Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding

Table 1 Clinical and laboratory parameters of the study population (median values)

Parameters (n = 1581)	Median value	IQ range
Age	66	55	76
Rockall score	5	3	6
Hb	8	7	10
Hospitalization length	5	3	7

Hb: Hemoglobin value; IQ range: Interquartile range.

Table 2 Type of endoscopic treatment applied to the study population

Endoscopic therapy	No. of patients	% out of entire batch
Simple therapy	174	11.01
Epinephrine injection	62	3.92
Bipolar coagulation	18	1.14
Hemoclip	74	4.68
Banding1	7	0.44
Argon plasma coagulation	13	0.83
Combined therapy	375	23.72
Epinephrine injection + bipolar coagulation	126	7.97
Epinephrine injection + hemoclip	206	13.04
Epinephrine injection + bipolar coagulation + hemoclip	35	2.21
Bipolar coagulation + hemoclip	4	0.25
Epinephrine injection + argon plasma coagulation + hemoclip	1	0.06
Epinephrine injection + banding	2	0.15
Epinephrine injection + argon plasma coagulation	1	0.06

¹ banding was used for endoscopic hemostasis in 4 cases of Mallory-Weiss syndrome and 3 cases of Dieulafoy lesion.

Table 3 Clinical and endoscopic features of the study population: Association with rebleeding

Parameter	No-rebleeding (no. pts, %)	Rebleeding, (no. pts, %)	Total no. patients, %	Total (% out of entire batch)	P value
Rockall score	1435 (92.16)	122 (7.84)	1.557 (100)	100	< 0.001
Simple therapy	143 (82.18)	31 (17.82)	174 (100)	11.01	< 0.001
Combined therapy	318 (84.8)	57 (15.2)	375 (100)	23.72	< 0.001
SBP (mmHg) < 100	240 (83.33)	48 (16.67)	288 (100)	18.22	< 0.001
Pulse (beats per minute) > 100	404 (87.26)	59 (12.74)	463 (100)	29.32	< 0.001
Cardiovascular comorbidities	901 (92.32)	75 (7.68)	976 (100)	61.73	0.857
Diabetes mellitus	272 (91.89)	24 (8.11)	296 (100)	18.72	0.815
Respiratory comorbidities	184 (89.32)	22 (10.68)	206 (100)	13.03	0.096
Renal comorbidities	303 (91.82)	27 (8.18)	330 (100)	20.87	0.759
Liver cirrhosis	128 (90.78)	13 (9.22)	141 (100)	8.92	0.504
Neoplasias	232 (90.63)	24 (9.38)	256 (100)	16.19	0.298
Neurologic comorbidities	202 (94.39)	12 (5.61)	214 (100)	13.54	0.202
Obesity	125 (93.28)	9 (6.72)	134 (100)	8.48	0.631
Sepsis	38 (80.85)	9 (19.15)	47 (100)	2.97	0.003
Acute pancreatitis	6 (75)	2 (25)	8 (100)	0.51	0.068
Acute abdomen	4 (66.67)	2 (33.33)	6 (100)	0.38	0.019

SBP: Systolic blood pressure.

Table 4 Logistic regression for rebleeding

Variables	Odds ratio	95% Confidence interval		P value
Age	0.98	0.96	0.99	0.030
No. of blood units	1.46	1.32	1.62	< 0.001
Sepsis	2.95	1.26	6.94	0.008
Rockall score	1.41	1.25	1.58	< 0.001
Simple therapy	3.18	1.92	5.28	< 0.001
Combined therapy	1.75	1.31	2.33	< 0.001

Table 5 Clinical and laboratory parameters of the study population: Association with deaths due to bleeding

Parameters	Deaths due to bleeding	Median (IQ range)	P value
Age (yr)	No	65 (55-76)	0.012
	Yes	72 (57-82)
Rockall score	No	5 (3-6)	< 0.001
	Yes	7 (7-8)
Hb (g/dL)	No	8 (7-11)	< 0.001
	Yes	7 (5-8)
Hospitalization length (d)	No	5 (3-7)	< 0.001
	Yes	1 (1-2)

Hb: Hemoglobin value; IQ range: Interquartile range.

Table 6 Clinical and endoscopic features of the study population: Association with deaths due to bleeding

Parameter	Survivors (no. pts)	Deaths due to bleeding (no. pts)	P value
Gender	1534	47	0.989
Lesion	1534	47	0.140
Rockall score	1514	43	< 0.001
Simple therapy	167	7	0.196
Combined therapy	363	12	0.966
SBP < 100 mmHg	252	36	< 0.001
Pulse > 100 beats per minute	429	34	< 0.001
Rebleeding	113	10	< 0.001
No. blood units	1532	47	< 0.001
Aspirin	310	6	0.451
NSAIDs	240	5	0.350
Surgery	51		0.204
Antiaggregants	104	2	0.179
Anticoagulants	93	7	0.110
Cardiovascular comorbidities			0.221
Diabetes mellitus	189	12	0.224
Respiratory comorbidities	189	17	< 0.001
Renal comorbidities	320	10	0.945
Liver cirrhosis	134	7	0.145
Neoplasias	248	8	0.876
Neurologic comorbidities	209	5	0.556
Obesity	133	1	0.113
Sepsis	42	5	0.002
Acute pancreatitis	4	4	0.620
Acute abdomen	5	1	0.048

