RETROSPECTIVE REVIEW OF HEMOGRAM PARAMETERS AND VITAL FINDINGS IN PATIENTS WITH NON-VARICEAL UPPER GASTROINTESTINAL TRACT BLEEDING

Öz

Objective Bleeding originating from proximal to the ligament of Treitz is referred to as upper gastrointestinal tract (GI) bleeding. Upper GI bleeding is an important cause of morbidity and mortality and should be excluded in patients presenting with blood in the mouth, black stools or blood in the stool. Diagnosis of upper GI bleeding, prediction of prognosis and mortality, and early intervention are crucial in emergency departments. In this study, we aimed to determine the prognostic value of hemogram parameters, vital values and risk scores in patients hospitalized with upper GI bleeding from emergency department. Material and Method In this study, 259 patients aged 18 years and older who were admitted to Süleyman Demirel University Faculty of Medicine Emergency Department between January 2015 and January 2020 for upper GI bleeding were retrospectively evaluated. Vital signs, hemogram parameters such as hemoglobin, hematocrit, red cell distribution width (RDW), white blood cell (WBC), platelet, vital values and risk scores (Glasgow-Blacthford and AIMS65) at admission were recorded from hospital records. Then survival status was also investigated. Patients who were pregnant, had malignancy, hematologic disease, history of esophageal varices, patients who were discharged directly from the emergency department, patients who were referred, patients who left the emergency department by signing a refusal of treatment or without permission, and patients whose file data could not be accessed were not included in the study. Results A total of 259 patients (157 females, 102 males, mean age: 72.7±17 years) with non-variceal upper GI bleeding were included in the study. Patients who died had significantly higher age, shock index, pulse rate, neutrophil/lymphocyte ratio, RDW, Glasgow- Blatchford and AIMS65 scores (p:0.009; p<0.001; p:0.004; p:0.013; p:0.001; p<0.001; p<0.001; respectively) and lower mean arterial pressure (p:0.006). As a result of the ROC analysis, it was observed that AIMS65 score above the threshold of 2 had the highest sensitivity (82.5%) and RDW above the threshold of 16.5 had the highest specificity (62.6%) in predicting mortality in patients with upper GI bleeding. Conclusion Evaluation of vital values, shock index, neutrophil/ lymphocyte ratio, RDW, AIMS65 and Glasgow- Blatchford score in patients with upper GI bleeding admitted to the emergency department contributes to the emergency physician to predict prognosis, need for early treatment and mortality. WBC and platelet indices are thought to have no effect in predicting prognosis and mortality.

Anahtar Kelimeler

• Upper gastrointestinal bleeding
• vital signs
• hemogram

VARİS DIŞI ÜST GASTROİNTESTİNAL SİSTEM KANAMALI HASTALARDA HEMOGRAM PARAMETRELERİ VE VİTAL BULGULARIN GERİYE DÖNÜK İNCELENMESİ

Öz

Amaç Üst gastrointestinal sistem (GİS) kanamaları treitz ligamentinin proksimalinden kaynaklanan kanamalardır. Ağızdan kan gelmesi, dışkıda siyahlaşma veya dışkıda kan görülmesi şikâyeti ile başvuran hastalarda dışlanması gereken üst GİS kanaması önemli bir morbidite ve mortalite sebebidir. Acil servislerde üst GİS kanama tanısı, prognoz ve mortalitenin tahmin edilmesi ve erken müdahale oldukça önemlidir. Biz bu çalışmamızda acil servise varis dışı üst GİS kanama ile başvuran ve yatışı yapılan hastalarda hemogram değerleri, vital bulgular ve risk skorlamalarının prognostik değerini sorgulamayı amaçladık. Gereç ve Yöntem Çalışmamızda Süleyman Demirel Üniversitesi Tıp Fakültesi Acil Servisi’ne üst GİS kanama sebebiyle Ocak 2015 – Ocak 2020 tarihleri arasında başvuran 18 yaş ve üzeri hastalar dahil edilmiştir. Vital bulgular, hemoglobin, hemotokrit, eritrosit dağılım genişliği (RDW), beyaz kan hücresi (WBC), trombosit gibi hemogram parametreleri, vital değerler ve başvuru sırasındaki risk skorları (Glasgow-Blacthford ve AIMS65) hastane kayıtlarından kaydedilmiştir. Sonrasında hastaların sağkalım durumu incelenmiştir. Çalışmaya gebe olan, malignitesi olan, hematolojik hastalığı olan, özefagus varisi öyküsü olan, acil servisten direkt taburcu olan, sevk edilen, tedavi reddi imzalayarak veya izinsiz olarak acil servisi terk eden hastalar ile dosya verilerine ulaşılamayan hastalar dahil edilmemiştir. Bulgular Çalışmaya varis dışı üst GİS kanaması olan toplam 259 hasta (157 kadın, 102 erkek, ortalama yaş: 72,7±17 yıl) dahil edildi. Sağkalım durumu incelendiğinde ölen hastaların anlamlı derecede daha yüksek yaşa, şok indeksine, nabız sayısına, nötrofil/lenfosit oranına, RDW, Glasgow-Blatchford ve AIMS65 skorlarına sahip oldukları (p:0,009; p<0,001; p:0,004; p:0,013; p:0,001; p<0,001; p<0,001; sırasıyla), daha düşük ortalama arter basıncına sahip oldukları (p:0,006) görüldü. Yapılan ROC analizi sonucunda üst GİS kanamalı hastalarda mortalite tahmininde AIMS65 skorunun 2 eşik değerin üzerinde olması en yüksek sensitiviteye (%82,5) RDW’nin 16,5 eşik değerin üzerinde olması en yüksek spesifiteye (%62,6) sahip olduğu gözlendi. Sonuç Acil servise başvuran üst GİS kanamalı hastalarda vital değerler, şok indeksi, nötrofil/lenfosit oranı, RDW, AIMS65 ve Glasgow-Blatchford skorunun değerlendirilmesi acil servis hekimine prognoz, erken tedavi ihtiyacı ve mortaliteyi tahmin etmesinde katkı sağlamaktadır. WBC ve trombosit indekslerinin prognoz ve mortaliteyi tahmin etmede bir etkisinin olmadığı düşünülmektedir.

