must determine both the location and the severity of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic approaches.
OBJECTIVES: To identify the historical features, symptoms, signs, bedside maneuvers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to have severe bleeding that necessitates an urgent intervention.
DATA SOURCES: A structured search of MEDLINE (1966-September 2011) and reference lists from retrieved articles, review articles, and physical examination textbooks.
STUDY SELECTION: High-quality studies were included of adult patients who were either admitted with GIB or evaluated in emergency departments with bedside evaluations and/or routine laboratory tests, and studies that did not include endoscopic findings in prediction models. The initial search yielded 2628 citations, of which 8 were retained that tested methods of identifying a UGIB and 18 that identified methods of determining the severity of UGIB.
DATA EXTRACTION: One author abstracted the data (prevalence, sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality, with confirmation by another author. Data were combined using random effects measures.
DATA SYNTHESIS: The majority of patients (N = 1776) had an acute UGIB (prevalence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitrogen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Conversely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38) decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the likelihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (summary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires urgent intervention.
CONCLUSIONS: Melena, nasogastric lavage with blood or coffee grounds, or serum urea nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which does not require nasogastric lavage, is very efficient for identifying patients who do not require urgent intervention.

PMID 22416103  JAMA. 2012 Mar 14;307(10):1072-9. doi: 10.1001/jama.201・・・
著者: Càndid Villanueva, Alan Colomo, Alba Bosch, Mar Concepción, Virginia Hernandez-Gea, Carles Aracil, Isabel Graupera, María Poca, Cristina Alvarez-Urturi, Jordi Gordillo, Carlos Guarner-Argente, Miquel Santaló, Eduardo Muñiz, Carlos Guarner
雑誌名: N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJMoa1211801.
Abstract/Text BACKGROUND: The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.
METHODS: We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.
RESULTS: A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.
CONCLUSIONS: As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).

PMID 23281973  N Engl J Med. 2013 Jan 3;368(1):11-21. doi: 10.1056/NEJ・・・
著者: W C Wu, S S Rathore, Y Wang, M J Radford, H M Krumholz
雑誌名: N Engl J Med. 2001 Oct 25;345(17):1230-6. doi: 10.1056/NEJMoa010615.
Abstract/Text BACKGROUND: Anemia may have adverse effects in patients with coronary artery disease. However, the benefit of blood transfusion in elderly patients with acute myocardial infarction and various degrees of anemia is uncertain.
METHODS: We conducted a retrospective study of data on 78,974 Medicare beneficiaries 65 years old or older who were hospitalized with acute myocardial infarction. Patients were categorized according to the hematocrit on admission (5.0 to 24.0 percent, 24.1 to 27.0 percent, 27.1 to 30.0 percent, 30.1 to 33.0 percent, 33.1 to 36.0 percent, 36.1 to 39.0 percent, or 39.1 to 48.0 percent), and data were evaluated to determine whether there was an association between the use of transfusion and 30-day mortality.
RESULTS: Patients with lower hematocrit values on admission had higher 30-day mortality rates. Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission fell into the categories ranging from 5.0 to 24.0 percent (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.11 to 0.45) to 30.1 to 33.0 percent (adjusted odds ratio, 0.69; 95 percent confidence interval, 0.53 to 0.89). It was not associated with a reduction in 30-day mortality among those whose hematocrit values fell in the higher ranges. In one of seven subgroup analyses (among patients who survived at least two days), transfusion was not associated with a reduction in mortality for patients with hematocrit values of 30.1 percent or higher.
CONCLUSIONS: Blood transfusion is associated with a lower short-term mortality rate among elderly patients with acute myocardial infarction if the hematocrit on admission is 30.0 percent or lower and may be effective in patients with a hematocrit as high as 33.0 percent on admission.

