Introduction
Massive gastrointestinal bleeding (MGB) is a life-threatening condition that requires prompt recognition and resuscitation to increase the chance of good outcomes (1).
Aims & Methods
Aims: Analyze risk factors, comorbidities and outcomes of MGB.
Methods: Retrospective analysis of a prospective registry of upper gastrointestinal bleed (UGIB) patients admitted to ‘Virgen de las Nieves University Hospital’ between 2013-2020.
MGB was defined as UGIB with transfusion of >2 pRBCs in the emergency room or during the first 24h of hospital stay and signs of shock (2). Main outcomes were 30-day mortality, rebleeding, bleeding persistence or severe complication throughout admission and complications within the first 6 months after discharge (including cardiovascular, hemorrhagic or deaths).
Statistical analysis was performed by SPSS.
Results
We included 1213 UGIB patients, 171 with MGB.
Multivariate logistic regression analysis showed that, being admitted for another condition (HR 1.72,95%CI 1.04-2.58,p=0.035), having a systemic disease (HR 2.30,95%CI 1.22-5.32,p=0.045), a disseminated malignancy (HR 2.07,95%CI 1.02-4.21,p=0.045) or suffering a severe comorbidity (HR 2.21,95%CI 1.25-3.91,p=0.009) were independent risk factor for MGB.
Among 171 MGB patients, 21% died, with 10 deaths directly from hypovolemic shock secondary to UGIB, and 11% due to complications.
Table shows significance differences between deaths and survivors.
Relevant Comorbidities ASA 3-4 (%) | Deaths
96.7% | Survivors
78.5% | p
0.0018 |
| Active bleeding (%) | 76.3 | 43.3 | 0.007 |
| Interventional radiology (%) | 13.3 | 3.7 | 0.034 |
| SBP (mean±SD mmHg) | 79±8 | 84±9 | 0.025 |
| Albumin (mean±SD mg/dl) | 2.4±0.5 | 2.8±0.6 | 0.011 |
| Calcium (mean±SD mg/dl) | 7.7±0.6 | 8.2±0.8 | 0.032 |
| Platelets (mean±SD /mm3) | 158*103±101*103 | 206*103±106*103 | 0.027 |
| Severe complications during hospitalization | 76.7 | 22.1 | <0.0001 |
| Bleeding persistence (%) | 63.3 | 17.6 | <0.0001 |
| Rebleeding (%) | 40 | 17 | 0.005 |
Multivariate analysis showed that active bleeding in endoscopy (HR 4.80,95%CI 1.06-21.62,p=0.041) and severe complications (HR 14.03,95%CI 3.30-59.60,p<0.0001) were independent predictors for mortality, being calcium levels a protective factor (HR 0.41,95%CI 0.16-0.94,p=0.045).
Among the survivors after the index episode,14% died after 6 months, being main causes of death recurrent bleeding(5.2%), neoplasms(4.4%), cirrhosis complications(2%), cardiovascular disease(1.5%) and sepsis(1.5%).
Delayed bleeding was caused by recurrent UGIB in 86.6%, lower GIB in 10% and from a non-GI origin in 3.4%. Delayed cardiovascular events were heart failure in 46%, thromboembolic events in 23%, myocardial ischemia in 15.4% and atrial fibrillation in 15.6%.
Conclusion
Our study is a prospectively collected single center registry of patients with massive UGIB, in which we observed that being an inpatient and harboring severe comorbidities, particularly systemic diseases and malignancies, were risk factors for this condition. Mortality among those patients was related to CKD, cirrhosis, severe comorbidities and excessive alcohol consumption. We also found an increased delayed mortality, probably related to a worsening health condition in which GI bleeding heralded poor outcomes, some of them potentially preventable with close follow-up.
References
- Nagata N, Sakurai T, Shimbo T, et al. Acute Severe Gastrointestinal Tract Bleeding Is Associated With an Increased Risk of Thromboembolism and Death. Clin Gastroenterol Hepatol. 2017;15:1882-1889 e1881.
- D'Amore K, Swaminathan A. Massive Gastrointestinal Hemorrhage. Emerg Med Clin North Am. 2020;38:871-889.