SBP: Systolic blood pressure; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 7 Clinical and laboratory parameters of the study population: Association with deaths

Parameters	Deaths	Median (IQ range)	P value
Age (yr)	No	65 (55-76)	0.001
	Yes	70 (58-80)
Rockall score	No	5 (3-6)	< 0.001
	Yes	7 (6-8)
Hb (g/dL)	No	8 (7-11)	< 0.001
	Yes	7 (6-9)
Hospitalization length (d)	No	5 (3-7)	< 0.001
	Yes	2 (1-4)

Hb: Hemoglobin value; IQ range: Interquartile range.

Table 8 Clinical and endoscopic features of the study population: Association with deaths

Parameter	Survivors (no. pts, %)	Deaths (no. pts, %)	Total no. patients, %	Total (% out of entire batch)	P value
Lesion	1453 (91.90)	128 (8.10)	1581 (100)	100	0.001
Rockall score	1442 (92.61)	115 (7.39)	1557 (100)	100	< 0.001
Simple therapy	160 (91.95)	14 (8.05)	174 (100)	11.01	0.069
Combined therapy	355 (94.66)	20 (5.34)	375 (100)	23.72	0.209
SBP < 100 mmHg	216 (75)	72 (25)	288 (100)	18.22	< 0.001
Pulse > 100 beats per minute	392 (84.67)	71 (15.53)	463 (100)	29.32	< 0.001
Rebleeding	109 (88.62)	14 (11.38)	123 (100)	7.78	0.164
Hospitalization length	1449 (91.94)	127 (8.06)	1576 (100)	100	< 0.001
No. blood units	1452 (91.96)	127 (8.04)	1579 (100)	100	< 0.001
Aspirin	301 (95.56)	14 (4.44)	315 (100)	19.92	0.028
NSAIDs	237 (96.73)	8 (3.27)	245 (100)	15.50	0.003
Surgery	51 (100)	0.00 (0.00)	51 (100)	3.23	0.031
Cardiovascular comorbidities	895 (91.70)	81 (8.30)	976 (100)	61.73	0.707
Diabetes mellitus	268 (90.54)	28 (9.46)	296 (100)	18.72	0.340
Respiratory comorbidities	156 (75.73)	50 (24.27)	206 (100)	13.03	< 0.001
Renal comorbidities	285 (86.36)	45 (13.64)	330 (100)	20.87	< 0.001
Liver cirrhosis	115 (81.56)	26 (18.44)	141 (100)	8.92	< 0.001
Neoplasias	225 (87.89)	31 (12.11)	256 (100)	16.19	0.010
Neurologic comorbidities	193 (90.19)	21 (9.81)	214 (100)	13.54	0.322
Obesity	127 (94.78)	7 (5.22)	134 (100)	8.48	0.203
Sepsis	25 (53.19)	22 (46.81)	47 (100)	2.97	< 0.001
Acute pancreatitis	4 (50)	4 (50)	8 (100)	0.51	< 0.001
Acute abdomen	5 (83.33)	1 (16.67)	6 (100)	0.38	0.441

SBP: Systolic blood pressure; NSAIDs: Non-steroidal anti-inflammatory drugs.

Table 9 Logistic regression for death

Death	Odds ratio	95% Confidence interval		P value
Rockall score	1.73	1.53	1.96	< 0.001
Respiratory comorbidities	3.29	2.06	5.25	< 0.001
Liver cirrhosis	2.91	1.64	5.15	< 0.001
Sepsis	8.03	3.81	16.93	< 0.001
Acute pancreatitis	6.58	1.04	41.63	0.045

Table 10 Studies regarding predictors of rebleeding and mortality in patients with upper digestive bleeding (nonvariceal/all causes)