PMID 11680442  N Engl J Med. 2001 Oct 25;345(17):1230-6. doi: 10.1056/・・・
著者: Anoush Razzaghi, Alan N Barkun
雑誌名: J Clin Gastroenterol. 2012 Jul;46(6):482-6. doi: 10.1097/MCG.0b013e31823d33e3.
Abstract/Text BACKGROUND: There exists uncertainty as to the optimal platelet values when managing patients with nonvariceal upper gastrointestinal (GI) bleeding. GOALS AND STUDY: A systematic review was carried out to determine the optimal approach when managing patients with thrombocytopenia in the setting of nonvariceal upper GI bleeding.
RESULTS: Eighteen of 803 potential articles were selected and reviewed, including 4 randomized controlled trials and 6 cohort studies. The only empirical clinical data available pertained to the management of hematology or oncology patients. There was no high-level evidence that determined the proper threshold of platelet transfusion specifically in GI bleeding. We were, therefore, limited to include principally consensus opinions, recommendations, and guidelines for platelet transfusion trigger as they apply to the treatment (including prophylaxis) of bleeding in general, with a paucity of data addressing major bleeding, let alone bleeding from a gastroenterologic origin. Randomized clinical trials were individually underpowered in allowing definitive conclusions, even though resulting recommendations were supported by similarly underpowered retrospective and prospective observational studies.
CONCLUSIONS: There exist a paucity of data to recommend optimal therapeutic platelet count targets in patients with active GI bleeding. Based principally on expert opinion recommendations, we propose a count of 50×10/L. Some professional associations have suggested in very specific clinical settings (postcardiopulmonary bypass surgery or central nervous system trauma) a higher value of up to 100×10/L. Properly designed randomized trials are required to more precisely address this important clinical question.

PMID 22688143  J Clin Gastroenterol. 2012 Jul;46(6):482-6. doi: 10.109・・・
著者: A Shingina, A N Barkun, A Razzaghi, M Martel, M Bardou, I Gralnek, RUGBE Investigators
雑誌名: Aliment Pharmacol Ther. 2011 May;33(9):1010-8. doi: 10.1111/j.1365-2036.2011.04618.x. Epub 2011 Mar 8.
Abstract/Text BACKGROUND: The prognostic value of an elevated international normalised ratio (INR) as part of initial risk stratification in nonvariceal upper gastrointestinal bleeding (NVUGIB) remains poorly characterised.
AIM: To assess the usefulness of the initial INR in patients with NVUGIB.
METHOD: After a systematic review, we included the presenting INR and other validated prognosticators in multivariable models predicting rebleeding and mortality. Data are reported as odd ratios and 95% confidence intervals.
RESULTS: Only two of 769 candidate studies were useful, but reported disparate, highly selected NVUGIB patients with varying threshold initial INR values, yielding conflicting results on predictive ability. The RUGBE cohort included 1869 patients (mean age 66.3 ± 16.8, 38.1% female) with a mean presenting INR of 1.5 ± 1.7. 462 (24.7%) patients had an elevated INR (INR > 2.5 in 7.6%). INR did not add to the prediction of rebleeding. An INR >1.5, in contradistinction, significantly predicted mortality (OR: 1.96; 95% CI: 1.13-3.41).
CONCLUSIONS: An elevated INR at initial presentation does not predict rebleeding in NVUGIB. A value 1.5 or greater, however, is associated with increased patient mortality after adjustment for validated prognosticators. The INR appears most useful as proxy of co-morbid burden at the time of initial assessment in NVUGIB.

© 2011 Blackwell Publishing Ltd.
PMID 21385193  Aliment Pharmacol Ther. 2011 May;33(9):1010-8. doi: 10.・・・
著者:
雑誌名: N Engl J Med. 1985 May 16;312(20):1311-8. doi: 10.1056/NEJM198505163122008.
Abstract/Text
PMID 3990728  N Engl J Med. 1985 May 16;312(20):1311-8. doi: 10.1056/・・・
著者: Loren Laine, Abbid Shah
雑誌名: Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642. doi: 10.1038/ajg.2010.277. Epub 2010 Jul 20.
Abstract/Text OBJECTIVES: We sought to determine, in patients with serious hematochezia, the proportion who have an upper gastrointestinal (GI) source and whether urgent colonoscopy improves outcomes as compared with elective colonoscopy in those without an upper source.
METHODS: Patients with hematochezia were eligible if they also had heart rate >100, systolic blood pressure <100, orthostatic change in heart rate or blood pressure >20, hemoglobin drop ≥ 1.5 g/dl, or blood transfusion. Patients had upper endoscopy within 6 h. Those without an upper source were randomized to urgent (≤ 12 h) or elective (36-60 h after presentation) colonoscopy. The primary end point was further bleeding. Patients were followed for the duration of hospitalization.
RESULTS: Eighty-five eligible patients had urgent upper endoscopy; 13 (15%) had an upper source. The remaining 72 were randomized to urgent (N=36) or elective (N=36) colonoscopy. Further bleeding occurred in 8 (22%) vs. 5 (14%) of the urgent vs. elective groups (difference=8%, 95% confidence interval (CI)=-9 to 26%). Units of blood (1.5 vs. 0.7), hospital days (5.2 vs. 4.8), subsequent diagnostic or therapeutic interventions for bleeding (36% vs. 33%), and hospital charges ($27,590 vs. $26,633) also were not lower in the urgent group. A major limitation is that the study was terminated before reaching the prespecified sample size.
CONCLUSIONS: Patients with clinically serious hematochezia should have upper endoscopy initially to rule out an upper GI source. Use of urgent colonoscopy in a population hospitalized with serious lower GI bleeding showed no evidence of improving clinical outcomes or lowering costs as compared with routine elective colonoscopy.