Anahtar Kelimeler

• Üst gastrointestinal sistem kanaması
• vital bulgular
• hemogram

Kaynakça

1. 1. Khamaysi I, Gralnek IM. Acute upper gastrointestinal bleeding (UGIB)–initial evaluation and management. Best Practice & Research Clinical Gastroenterology 2013;27(5):633-8.
2. 2. Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Expert Review of Gastroenterology & Hepatology 2019;13(12):1161-7.
3. 3. O’malley T, Langhorne P, Elton RA, et al. Platelet size in stroke patients. Stroke 1995;26(6):995-9.
4. 4. Berdzuli N, Lomia N, Staff AC, et al. Audit of early and late maternal deaths in georgia: potential for improving substandard obstetric care. International Journal of Women's Health 2021;205-19.
5. 5. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. The Lancet 2000;356(9238):1318-21.
6. 6. Hyett BH, Abougergi MS, Charpentier JP, et al. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointestinal Endoscopy 2013;77(4): 551-7.
7. 7. Zaltman C, Souza HS, Castro ME, et al. Upper gastrointestinal bleeding in a Brazilian hospital: a retrospective study of endoscopic records. Arquivos de Gastroenterología 2002;39:74-80.
8. 8. Altinbilek E, Öztürk D, Kavalci C. Neutrophil/lymphocyte ratio and Red blood cell distribution width are independent risk factors for 30-day mortality in Gastrointestinal system bleeding patients. Signa Vitae: Journal for Intesive Care and Emergency Medicine 2019;15(2):59-64.

9. 9. Alyeşil E, Usta H, Kızdanoglu H, et al. Kliniğimize yatırılan üst GIS kanamalı hastaların değerlendirilmesi. İstanbul Tıp Dergisi 2005;4:7-10.
10. 10. Robertson M, Majumdar A, Boyapati R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointestinal Endoscopy 2016;83(6):1151-60.
11. 11. Bishay K, Tandon P, Fisher S, et al. Clinical factors associated with mortality in cirrhotic patients presenting with upper gastrointestinal bleeding. Journal of the Canadian Association of Gastroenterology 2020;3(3):127-34.
12. 12. Fukuda S, Shimodaira Y, Watanabe K, et al. Risks for rebleeding and in-hospital mortality after gastrointestinal bleeding in a tertiary referral center in Japan. Digestion 2020;101(1):31-7.
13. 13. Rassameehiran S, Teerakanok J, Suchartlikitwong S, et al. Utility of the shock index for risk stratification in patients with acute upper gastrointestinal bleeding. Southern Medical Journal 2017;110(11):738-43.
14. 14. Peng B, Wang YH, Liu YM, et al. Prognostic significance of the neutrophil to lymphocyte ratio in patients with non-small cell lung cancer: a systemic review and meta-analysis. International Journal of Clinical and Experimental Medicine 2015;8(3):3098.
15. 15. Chen IC, Hung MS, Chiu TF, et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med 2007;25:774-9.
16. 16. Oakland K. Risk stratification in upper and upper and lower GI bleeding: Which scores should we use? Best Pract Res Clin Gastroenterol 2019;42-43:101613.
17. 17. Abusaada K, Asad-Ur-Rahman F, Pec V, et al. Blatchford score is superior to AIMS65 score in predicting the need for clinical interventions in elderly patients with nonvariceal upper gastrointestinal bleed. Advances in Medicine 2016; 6850754.
18. 18. Tantai XX, Liu N, Yang LB, et al. Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding. World Journal of Gastroenterology 2019;25(45):6668.