Hypotension and endoscopic stigmata of recent haemorrhage in bleeding peptic ulcer: Risk models for rebleeding and mortality

Abstract

Clinical and endoscopic data were collected prospectively in 1050 patients with bleeding peptic ulcer admitted between September 1985 and July 1989 to the care of one surgical team. Seventy-nine patients underwent therapeutic endoscopy soon after admission and in 129 patients either immediate or early elective surgery was performed. Eight hundred and forty-two patients, in whom therapeutic endoscopy was not performed at any stage, underwent initial conservative management and data from this latter group are now presented. Shock on admission was defined as systolic blood pressure (BP) less than or equal to 100 mmHg on presentation. There were 10 deaths of 147 shocked patients (6.8%) compared with only 25 deaths of 695 patients (3.6%) not in shock (P less than 0.08). Bleeding recurred in 30 patients (20.4%) shocked on presentation but in only 96 (13.8%) with a BP greater than 100 mmHg (P less than 0.05). Twenty-one of 358 patients (5.9%) with endoscopic stigmata of recent haemorrhage (ESRH) died, but only 14 of 484 patients (2.9%) without such stigmata (P less than 0.05) died. In shocked patients rebleeding was evident in 21 of 73 (28.8%) cases with ESRH but in only 9 of 74 (12.2%) patients in whom ESRH were absent (P less than 0.02). In the absence of fresh blood at endoscopy rebleeding occurred in 22 of 124 (17.8%) shocked patients and only 74 of 629 (11.8%) of those not shocked on presentation (P less than 0.07). When ulcer size was documented rebleeding rates for ulcers less than or equal to 1 cm, less than or equal to 2 cm and greater than 2 cm in size were 54 of 485 (11.1%), 30 of 142 (21.2%) and 12 of 44 (27.3%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Bleeding peptic ulcer: An evolving role for surgical intervention

“…In particular, it has been recommended that elderly patients with a large ulcer who have experienced shock and have ESRH undergo early elective operation after endoscopic haemostasis 30 , 31 . This is in keeping with our own previous experience with 1050 patients wherein early elective surgery following peptic ulcer haemorrhage carried no mortality in 53 selected patients 4 . Although high‐risk lesions in patients considered to be poor surgical candidates are believed to be best dealt with in an elective setting, 3 whenever possible, we now do not advise operation if therapeutic endoscopy has convincingly controlled the bleeding.…”

“…The risk of further bleeding is only 1–2% when an ulcer base is clean without such endoscopic stigmata of recent haemorrhage (ESRH) and 5% if a central spot is evident 1 . Endoscopic stigmata of recent haemorrhage are known to be more frequent in patients with an ulcer > 1 cm in diameter, 2 –4 larger ulcers being more frequently found in patients > 60 years of age 2 , 4 …”

“…An increased risk of rebleeding has also been documented when admission systolic blood pressure is ≤ 100 mmHg 3 , 4 . Rebleeding and mortality rates have been shown to be higher in patients > 60 years in whom the risk of a fatal outcome is increased 10‐fold 2 , 3 .…”

Disability and Severe Gastrointestinal Hemorrhage. A Prospective Study of Community‐Dwelling Older Persons

“…Several clinical and epidemiologic studies have described the occurrence of gastrointestinal hemorrhage, and have identified a number of predictors for lower and upper tract origin of the event. 5 -17 Although gastrointestinal hemorrhage is caused by heterogeneous diseases, common risk factors including age, gender, medications, and comorbidity play a role that is independent of the underlying diagnoses.v 10,15 Studies utilizing multivariate analysis have shown that advancing age independently predicts gastrointestinal hemorrhage after adjusting for other known risk factors.I: 8,10,14 Thus, it can be hypothesized that other factors not investigated in previous studies and frequently associated with aging could explain the age-gastrointestinal hemorrhage association. Some of these factors, such as physical disability and cognitive impairment, are important components of frailty.…”

Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer

“…Nineteen of them were excluded, for a variety of reasons. Ten articles included (either in addition or exclusively) patients without endoscopic treatment 2, 28–36 . Five did not perform or did not report the results of multivariate analysis 37–41 .…”