Study	Yr	Condition	Type of study		No. of patients	Mean age (yr)	Mortality rate, (%)	Rebleeding rate (%)	Predictive factors for mortality	Odds ratio, (OR)	Predictive factors for rebleeding	Odds ratio, (OR)	Surgery (%)
			Prospective/retrospective	Uni-/multicentric
Barkun et al[1]	2004	NVUDB	R	M	869	66 ± 17	5.4	14.1	(1) PPI use; (2) Endoscopic therapy	(1) 0.18; (2) 0.31	(1) PPI use; (2) Endoscopic hemostasis in patients with high risk stigmata	(1) 0.53; (2) 0.39	6.5
Travis et al[6]	2008	NVUDB	R	M	236	67	NA	7.1%, 16.4%, 37.0%, 75.0% and 100% for zero, one, two, three or four risk factors	NA	NA	(1) Use of PPI postprocedure; (2) Endo-scopically demonstrated bleeding; (3) Hemostasis with epineph-rine monotherapy; (4) Postprocedure i.v or LMWH use; (5) Moderate/severe liver disease; (6) Peptic ulcer as the source of bleeding	(1) 0.25; (2) 2; (3) 3.35; (4) 8.09; (5) 4.92	NA
Sung et al[7]	2010	PUB	P	U	10428	61.0 (sur-vivors)	6.23	2.93	(1) Use of NSAIDs/ aspirin; (2) Active bleeding ulcer; (3) Cloth/vessel at the base of ulcer; (4) Hemodymamic shock (bleeding-related death)	(1) 3.70; (2) 12.96; (3) 12.29; (4) 3.75	NA	NA	2.8 (deaths during surgery)
						72.5 (deaths)
Zhang et al[8]	2010	NVUDB	R	U	223	NA	NA	19.3 (failure of endoscopic treatment)	(1) No. of comorbidities > 1; (2) Spurting of blood	(1) 9.580; (2) 9.971	(1) Shock; (2) History of GI bleeding; (3) PLT 100 x 109/L; (4) Active spurting of blood; (5) Large lesion size	(1) 3.058; (2) 2.809; (3) 0.067; (4) 10.390; (5) 7.111	NA
González-González et al[9]	2011	NVUDB	P	U	1077	58.8 ± 18.9	10.2	3.4	(1) No. of comorbidities/patient; (2) Serum albumin level < 2.6 g/dL; (3) Rebleeding; (4) Rockall score preendoscopy; (5) Lengths of hospital stay	(1) 1.6; (2) 4.9; (3) 6.5; (4) 1.3; (5) 1.04	NA	NA	1.5
Morales Uribe et al[10]	2011	UDB	P	M	464	59.7	9.9	17.4	(1) Bleeding site (inhospital vs outpatients); (2) Comorbidities	(1) 2.4; (2) 2.5	NA	NA	2.2
Nahon et al[11]	2012	UDB	P	M	3298	63 ± 18	8.3	9.9	(1) Rockall score; (2) Comorbidities; (3) SBP < 100 mmHg	(1) 2.8; (2) 3.6 (for each additio-nal comorbidity); (3) 2.1	(1) Need for transfusions; (2) Hb < 10 g/dL; (3) Rockall score; (4) SBP < 100 mmHg; (5) Signs of recent bleeding	(1) 19.1; (2) 1.7; (3) 1.4 (for each point score increase); (4) 1.9; (5) 2.4	NA
Del Piano et al[12]	2013	NVUDB	P	M	1413	(1) -66.5 ± 15.8 male; (2) -74.2 ± 14.6 female	5.4	4	NA	NA	(1) Female sex; (2) Neoplasia; (3) Multiple comorbidities; (4) Shock at admission; (5) Early rebleeding	(1) 2.19; (2) 2.7; (3) 5.04; (4) 4.55; (5) 1.47	14.3 (of early rebleeders)
Taha et al[13]	2014	UDB	R	U	2669	NA	7.1		(1) Age; (2) Charlson score; (3) Rockall score; (4) Units of blood transfused	(1) 1.020; (2) 1.291; (3) 1.274; (4) 1.085	NA	NA	2.1
Marmo et al[14,15]	2014	NVUDB	P	M	2317	67.9 ± 16.7	4.573	5.61	(1) Hemodynamic instability on presentation; (2) ASA class 3 or 4; (3) Low-dose aspirin use; (4) History of peptic ulcer; (5) Rebleeding; (6) Failed endoscopic treatment	(1) 7.311; 2.312; (2) 6.721; 3.892; (3) 0.121; 0.252; (4) 3.181; 1.542; (5) 5.222; 14.292	NA	NA	(1) 1.51; (2) 22
								3.42
Lee et al[16]	2016	NVUDB	P	U	184	59.81	8.73	14.73	(1) Diabetes mellitus; (2) Metastatic malignancy; (3) Age ≥ 65 yr; (4) Hypotension	(1) 12.67; (2) 29.24; (3) 5.06; (4) 16.63	NA	NA	NA
Hwang et al[17]	2016	NVUDB	P	M	1584	65	3.43	7.3	(1) Age > 65 yr; (2) Hemodynamic instability; (3) Serum BUN levels > 40 mg/dL; (4) Active bleeding at endoscopy; (5) Transfusions; (6) Comorbidities; (7) Rebleeding	(1) 2.627; (2) 2.217; (3) 1.895; (4) 2.434; (5) 3.811; (6) 3.481; (7) 10.581	NA	NA	2.8 (surgery/ percutaneous embolisation)

¹ bleeding occurs in patients already hospitalized for another condition;

² in-hospital bleeding; ³ at 30-d from the bleeding episode. NA: Not available; NVUDB: Nonvariceal upper digestive bleeding; UDB: Upper digestive bleeding (all causes); PUB: Peptic ulcer bleeding; R: Retrospective study; P: Prospective study; U: Unicentric study; M: Multicentric study; PPI: Proton pump inhibitor; LMWH: Low molecular weight heparin; GI: Gastrointestinal; PLT: Platelets.