Copyright
©The Author(s) 2019.
World J Gastroenterol. Jan 7, 2019; 25(1): 69-84
Published online Jan 7, 2019. doi: 10.3748/wjg.v25.i1.69
Published online Jan 7, 2019. doi: 10.3748/wjg.v25.i1.69
Severe/recurrent bleeding | In-hospital complications3 | Adverse outcomes4 | Mortality | |
Patient characteristic | ||||
Older age | 2.31 | - | 4.21 | 4.92 |
Male sex | 6 | - | - | 1.5-1.6 |
Lower body mass index | - | - | - | 2.0 |
Smoking | - | - | 0.5 | - |
Comorbidities | ||||
Charlson index > 2 or ≥ 2 | 1.7-1.9 | - | - | 3.0 |
Unstable comorbid diseases | - | 2.9 | - | - |
Congestive heart failure | - | - | - | 1.5 |
Cardiovascular disease | 6 | - | - | - |
Dementia | 6 | - | - | 5.2 |
Metastatic cancer | - | - | - | 5.0 |
Chronic kidney disease | - | - | - | 1.8-2.2 |
Liver disease | - | - | - | 1.9 |
Chronic pulmonary disease | - | - | - | 1.6 |
History of colonic diverticulosis and/or angiodysplasia | 6 | - | - | 6 |
Presenting symptom | ||||
Syncope / altered mental status | 2.5-3.3 | 2.0 | - | 6 |
No diarrhea | 2.2 | - | - | - |
No abdominal tenderness | 2.4-3.0 | - | - | - |
Ongoing bleeding | - | 3.1 | - | - |
Bleeding in the first 4 h | 2.3 | - | - | - |
Medication | ||||
NSAIDs (non-aspirin)1 | 2.5 | - | - | 1.5 |
Aspirin | 1.9-2.1 | - | - | - |
Antiplatelet drugs (non-aspirin) | 2.0 | - | - | - |
Anticoagulants | - | - | - | 1.5 |
Physical examination | ||||
Blood pressure ≤ 100 or ≤ 115 mmHg | 2.3-3.5 | 3.0 | - | 6 |
Heart rate ≥ 100/min | 3.7 | - | - | - |
Abnormal vital signs after 1 h | 4.3 | - | - | - |
Abnormal hemodynamic parameters | - | - | 2.1 | - |
Gross blood on rectal examination | 3.5-3.9 | - | - | 6 |
Laboratory data | ||||
Hemoglobin < 10 g/dL | 3.6 | - | - | - |
Albumin < 3.0 or < 3.8 g/dL | 2.0-2.9 | - | - | 2.9 |
Creatinine > 150 or > 133 µmol/L | 6 | - | 10.3 | 6 |
Hematocrit < 35% or < 30% | 4.7-6.3 | - | - | 6 |
Prothrombin time > 1.2 times control | - | 2.0 | - | - |
Clinical course | ||||
Rebleeding | - | - | 1.9 | - |
Intestinal ischemia | - | - | - | 3.5 |
Coagulation defects | - | - | - | 2.3 |
Hypovolemia | - | - | - | 2.2 |
Blood transfusion | - | - | - | 1.6-2.8 |
Need for intervention5 | - | - | - | 2.3-2.4 |
In-hospital onset LGIB | - | - | - | 2.4 |
Table 2 Risk scoring systems for severe acute lower gastrointestinal bleeding which have been validated
Derivation study | Outcomes | Risk factors | ROC-AUC | Validation study |
Strate et al[21] | Severe bleeding | Syncope | 0.76 | Prospective cohort (n = 275) |
(n = 252) | (continuous and/or recurrent bleeding) | No abdominal tenderness | ROC-AUC: 0.75 | |
Aspirin use | ||||
Heart rate ≥ 100/min | ||||
Systolic blood pressure ≤ 115 mmHg | ||||
Bleeding per rectum in the first 4 h | ||||
Charlson comorbidity index > 2 | ||||
Das et al[22] | Rebleeding | (19 factors) | 0.92 | Prospective cohort (n = 142) |
(n = 120) | Need for intervention | Age | 0.93 | |
Artificial neural network based model | In-hospital mortality | Comorbidity (5 factors) | 0.95 | |
History (4 factors) | ||||
