T1310

Early Intensive Resuscitation of Patients with Upper Gastrointestinal Bleeding Decreases Mortality Robin Baradarian Susan Ramdhaney, Rajeev Chapalamadugu, Leor Skoczylas, Karen Wang, Kristin Remus, Svetlana Rivdis, lra Mayer, Kadirawel lswara, ~-ott Tenner

Despite advances in diagnostic and therapeutic endoscopy, the mortality of patients with upper gastrointestinal bleeding (UGIB) has remained relatively constant, hradequate early resuscitation is beheved to be a major factor in the persistently high mortality rate in patiems with UGIB In order to evaluate the role of intensive resuscitation in the outcome of patients with UGIB, we conducted the following prospective study A consecutive series of patients with UGIB complicated by hemodynamic instability, related to the Needing was enrolled in the study. Au initial cohort of patients (Observation Group) was followed by a team of physicians to collect data regarding demographics, and time intervals between presentation and correction of hemodynamics hematocrit (HCT), coagulopathy and medicabeendoscopic intervention. A subsequent group of patients (Intensive Resuscitation Group) was also prospectively followed. Similar data were collected, However, for thase patients, the physi- cians involved in data collection also provided intense guidance to the heahh care team managing the patients, The goal thr this group of patients was to decrease the time interval from admission to correction of hemodynamics, HCT, coagulopathy and medics intervention. Seventy-two patients were included in the sntdy, 36 mak, 36 female, mean age 70 (range 21-94), Thirty-six paUents were tbllowed in the Observational Group and 36 in the lntercsive Resuscitation Group There were no significant difterences regarding age, gender, number and t}qpe of corrmrbid diseases, history" of prior gastrointestinal Needing and enology of gastrointestinal bleeding between the two groups, Patients treated in the intensive Resnscitatinn Group had a significant decrease in the time interval from admission to stabilization of hemodynam~cs and the correction of HCT There were no signffmant ditt}rences in (he time interval from admission to endoscopic intervention, number of hospital days or number of units of blood given, However, mortality" was lower in the Intensive Resuscitation Group (1 death) compared to the Observational Group (4 deaths), p = 004. Intensive early resuscitation of patients with upper gastrointestinal bleeding signifi- candy decreases mortality, Physicians involved with the care of patients with UGIB shnuld locus on earl)," and rapid correction of hemodynamics, HCT and underlymg coagnlopathy.

T13l l

Are We Performing Unnecessary Endoscopies for Suspected Upper Gastrointestinal Bleeding in Hospitalized Patients? Geottl:ey C Davis, Sripathi R Kethu, Usman C. Ramzan, Steven F Moss

Background: Prompt endoscopy tot upper gastrointestinal Needing (UGIB) is ot estabhshed bendh in outpatients as peptic ulcers are common in this setting. In contrast, advances in medical care and widespread prophylactic acid suppression are changing the pathophysiology of UGIB developing in hospitalized patients. Data to guide the management of these patients is lacking. Aim: To determine the dinical utility of upper endoscopies (EGDs) in hospitafized patients devdoping UGIB. Methods: Retrospective chart revqew of all EGDs pertbmled on patients trom Jan 2001-Apt 2002 ~dr an indicatinn of suspected UGtB that developed > 48 hrs after hospitalization at our 600&ed acute care ttospitaL Cases were identified trom an endoscopy database, ang demographic, clinical and endoscopic data extracted by chart review Bleeding was characterized as clinically important (CI), or non-CI (Cook D et al, NEJM 1998;338:12), Le. C1 = overt Needing with hemodynamic distm'bance m" Hgb drop > 2 g or need for transfusion > 2 units blood within 24 hrs Results: 323 charts were reviewed 86 met niclusion criteria The mean (range') patient age was 65 (17-91), length of hospitahaation prior to bleeding 18 days (3-235) and total hospitalization 34 days (5- 245) 46% received anticoaguiantsrthrombolytics, 57% aspinn/NSAlDs and 26% both, 20% steroids and 86% received at least one ot these medh'ations CI bleeding occurred in 17% of patients Endoscopic findings esophagitis (22%), gastric and/or duodenal erythemaJ erosions (44%) gastric ulcers (8%), duodenal ulcers (2%), other ([5%],varices, duodenal feeding tube erosion, duodena/AVM, and anastomotic ulceration) 23% of patients had no clear source of UGIB Endoscopic therapy was required in 11% of patients (all had presented with C[ bleeding). I patient on cfironic steroids with non-Ci bleeding had candida esophagus Otherwise, EGD prompted no management changes in the non-Cl group Overall mortality: C1 bleeding 33%, non-CI bleeding: 10% No death was directly related to UGIB. Conclusions: Patients developing UG1B in hospital have prolonged hospitafizations and high in-hospital mortafity related to the severity of underlying illness, not UGIB Most patients were taking anticoagnlant/thrombolyrics 'or aspmn/NSAiDs. Endoscopic therapy was needed only in patients with CI bleeding; the minority group (17%) of patients who had EGD Conservative management can be recommended kn UGIB in hospitalized patients who do not meet criteria tora CI bleed

