Upper gastrointestinal bleeding

The accuracy of bedside diagnoses was prospectively studied in 100 consecutive patients admitted to the neurology service at New England Medical Center, Boston. Each patient was evaluated independently by a junior resident, a senior resident, and a staff neurologist, who were required to make an anatomical and etiological diagnosis based solely on the history and physical examination. Fourteen patients were excluded because their diagnoses were known before admission. Of the remaining 86 patients, it was possible to confirm anatomical and etiological diagnoses in 40 by matching the clinical syndromes with highly specific laboratory findings. In the other 46 patients, the diagnoses could not be confirmed because the laboratory studies (including magnetic resonance imaging) were negative or nondiagnostic. In the 40 patients with laboratory confirmed final diagnoses, the clinical diagnoses of the junior residents, senior residents, and staff neurologists were correct in 26 (65%), 30 (75%), and 31 (77%), respectively. There was a trend for error rates to be higher among junior residents than staff (p = 0.06). The errors by the junior residents, [senior residents], (staff) were attributed to incomplete history and examination in 4 [1] (0), inadequate fund of knowledge in 4 [3] (3), and poor diagnostic reasoning in 6 [6] (6). These results indicate that technology is not a panacea for our diagnostic difficulties and that there is room for improvement in our clinical skills, especially diagnostic reasoning.

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The accuracy of bedside neurological diagnoses

Chimowitz

Logigian

Caplan

1990

Annals of Neurology

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Evaluation and Medical Therapy of Acute Gastrointestinal Bleeding

Spiro

Peppercorn

1982

Pharmacotherapy

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Gastrointestinal bleeding is a major reason for hospitalization and an important cause of morbidity and mortality. Diagnosis and treatment of this common clinical problem has changed markedly over the past 40 years. The initial approach to patients with gastrointestinal bleeding should be both therapeutic and diagnostic, with close attention to cardiovascular status and clotting parameters. Once the patient is stabilized, clinical history, physical examination, gastric aspirate, and laboratory data should be assessed to determine if the bleeding site is in the upper or lower gastrointestinal tract. Once that is determined, a more specific diagnosis should be made if possible, as therapy often will depend upon a precise diagnosis. Therapy includes angiographic and pharmacologic techniques, as well as tamponade in the case of esophageal varices. The use of antacids in acute upper gastrointestinal bleeding is well established, while the role of cimetidine is less clear. Newer modalities of treatment, such as the use of laser coagulation, are currently being evaluated.

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Why have controlled trials failed to demonstrate a benefit of esophagogastroduodenoscopy in acute upper gastrointestinal bleeding?

Erickson

Glick

1986

Digest Dis Sci

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Numerous prospective randomized trials have failed to demonstrate a benefit attributable to early diagnostic esophagogastroduodenoscopy (EGD) in acute upper gastrointestinal bleeding (UGIB). The clinical implications of these studies have received extensive editorial comment and analysis. We have employed a probability model to further analyze the reasons why these studies have failed to demonstrate an impact of EGD on UGIB. The clinical course of each bleeding lesion can be predicted from the literature. For each lesion, the mortality associated with early specific intervention afforded by an early specific diagnosis can be compared with the mortality of intervention delayed by applying EGD only to those patients who have a complicated course marked by continued bleeding or rebleeding. Using optimistic assumptions that would tend to overstate the impact of EGD, this analysis estimates the maximum decrease in overall mortality in any of these trials afforded by early diagnostic EGD to be 1.2% which would require randomization of over 5000 patients to demonstrate this benefit in a prospective trial.

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Upper gastrointestinal bleeding

Cited by 15 publications

References 5 publications

The accuracy of bedside neurological diagnoses

The accuracy of bedside neurological diagnoses

Evaluation and Medical Therapy of Acute Gastrointestinal Bleeding

Why have controlled trials failed to demonstrate a benefit of esophagogastroduodenoscopy in acute upper gastrointestinal bleeding?

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