Features at presentation (2 factors) | ||||
Features at initial assessment (2 factors) | ||||
Initial laboratory data (5 factors) | ||||
Aoki et al[24] | Severe bleeding | (NOBLADS) | 0.77 | Prospective cohort (n = 161) |
(n = 439) | (Continuous and/or recurrent bleeding) | NSAIDs use | ROC-AUC: 0.76 | |
No diarrhea | Retrospective cohort (n = 511) | |||
No abdominal tenderness | ROC-AUC: 0.74 | |||
Blood pressure (systolic) ≤ 100 mmHg | ||||
Albumin level < 3.0 g/dL | ||||
Antiplatelet drugs use (non-aspirin) | ||||
Disease score ≥ 21 | ||||
Syncope | ||||
Oakland et al[27] | Safe discharge | Age | 0.84 | Prospective cohort (n = 288) |
(n = 2336) | (Absence of death, rebleeding, intervention, blood transfusion, | Male sex | ROC-AUC: 0.79 | |
or 28 d readmission) | Blood on rectal examination | |||
Heart rate | ||||
Systolic blood pressure | ||||
Hemoglobin level | ||||
Previous LGIB admission | ||||
Sengupta et al[28] | 30 d mortality | Age | 0.81 | Retrospective cohort (n = 2060) |
(n = 4044) | Dementia | ROC-AUC: 0.72 | ||
Metastatic cancer | ||||
Chronic kidney disease | ||||
Chronic pulmonary disease | ||||
Anticoagulant use | ||||
Hematocrit level | ||||
Albumin level |
Table 3 Utility of early colonoscopy compared with elective colonoscopy according to randomized controlled trials and meta-analyses
Study | Study design | Sample size | Bleeding source localization | Endoscopic intervention | Surgery required | Rebleeding | Length of stay | Adverse events | Mortality |
Green et al[41] | RCT1 | 100 | 2.6 (1.1-6.2)4 | - | NS | NS | NS | NS | NS |
Laine et al[42] | RCT2 | 72 | NS | - | - | NS | NS | - | - |
Sengupta et al[44] | Meta-analysis3 | 901 | 2.97 (2.11-4.19)4 | 3.99 (2.59-6.13)4 | NS | NS | - | - | NS |
Kouanda et al[43] | Meta-analysis3 | 24,396 | NS | 1.70 (1.08-2.67)4 | - | NS | - | NS | NS |
Seth et al[45] | Meta-analysis3 | 23,419 | SRH detection 2.85 (1.90-4.28)4 | NS | NS | NS | NS | - | NS |
Table 4 Clinical significance of performing contrast-enhanced computed tomography before colonoscopy for colonic diverticular bleeding
Study | Study design | Sample size1 | Detection rate of extravasation on CT (%) | SRH detection rate on CS after extravasation on CT (%) | SRH detection rate on CS after no extravasation on CT (%) | Predictors for extravasation on CT |
Obana et al[57] | Prospective | 52 | 15 | 50 | 36 | History of diverticular bleeding |
Within 2 h of last hematochezia | ||||||
Nakatsu et al[54] | Retrospective | 346 | 30 | 68 | 20 | - |
Nagata et al[53] | Retrospective | 77 | 31 | 63 | 38 | History of diverticular bleeding |
Sugiyama et al[55] | Retrospective | 55 | 36 | 60 | 31 | - |
Wada et al[118] | Retrospective | 100 | 23 | 70 | - | - |
Umezawa et al[56] | Prospective | 202 | 25 | 76 | 18 | Within 4 h of last hematochezia |
- Citation: Aoki T, Hirata Y, Yamada A, Koike K. Initial management for acute lower gastrointestinal bleeding. World J Gastroenterol 2019; 25(1): 69-84
- URL: https://www.wjgnet.com/1007-9327/full/v25/i1/69.htm
- DOI: https://dx.doi.org/10.3748/wjg.v25.i1.69