T1312

External Validation of the Rockall Scoring System tor Acute Upper GI Hemorrhage: A Mnhisite VA Study Thomas F Imperia]e, Jason A, Dorninitz, Dawn T, Provenzate, Lynn P, Boes Jill C Bowers Cindy M Rose, Beverly S Musick

Backgromrd: Ahhough the R~kall scoring system (RSS) has been validated in selected cohorts w~th acute UGIH, its peribrmance among VA patients (pts) has not been established. Objective: To determine the extent to which the RSS can predict outcome in a VA cohort vdth acute UGIH. Methods: From 10/99 to 9/02, consecutive pts admitted to 1 of 3 VA hospitals with acute UG1H were prospectively evaluated and enrolled into the cohort. Medical records were abstracted to produce a Rockall score for all pts meeting the originally published Rockall criteria for acute UGIH ("Rockall VA subgroup" (RVAS)) and tot all pts (ALL) in the cohort, Pts were tol/owed during hospitalization for complications (rebleedmg need for urgent surgery, new or worsennig co-morbidity, mortality'), and completed a telephone tollow-up survey 30 days post-discharge, The original Rockall cohort (ORC) was compared to the RVAS and to ALL for score distribution, area under the receiver operating charactenstics

curve (AROC), and proportion of low-risk (score < = 2) and high-nsk (score > =8) pts who rebled {nd/or died. Results: 391 pts (99% men, mean age 63.4 yrs) comprised the cohort, of which 52 (13%) were low-risk, 24% were hypotensive at baseline, 16% had unstable comorbidity upon admission, 35% bled fi'om PUD, 14% rebled by Rockall criteria, and 3% died dunng hospitalization, 292 (75%) pts were induded in the RVAS, of which 29 (10%) were low-risk Resufis are showm in the table, in wSich all comparisons involve the ORC Only 1 of 4 low-risk pts who rebled required subsequent transthsion. Conclusion: Despite a more severe spectrum of acute UG1H in the VA cohort by score distrfbutmn, and less discrimination of the Rockall scoring system by ROC criteria, there were no statistically sigmficant difl?rences in rebleeding or mortality among low-risk subgroups. These results suggest that the RSS may be useful to stratify risk for rebleeding and mortality among veterans w~th acute UGIH, Whether RSS can be used for early" hospital discMrge is uncertain, since it does not consider outcomes such as new or worsening comorbidit

parameter ORe RVAS ALL % M~ risk 26 10 (P<0 0001) 13 (P<0.0001) % high risk 6.4 11 (P=0.0034) 8.7 (P=0.09) AROC (Cl) r~ l ,~ l 0.73 (0.71-0.75) 0.49 (0.39-0.59) 0.52 (0.44-0.60) t~OC (Cl) death 0.80 (0.78-0.82) 021 (0.53-0.89) 0.64 (0.48-0.80)(P=0.03) % Iow-~k rebh~l 4,5 10.3 (P=0,15) 7.7 (P=0.30) % Im~r~k death 0.13 0 (P--I.00) 1.9 (P=0.12) % high-risk rebleed 53 25 (P=0.004) 26 (P=0.005) % high-risk death 41 9.4 (P=0.0003} 8.8 {P=0.0002}

T1313

Risk Stratification in Acute Lower Intestinal Bleeding: Prospective Validation of a Clinical Prediction Rule hsa L Strate, Sarah Canal< Pie Ookubo, Margery Rosenbhnt Ajita Mathur, Mnthoka L. Mutinga, John Saltzman, Sapna Syngal