PMID 20648004  Am J Gastroenterol. 2010 Dec;105(12):2636-41; quiz 2642・・・
著者: David Ponka, Faisal Baddar
雑誌名: Can Fam Physician. 2013 May;59(5):510.
Abstract/Text
PMID 23673588  Can Fam Physician. 2013 May;59(5):510.
著者: D M Jensen, G A Machicado, R Jutabha, T O Kovacs
雑誌名: N Engl J Med. 2000 Jan 13;342(2):78-82. doi: 10.1056/NEJM200001133420202.
Abstract/Text BACKGROUND: Although endoscopy is often used to diagnose and treat acute upper gastrointestinal bleeding, its role in the management of diverticulosis and lower gastrointestinal bleeding is uncertain.
METHODS: We studied the role of urgent colonoscopy in the diagnosis and treatment of 121 patients with severe hematochezia and diverticulosis. All patients were hospitalized, received blood transfusions as needed, and received a purge to rid the colon of clots, stool, and blood. Colonoscopy was performed within 6 to 12 hours after hospitalization or the diagnosis of hematochezia. Among the first 73 patients, those with continued diverticular bleeding underwent hemicolectomy. For the subsequent 48 patients, those requiring treatment received therapy, such as epinephrine injections or bipolar coagulation, through the colonoscope.
RESULTS: Of the first 73 patients, 17 (23 percent) had definite signs of diverticular hemorrhage (active bleeding in 6, nonbleeding visible vessels in 4, and adherent clots in 7). Nine of the 17 had additional bleeding after colonoscopy, and 6 of these required hemicolectomy. Of the subsequent 48 patients, 10 (21 percent) had definite signs of diverticular hemorrhage (active bleeding in 5, nonbleeding visible vessels in 2, and adherent clots in 3). An additional 14 patients in this group (29 percent) were presumed to have diverticular bleeding because although they had no stigmata of diverticular hemorrhage, no other source of bleeding was identified. The other 24 patients (50 percent) had other identified sources of bleeding. All 10 patients with definite diverticular hemorrhage were treated endoscopically; none had recurrent bleeding or required surgery.
CONCLUSIONS: Among patients with severe hematochezia and diverticulosis, at least one fifth have definite diverticular hemorrhage. Colonoscopic treatment of such patients with epinephrine injections, bipolar coagulation, or both may prevent recurrent bleeding and decrease the need for surgery.

