Predicting outcomes in lower gastrointestinal bleeding: more work ahead

Abstract

Lower gastrointestinal bleeding (LGIB) is a common symptom for which patients present to emergency departments and healthcare providers for evaluation. The management approach to LGIB differs according to the clinical presentation and the source of bleeding. For instance, mild hemorrhoidal bleeding can be managed in the outpatient setting, whereas severe diverticular bleeding may require intensive care unit monitoring and urgent therapeutic interventions. However, triaging patients to the appropriate level of care is not always straightforward, and urgent colonoscopy is challenging to perform and not appropriate for all patients. Therefore, prediction tools would be useful to facilitate the identification of high-risk and low-risk patients and in turn to improve the use of healthcare resources and achieve optimal patient outcomes. The largest prospective study to date on this topic by Oakland et al 1 identified 7 predictors of safe discharge in 2336 patients from 143 institutions in the United Kingdom. These predictors (age, sex, previous LGIB, blood on digital rectal examination, heart rate, systolic blood pressure, and hemoglobin on admission) were used to develop a weighted risk score that was validated in an external cohort. A score of 8 predicted a 95% probability of safe discharge, and this score was better able to predict safe discharge, blood transfusion, and readmission than were 6 other upper GI bleeding (UGIB) and LGIB scores, including the Rockall, et al, 2 Blatchford et al, 3 ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, unstable comorbid disease (BLEED), Kollef et al 4 , albumin < 3.0g/dL, international normalized ratio > 1.5, altered mental status, systolic blood pressure < 90mm Hg, age > 65 years (Aims65), Saltzman JR, et al 5 , Strate et al, 6,7 , and nonsteroidal anti-inflammatory drugs use, no diarrhea, no abdominal tenderness, blood pressure < 100 mm Hg, antiplatelet drug use, albumin < 3.0 g/dL, disease score >2 and syncope (NOBLADS) Aoki et al, 8 scores, as cited by Oakland et al. 1 However, this score was intended to predict safe discharge, not specifically the need for therapeutic interventions such as urgent colonoscopy and angiography. The question whether to pursue intensive monitoring and urgent interventions is a

Safe discharge for patients admitted for lower gastrointestinal bleeding (LGITB): derivation and validation of a novel scoring system

“…Multiple clinical scores have been published to assess the outcomes in patients who presented with LGITB. However, the outcomes measured are heterogeneous and most of the scores have not been validated in an external population [ 7 , 9 – 16 ]. This study aims to develop a scoring system to predict safe discharge in patients with LGITB.…”

Advancing care for acute gastrointestinal bleeding using artificial intelligence

“…The reasons for this may include ignorance, cumbersomeness of calculating the score, and unclearly defined responsibility in the use of these risk scores 17 . For lower gastrointestinal bleeding, none of the scores developed have been adopted consistently in clinical practice, and existing scores suffer from limitations of being developed in large administrative data registries and in small samples of patients 18 …”