Background: Patients who present to the emergency department with Acute Lower IntestinaI Bleeding (ALIB) are a heterogeneous group, and identification of high-risk patients at the time of presentation is difficult. Clinical prediction roles are routinely utilized in the evaluation and management of patients with upper GI bleeding. By contrast, prognostic tactors in ALIB have not been previou@ defined. Purpose: To prospectively validate a clinical prediction rule for severity of AL[B Methods: In a prior study of 252 patients with ALIB, we identified 7 independent predictors of severe bleeding defined as continued bleeding and/or recurrent bleednig after 24 hours of stability Using these factors, a predictive index was developed. We then prospectively identified 184 consecutive patients presenting with ALIB to the emergency departments of an academic and a community hospital Data were collected using a standardized instrument Clinical features on presentation were documented and patients were followed for the duration of hospitalization. To assess the validity of the prediction model, the proportion of patients with severe bleeding in each risk category and die areas under the receiver-operating characterisuc (ROC) were compared between the derivation and vahdation cohorts. Resuhs: Severe bleeding occurred in 123 patients (49%) in the derivation cohort and 92 (50%) in the validation cohort. The 7 independent correlates of severe bleeding in the derivation cohort were: Heart rate -> 100bpm, Systolic Blood Pressure -< 115mmHg, Syncope, Nontender abdominal exam, Bleeding per rectum in the 1 ~ 4 hrs of evaluation, Aspirin use, > 2 comorbid conditions, Patients veere stratified into 3 risk groups: Low (no risk factors), Moderate (1-3 risk factors), and High (> 3 risk factors). Rates of severe Needing in each risk category- were similar m the derivation and validation cohorts: Low risk 9% (1/11) vs 0% (0/8), Moderate risk 43% (85/197) vs 45% (62/137) and High risk 84% (37/44) vs 77% (30/39) The area under the ROC curve was 0.755 for the wafidafion cohort and 0761 tot the derivation cohort, suggesting excellent and nearly equivalent performance of the model Conclusions: We have developed and prospectively validated the first clinical prediction role for severity of ALIB Using 7 predictors readdy available on presentation, clinicians can reliably risk-stratity patients with ALIB, and identify those who will benefit most from aggressive care and mNent interventions.

T1314

Acute Gastrointestinal Hemorrhage in the Jehovah's Witness (JW): A Ten Year Study of Outcomes Darren C. Schwartz, Sumit N. Ringwala, Adrian Said, ,\lark Reichelderfer

Introduction: There are no reports of gastrointestinal bleeding outcomes m JW patients m the medical literature (Medlme review to 1966). Those caring forJW patients with signihcant blood loss often do so with trepidation owing to the inability to transfuse blood products We aimed to determine whetber being a JW with acute gastrointestinal hamorrhage impacts endoscopic and/or surgical management, as well as morbidny, mortality, and length of hospitalization. Methods: Aduh JW patients at least 18 years of age were identified through an interdepartmental database of patients admitted to our msnmtinn with gastrointestinal bleeding between July 1992 and August 2002, Controls were selected fi'om the same database in a stratified random design after controllmg tbr year of presentation. A retrospecnve chart revmw was then performed on all patients in both the case and control groups Resnhs: The study group was comprised ot 15 JW patients and 30 controls. Age, gender, comorbidity, and nonsteroldal anti-inflammatory drug, antiplatelet, and anticoagulation use were similar in the two groups. Frequency of hematemesis, mdena, and hematochezia was also similar, although hematocrit at presentation was lower in the JW group (p = 0.01). There was no difference among the groups in regard to bleedmg source. There was a trend toward more endoscopy" performed in the JW group (93.3%) compared to controls (86,7%), with an odds ratio (OR) of 215 (CI 0,22-21.18). JW patients were more likely to undergo surgery (OR 5.1, CI 0s and less likely to receive therapeutic endoscopy (0% vs. 15.4%, OR 0.46, CI 0.047-4.56). Median length of hospitahzation was longer m JW patients (7 days vs 4.5 days, p = 0,12), While morbidity, was no different in the two groups, the thi W- day mortality tended to be higher in JW patients (13.3%) compared to controls (3,3%), with an odds ratio of 4 4 6 (CI 037-53.7). Conclusions: JW patients admitted with acute gastrointestinal hemorrhage remain hospitalized longer and are more Iikely to be dead at

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