Background and Study Aims: The aims of this study were to identify risk factors for recurrence of hemorrhage in bleeding gastroduodenal ulcers after endoscopic injection therapy, and to develop a simple and relevant prognostic score which could be used to assess the early risk of recurrence and the residual risk of rebleeding. Patients and Methods: A prospective study was conducted from January 1995 to December 1998, in 738 patients who were admitted to our department for acute bleeding peptic ulcer and who underwent endoscopic examination. Ulcers with active bleeding or signs of recent bleeding were treated with injection therapy using epinephrine (1/10 000) and 1 % polidocanol. Results: Multivariate analysis revealed that liver cirrhosis, recent surgery, systolic blood pressure below 100 mmHg, hematemesis, Forrest classification, and ulcer size and site were significantly predictive variables for the recurrence of hemorrhage. Among these, Forrest classification was the most important. The overall accuracy of the predictive model was 71 % (95 % CI = 63 - 79 %). The model showed a better sensitivity of 90 % for early rebleeding (< 48 hours) than for late rebleeding (≥ 48 hours) where the sensitivity was 65 %. A prognostic score was obtained and patients were classified into four risk classes: very low (VL), low (L), high (H), and very high (VH). The rebleeding rates for the four classes were 0 %, 7.9 %, 31.8 % and 67.9 %, and the mortality rates were 5.9 %, 8.6 %, 13.9 % and 35.7 %, respectively. The residual risk of rebleeding after 48 hours was 0 %, 3.3 %, 10.4 %, and 14.3 % in the VL, L, H and VH classes, respectively. After 5 days the residual risk was under 4 % in all classes. Conclusions: This study demonstrates that the proposed prognostic score, which is easily obtained after emergency endoscopy, is useful in clinical practice because it can identify patients with different levels of rebleeding risk. It can be helpful in patient management and decision making for discharge.
References
1
Rockall T A, Logan R F, Devlin H B, Northfield T C.
Risk assessment after acute upper gastrointestinal haemorrhage.
Gut.
1996;
38
316-321
2
Rockall T A, Logan R F, Devlin H B, Northfield T C.
Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage.
Br Med J.
1995;
311
222-226
4
Imhof M, Schroders C, Ohmann C, Roher H.
Impact of early operation on the mortality from bleeding peptic ulcer - ten years’ experience.
Dig Surg.
1998;
15
308-314
6
Cook D J, Guyatt G H, Salena B J, Laine L A.
Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: A meta-analysis.
Gastroenterology.
1992;
102
139-148
7
Messmann H, Schaller P, Andus T. et al .
Effect of programmed endoscopic follow-up examinations on the rebleeding rate of gastric or duodenal peptic ulcers treated by injection therapy: A prospective randomized controlled trial.
Endoscopy.
1998;
30
583-589
8
Villanueva C, Balanzo J, Espinos J C. et al .
Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection.
Dig Dis Sci.
1993;
38
2062-2070
9
Saeed Z A, Cole R A, Ramirez F C. et al .
Endoscopic retreatment after successful initial hemostasis prevents ulcer rebleeding: A prospective randomized trial.
Endoscopy.
1996;
28
288-294
10
Bornman P C, Theodorou N A, Shuttleworth R D. et al .
Importance of hypovolaemic shock and endoscopic signs in predicting recurrent haemorrhage from peptic ulceration: A prospective evaluation.
Br Med J.
1985;
291
245-247
14
Chow L W, Gertsch P, Poon R T, Branicki F J.
Risk factors for rebleeding and death from peptic ulcer in the very elderly.
Br J Surg.
1998;
85
121-124
17
Schwarzer G, Vach W, Schumacher M.
On the misuses of artificial neural networks for diagnostic classification in oncology.
Statist Med.
2000;
19
541-561
21 Holtsberg A. Stixbox: A toolbox for Matlab. http://www.maths.lth.se/matstat/stixbox.
22
Bourienne A, Pagenault M, Heresbach D. et al .
Étude prospective multicentrique des facteurs pronostiqués des hémorragies ulcéreuses gastroduodénales.
Gastroenterol Clin Biol.
2000;
24
193-200
23
Rutgeerts P, Rauws E, Wara P. et al .
Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer.
Lancet.
1997;
350
692-696
27
Brullet E, Campo R, Calvet X. et al .
Factors related to the failure of endoscopic injection therapy for bleeding gastric ulcer.
Gut.
1996;
39
155-158
28
Coleman S Y, Pritchett C J, Wong J, Branicki F J.
Risk models for rebleeding and postoperative mortality in bleeding gastric ulcer.
Ann R Coll Surg Engl.
1991;
73
179-184
30
Lin H-J, Tseng G-Y, Lo W-C. et al .
Predictive factors for rebleeding in patients with peptic ulcer bleeding after multipolar electrocoagulation.
J Clin Gastroenterol.
1998;
26
113-116
33
Branicki F J, Coleman S Y, Fok P J. et al .
Bleeding peptic ulcer: A prospective evaluation of risk factors for rebleeding and mortality.
World J Surg.
1990;
14
262-269
34
Lin H J, Perng C L, Lee F Y. et al .
Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: A prospective study.
Gut.
1994;
35
1389-1393
35
Hsu P I, Lai K H, Lin X Z. et al .
When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of rebleeding.
Gastrointest Endosc.
1996;
44
382-387
36
Wara P.
Endoscopic prediction of major rebleeding - a prospective study of stigmata of hemorrhage in bleeding ulcer.
Gastroenterology.
1985;
88
1209-1214
37
Kolkman J J, Meuwissen S G.
A review on treatment of bleeding peptic ulcer: a collaborative task of gastroenterologist and surgeon.
Scand J Gastroenterol Suppl.
1996;
218
16-25
38
Brullet E, Campo R, Bedos G. et al .
Site and size of bleeding peptic ulcer. Is there any relation to the efficacy of hemostatic sclerotherapy?.
Endoscopy.
1991;
23
73-75