PMID 10631275  N Engl J Med. 2000 Jan 13;342(2):78-82. doi: 10.1056/NE・・・
著者: Michael D Witting, Laurence Magder, Alan E Heins, Amal Mattu, Carlos A Granja, Mona Baumgarten
雑誌名: Ann Emerg Med. 2004 Apr;43(4):525-32. doi: 10.1016/S0196064403009417.
Abstract/Text STUDY OBJECTIVE: We estimate the test characteristics of nasogastric aspiration to diagnose upper gastrointestinal tract hemorrhage in patients without hematemesis.
METHODS: In this retrospective cohort study, medical records from patients admitted to 2 urban hospitals between 1997 and 2002 for gastrointestinal tract bleeding without hematemesis were reviewed. Positive nasogastric aspiration results were classified by the severity of hemorrhage, and negative results were classified by the presence or absence of bile. The reference standard for nasogastric aspiration was the source of bleeding-upper versus non--upper gastrointestinal tract--from the hospital discharge summary. Confidence intervals (CIs) for proportions and likelihood ratios (LRs) were calculated.
RESULTS: Of 333 eligible patients, 235 were offered nasogastric aspiration, and 220 accepted the test. Results of 220 attempts were distributed as follows: negative, 158 (72%), including 9 (4%) with bile; nasogastric aspiration aborted, 13 (6%); and positive, 49 (23%), including 4 (2%) that were strongly positive (> or =450 mL red blood). Test characteristics of nasogastric aspiration to detect upper gastrointestinal tract bleeding in 213 patients with a reference standard diagnosis were as follows: sensitivity 42% (95% CI 32% to 51%), specificity 91% (95% CI 83% to 95%), negative predictive value 64% (95% CI 56% to 71%), and positive predictive value 92% (95% CI 79% to 97%). The nasogastric aspiration accurately predicted the source of bleeding in 66% of patients (95% CI 59% to 72%). The likelihood ratio of a positive nasogastric aspiration was 11 (95% CI 4 to 30), and the likelihood ratio of a negative nasogastric aspiration was 0.6 (95% CI 0.5 to 0.7).
CONCLUSION: In patients without hematemesis, a positive nasogastric aspiration, seen in 23%, indicates probable upper gastrointestinal tract bleeding (LR+ 11), but a negative nasogastric aspiration, seen in 72%, provides little information (LR- 0.6).

PMID 15039700  Ann Emerg Med. 2004 Apr;43(4):525-32. doi: 10.1016/S019・・・
著者: William G Kuhle, Robert G Sheiman
雑誌名: Radiology. 2003 Sep;228(3):743-52. doi: 10.1148/radiol.2283020756.
Abstract/Text PURPOSE: To evaluate the feasibility of helical computed tomography (CT) as an imaging modality for depicting active colonic hemorrhage in a swine model.
MATERIALS AND METHODS: Controlled extravasation of contrast material-enhanced blood (CEB) from 140 to 180 HU and at varying rates (0.3-1.0 mL/min) was performed during a 30-second period by using a microcatheter system placed within the descending colon of 14 swine. CEB was immediately followed by extravasation of unopacified blood at the same location and rate during serial helical CT imaging of the extravasation site. Region-of-interest analysis allowed quantification of the dilution of extravasated CEB as a function of time that was then modeled mathematically based on iodine mass and volume balances. Nonlinear least squares analysis was performed to optimize fitting of the model to experimental data, with a maximum regression value (R2) of 1.0 indicating a perfect fit. This model enabled the computer simulation of CT imaging of multiple combinations of bleeding rates and CEB attenuation to determine the sensitivity of helical CT for depicting active colonic bleeding.
RESULTS: Sixteen swine examinations yielded 16 CEB dilution curves. An excellent fit of the model to each dilution curve was achieved, as indicated by a mean R2 value of 0.8402. Swine examinations alone showed that targeted CT could depict CEB as low as 111 HU extravasating at a rate of 0.3 mL/min. Simulations that were based on helical CT images with 5-mm collimation reconstructed every 3 mm and that used the model indicated bleeding rates below 0.4 mL/min are detectable, provided peak aortic enhancement reaches 100 HU.
CONCLUSION: Conservatively, helical CT has the potential to depict active colonic hemorrhage at rates of 0.5 mL/min or less.

PMID 12954894  Radiology. 2003 Sep;228(3):743-52. doi: 10.1148/radiol.・・・
著者: Lisa L Strate
雑誌名: Gastroenterol Clin North Am. 2005 Dec;34(4):643-64. doi: 10.1016/j.gtc.2005.08.007.
Abstract/Text Lower gastrointestinal bleeding is one of the most common gastrointestinal indications for hospital admission, particularly in the elderly. Diverticulosis accounts for up to 50% of cases, followed by ischemic colitis and anorectal lesions. Though most patients stop bleeding spontaneously and have favorable outcomes, long-term recurrence is a substantial problem for patients with bleeding from diverticulosis and angiodysplasia. The management of LGIB is challenging because of the diverse range of bleeding sources, the large extent of bowel involved, the intermittent nature of bleeding, and the various complicated and often invasive investigative modalities. Advances in endoscopic technology have brought colonoscopy to the forefront of the management of LGIB. However, many questions remained to be answered about its usefulness in routine clinical practice. More randomized controlled trials comparing available diagnostic strategies for LGIB are needed.

