Corley D A, Stefan A M, Wolf M, Cook E F, Lee T H
Department of Medicine, Brigham & Women's Hospital and the Harvard Medical School, Boston, Massachusetts, USA.
Am J Gastroenterol. 1998 Mar;93(3):336-40. doi: 10.1111/j.1572-0241.1998.00336.x.
Endoscopy allows accurate risk stratification of patients presenting with gastrointestinal bleeding; frequently, however, it is not immediately available. Initial management and triage of patients thus depends on nonendoscopic information. We sought to risk stratify patients with upper gastrointestinal bleeding using variables available on initial presentation (ie., before endoscopy).
A retrospective observational study was performed using data from 335 admissions with an initial diagnosis of upper gastrointestinal hemorrhage. All patients underwent endoscopy and were evaluated for an adverse outcome during their hospitalization. An adverse outcome was defined as death, the need for any operation, recurrent hematemesis, recurrent melena after initial clearing, or a hematocrit falling despite transfusion.
Univariate analysis identified 17 distinct variables associated (p < 0.05) with an adverse outcome. A stepwise logistic regression identified five variables as independent predictors (p < 0.05) of an adverse outcome: an initial hematocrit <30%, initial systolic blood pressure < 100 mm Hg, red blood in the nasogastric lavage, history of cirrhosis or ascites on exam, and a history of vomiting red blood. We derived a decision rule based on patients having 0-5 of these independent predictors. This decision rule allowed identification of a large patient population with a <10% chance of an adverse outcome.
Risk stratification is possible from information available at the time of initial presentation. If confirmed in other populations, these predictors can be used to identify patients who require a less intensive level of care.
内镜检查可对出现胃肠道出血的患者进行准确的风险分层；然而，内镜检查常常无法立即进行。因此，患者的初始管理和分诊取决于非内镜检查信息。我们试图利用初始就诊时（即内镜检查前）可获得的变量对急性上消化道出血患者进行风险分层。
我们进行了一项回顾性观察性研究，使用了335例初步诊断为上消化道出血患者的入院数据。所有患者均接受了内镜检查，并在住院期间评估了不良结局。不良结局定义为死亡、需要进行任何手术、反复呕血、初始清除后反复出现黑便，或尽管输血但血细胞比容仍下降。
单因素分析确定了17个与不良结局相关（p<0.05）的不同变量。逐步逻辑回归确定了5个变量作为不良结局的独立预测因素（p<0.05）：初始血细胞比容<30%、初始收缩压<100 mmHg、鼻胃灌洗中有红色血液、检查时有肝硬化或腹水病史，以及呕血史。我们根据具有这些独立预测因素中的0-5个因素的患者得出了一个决策规则。该决策规则能够识别出不良结局可能性<10%的大量患者群体。
根据初始就诊时可获得的信息进行风险分层是可行的。如果在其他人群中得到证实，这些预测因素可用于识别需要较低护理强度的患者。
