Berger Matthew, Divilov Vadim, Teressa Getu
Department of Internal Medicine, Stony Brook Medicine, Stony Brook, NY, USA.
Gastroenterology Res. 2019 Feb;12(1):1-7. doi: 10.14740/gr1085w. Epub 2019 Feb 26.
There are validated clinical risk scores for risk stratifying patients presenting with acute upper gastrointestinal bleed (GIB), including Glasgow-Blatchford score (GBS), Pre-endoscopic Rockall score (RS-PE) and post-endoscopic complete Rockall Score (RS-C), and AIMS65. Several studies have explored the predictive value of lactic acid (LA) in the context of GI bleeding, but the prognostic role of LA and its incremental value in combination with existing clinical risk scores is not well defined.
We conducted a retrospective analysis of consecutive patients presenting to the emergency department of a single large academic tertiary care center from January 2014 to December 2015 with a charted diagnosis of acute GIB, inclusive of both upper and lower sources. We evaluated the independent role of LA as well as three clinical risk scores for predicting in-hospital mortality in these patients.
Out of 704 patients admitted with acute GI bleeding, 366 patients had LA measured on presentation to the emergency department. The mean LA level, GBS, RS-PE and RS-C were found to be significantly higher in non-survivors, while there was no difference in the mean AIMS65 score between survivors and non-survivors. A multivariate logistic regression analysis showed that LA level was an independent predictor of in-hospital mortality. The area under the curve (AUC) for the receiver operator characteristic for RS-C, RS-PE, and GBS were 0.742, 0.675, and 0.652, respectively. When integrating LA into the above risk scores, the AUC for RS-C, RS-PE, and GBS showed statistical significance improvements to 0.780 (P = 0.04), 0.774 (P = 0.012), and 0.706 (P = 003), respectively.
In unselected patients with GIB who presented to the emergency department, LA is an independent predictor of in-hospital mortality. Integration of LA into RS-C, RS-PE, and GBS risk scores improved their ability to predict in-hospital mortality. The modified LA-based RS-PE (L-Rockall pre-endoscopic) score demonstrated predictive value comparable to the post-endoscopic RS-C.
对于急性上消化道出血（GIB）患者，有经过验证的临床风险评分系统，包括格拉斯哥-布拉奇福德评分（GBS）、内镜检查前罗卡尔评分（RS-PE）、内镜检查后完整罗卡尔评分（RS-C）以及AIMS65评分。多项研究探讨了乳酸（LA）在消化道出血情况下的预测价值，但LA的预后作用及其与现有临床风险评分相结合的增量价值尚不明确。
我们对2014年1月至2015年12月期间在一家大型学术三级医疗中心急诊科就诊且确诊为急性GIB（包括上消化道和下消化道来源）的连续患者进行了回顾性分析。我们评估了LA以及三种临床风险评分在预测这些患者住院死亡率方面的独立作用。
在704例因急性消化道出血入院的患者中，有366例在急诊科就诊时检测了LA。结果发现，非幸存者的平均LA水平、GBS、RS-PE和RS-C显著更高，而幸存者和非幸存者的平均AIMS65评分无差异。多因素逻辑回归分析表明，LA水平是住院死亡率的独立预测因素。RS-C、RS-PE和GBS的受试者工作特征曲线下面积（AUC）分别为0.742、0.675和0.652。当将LA纳入上述风险评分时，RS-C、RS-PE和GBS的AUC分别显著提高至0.780（P = 0.04）、0.774（P = 0.012）和0.706（P = 0.03）。
在未经过筛选的急诊科GIB患者中，LA是住院死亡率的独立预测因素。将LA纳入RS-C、RS-PE和GBS风险评分可提高其预测住院死亡率的能力。基于LA的改良RS-PE（内镜检查前L-罗卡尔）评分显示出与内镜检查后RS-C相当的预测价值。