PMID 16303575  Gastroenterol Clin North Am. 2005 Dec;34(4):643-64. doi・・・
著者: Bryan T Green, Don C Rockey, G Portwood, Paul R Tarnasky, Steve Guarisco, Malcolm S Branch, Joseph Leung, Paul Jowell
雑誌名: Am J Gastroenterol. 2005 Nov;100(11):2395-402. doi: 10.1111/j.1572-0241.2005.00306.x.
Abstract/Text OBJECTIVES: We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care.
METHODS: Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy.
RESULTS: A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1-6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups-including: mortality 2%versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22%versus 30%, surgery 14%versus 12%, or late rebleeding 16%versus 14% (mean follow-up of 62 and 58 months).
CONCLUSION: Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.

PMID 16279891  Am J Gastroenterol. 2005 Nov;100(11):2395-402. doi: 10.・・・
著者: D M Jensen, G A Machicado
雑誌名: Gastroenterology. 1988 Dec;95(6):1569-74.
Abstract/Text The purpose of this study was to prospectively evaluate (a) the diagnosis and treatment of 80 consecutive patients with severe, ongoing hematochezia from unknown source and (b) the effectiveness and safety of urgent colonoscopy after oral purge. Fifty-two men and 28 women (mean age, 64.5 yr) received a mean of 6.5 U of blood and had negative anoscopy, rigid sigmoidoscopy, and nasogastric tube aspiration before our evaluation. Because of ongoing severe hematochezia in the intensive care unit, urgent diagnosis and treatment was recommended by the attending physicians and surgeons. Emergency panendoscopy was performed before purge. Urgent colonoscopy was performed in the intensive care unit after patients received oral purge and their gut was cleared of blood, clots, and stool. The final diagnosis in these patients was 74% colonic lesions (30% angiomata, 17% diverticulosis, 11% polyps or cancer, 9% focal ulcers, 7% other), 11% upper gastrointestinal lesions, and 9% presumed small bowel lesions. No lesion site was identified in 6%. Clinically significant fluid retention (medically controlled) occurred in 4% of patients after purge. Sixty-four percent of patients had intervention for control of bleeding: 39% had therapeutic endoscopy, 24% surgery, and 1% therapeutic angiography. For 22 patients who also had emergency visceral angiography, the diagnostic yield was 14% and the complication rate was 9%. Our conclusions for patients with severe ongoing hematochezia from an unknown site were as follows. (a) Oral purge was effective and safe for cleansing the colon of stool, clots, and blood. Sulfate purge appeared to be safer than saline purge. (b) Before urgent colonoscopy and purge, emergency panendoscopy was indicated to exclude an upper gastrointestinal bleeding source. (c) Urgent colonoscopy after purge was effective, safe, and often diagnostic. (d) Compared with urgent colonoscopy, urgent visceral angiography was often nondiagnostic. However, the examinations may be complementary. (e) Hemostasis via colonoscopy has a definitive role in the treatment of some focal colonic lesions such as bleeding angiomata.

PMID 3263294  Gastroenterology. 1988 Dec;95(6):1569-74.
著者: T Gregory Walker
雑誌名: Tech Vasc Interv Radiol. 2009 Jun;12(2):80-91. doi: 10.1053/j.tvir.2009.08.002.
Abstract/Text Although most cases of acute gastrointestinal (GI) hemorrhage either spontaneously resolve or respond to medical management and/or endoscopic treatment, there remain a significant number of patients who require emergency evaluation and treatment by the interventional radiologist. Any angiographic evaluation should begin with selective catheterization of the artery supplying the most likely site of bleeding, as determined by the available clinical, endoscopic, and imaging data. If a source of hemorrhage is identified, superselective catheterization followed by transcatheter embolization with microcoils is the most effective means of successfully controlling hemorrhage while minimizing potential complications. This is now well-recognized as a viable and safe alternative to emergency surgery. In selected situations transcatheter intra-arterial infusion of vasopressin may also be useful in controlling acute GI bleeding. One must be aware of the various side effects and potential complications associated with this treatment, however, and recognize the high rebleeding rate. In this article, we review the current role of angiography, transcatheter arterial embolization, and infusion therapy in the evaluation and management of GI hemorrhage.

PMID 19853226  Tech Vasc Interv Radiol. 2009 Jun;12(2):80-91. doi: 10.・・・
著者: Yann Geffroy, Mathieu H Rodallec, Isabelle Boulay-Coletta, Marie-Christine Jullès, Marie-Christine Fullès, Catherine Ridereau-Zins, Marc Zins
雑誌名: Radiographics. 2011 May-Jun;31(3):E35-46. doi: 10.1148/rg.313105206.
Abstract/Text Acute gastrointestinal (GI) bleeding remains an important cause of emergency hospital admissions, with substantial related morbidity and mortality. Bleeding may relate to the upper or lower GI tract, with the dividing anatomic landmark between these two regions being the ligament of Treitz. The widespread availability of endoscopic equipment has had an important effect on the rapid identification and treatment of the bleeding source. However, the choice of upper or lower GI endoscopy is largely dictated by the clinical presentation, which in many cases proves misleading. Furthermore, there remains a large group of patients with negative endoscopic results or failed endoscopy, in whom additional techniques are required to identify the source of GI bleeding. Multidetector computed tomography (CT) with its speed, resolution, multiplanar techniques, and angiographic capabilities allows excellent visualization of both the small and large bowel. Multiphasic multidetector CT allows direct demonstration of bleeding into the bowel and is helpful in the acute setting for visualization of the bleeding source and its characterization. Thus, multidetector CT angiography provides a time-efficient method for directing and planning therapy for patients with acute GI bleeding. The additional information provided by multidetector CT angiography before attempts at therapeutic angiographic procedures leads to faster selective catheterization of bleeding vessels, thereby facilitating embolization. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.313105206/-/DC1.

PMID 21721196  Radiographics. 2011 May-Jun;31(3):E35-46. doi: 10.1148/・・・
著者: R Gunderman, J Leef, K Ong, R Reba, C Metz
雑誌名: J Nucl Med. 1998 Jun;39(6):1081-3.
Abstract/Text UNLABELLED: We evaluated the effect on the diagnostic yield of visceral arteriography in patients with acute gastrointestinal bleeding of a protocol requiring a positive 99mTc-red blood cell scintiscan before the performance of arteriography (scintigraphic screening).
METHODS: A retrospective review was conducted of 249 scintiscans and 271 arteriograms obtained over 99 mo, with scintigraphic screening implemented during the final 18 mo.
RESULTS: Before the implementation of scintigraphic screening, arteriograms detected bleeding at a rate of 22%. After its implementation, 53% of the arteriograms detected bleeding. This represented a statistically significant increase (0.53 versus 0.22, p = 0.015).
CONCLUSION: Scintigraphic screening appears to increase by a factor of 2.4 the diagnostic yield of arteriography by screening out patients who are not actively bleeding at the time of the examination, thus sparing them the risks and costs of a nondiagnostic invasive study.

PMID 9627348  J Nucl Med. 1998 Jun;39(6):1081-3.
著者: R Dusold, K Burke, W Carpentier, W P Dyck
雑誌名: Am J Gastroenterol. 1994 Mar;89(3):345-8.
Abstract/Text OBJECTIVE: To evaluate the success of technetium-99m-labeled red blood cell scintigraphy in localizing the site of gastrointestinal bleeding, and to identify the clinical and technical factors that contribute to scan accuracy.
METHODS: A retrospective review was conducted of all patients who underwent a tagged red blood cell scan for the evaluation of gastrointestinal bleeding at our institution from 1981 to 1991.
RESULTS: Of a total of 153 patients, 90 (59%) had positive scans, whereas, in 63 (41%), they were negative. Of the 90 patients who had positive scans, it was possible to assess scan accuracy in 44 who had corrective surgery or an additional diagnostic procedure which definitively localized the site of bleeding. Of those 44 patients, the correct bleeding site was identified by red blood cell scanning in 33 patients (75%) overall and in all six patients with a left colon bleeding site. In this group of 44 patients, 22 scans were positive within 2 h, and of these the scan was accurate in localizing the bleeding site in 19 of 22 (86%). When the three subjects with upper gastrointestinal bleeding were excluded, the scan was positive in 100% of the remaining 19 patients.
CONCLUSION: The technetium-labeled red blood cell scan is a reliable tool for the assessment of unexplained lower gastrointestinal bleeding when the scan is positive within the first 2 h, and an upper gastrointestinal source has already been excluded.

PMID 8122642  Am J Gastroenterol. 1994 Mar;89(3):345-8.
著者: J J Farrell, L S Friedman
雑誌名: Gastroenterol Clin North Am. 2001 Jun;30(2):377-407, viii.
Abstract/Text Among patients with acute gastrointestinal bleeding, older age is associated with an increased rate of comorbidity, greater medication use, and atypical clinical presentations. The aging of the population makes the evaluation and management of gastrointestinal bleeding in the elderly a special and increasingly common clinical challenge. The unique features and common causes of upper and lower gastrointestinal bleeding in the elderly are reviewed. Important management issues considered include hemodynamic resuscitation; anticoagulation; and medical, surgical, and endoscopic therapy.

PMID 11432297  Gastroenterol Clin North Am. 2001 Jun;30(2):377-407, vi・・・
著者: M Bokhari, A M Vernava, T Ure, W E Longo
雑誌名: Dis Colon Rectum. 1996 Feb;39(2):191-5.
Abstract/Text PURPOSE: Elderly patients frequently develop lower gastro-intestinal bleeding secondary to diverticulosis. This select group of patients potentially tolerates blood loss poorly, often have coexisting cardiovascular morbidity, and may not tolerate surgical intervention. Thus, optimal management of elderly patients with diverticular hemorrhage remains difficult.
METHODS: All patients who were admitted with the diagnosis of diverticulosis at the St. Louis University affiliated hospitals during the past 60 months were identified. Those with diverticular bleeding were extracted. Patients were reviewed as to age, sex, diagnosis of diverticular bleeding, number of bleeding episodes, lowest hemoglobin before transfusion, amount of blood received, treatment, operations, the presence of recurrent bleeding, morbidity, and mortality.
RESULTS: One hundred fifteen consecutive patients, age 70 years admitted with lower gastrointestinal hemorrhage secondary to diverticulosis who required transfusion, were identified. Mean age was 79 years; 26 of 115 (23 percent) were more than 80 years of age; 78 of 115 (54 percent) were males; 39 of 115 (34 percent) had more than one previous admission for diverticular hemorrhage. The mean serum hemoglobin was 8.9 g/dl. All patients underwent colonoscopy; 34 of 115 (29 percent) underwent 99Tc scanning, of which 18 of 34 (54 percent) underwent arteriogram. Seven of 18 (39 percent) demonstrated extravasation secondary to bleeding diverticulosis. The mean transfusion requirement was 2.8 (range, 1-17) units; 21 of 115 (18 percent) required intestinal resection; 2 of 21 (9 percent) experienced a 30-day mortality. Among those, 94 of 115 were treated without surgery, and 3 of 94 (4 percent) died. Mortality was independent of initial hemoglobin (P = 0.21), previous diverticular hemorrhage (P = 0.44), amount of blood transfused (P = 0.36), and type of treatment (0.09).
CONCLUSIONS: Most diverticular bleeding in the elderly is well tolerated using nonoperative management. Success and safety of treatment does not seem to depend on a history of previous diverticular bleeding, initial hemoglobin, or amount of blood transfused. The majority of patients are treated nonoperatively. Surgical intervention seems to be well tolerated.

PMID 8620786  Dis Colon Rectum. 1996 Feb;39(2):191-5.
著者: M H Kollef, J D O'Brien, G R Zuckerman, W Shannon
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.

PMID 9233736  Crit Care Med. 1997 Jul;25(7):1125-32.
著者: Lisa L Strate, E John Orav, Sapna Syngal
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.

PMID 12695275  Arch Intern Med. 2003 Apr 14;163(7):838-43. doi: 10.100・・・
著者: Lisa L Strate, John R Saltzman, Rie Ookubo, Muthoka L Mutinga, Sapna Syngal
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.

PMID 16086720  Am J Gastroenterol. 2005 Aug;100(8):1821-7. doi: 10.111・・・
著者: Fernando S Velayos, Ann Williamson, Karen H Sousa, Edward Lung, Alan Bostrom, Ellen J Weber, James W Ostroff, Jonathan P Terdiman
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 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.

PMID 15181617  Clin Gastroenterol Hepatol. 2004 Jun;2(6):485-90.
著者: J Newman, J E F Fitzgerald, S Gupta, A C von Roon, H H Sigurdsson, T G Allen-Mersh
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.
PMID 21910819  Colorectal Dis. 2012 Aug;14(8):1020-6. doi: 10.1111/j.1・・・

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