Article

Suspected lower gastrointestinal bleeding in emergency departments, from bleeding symptoms to diagnosis

GI bleeding in ED: from “>772 Correspondence / American Journal of Emergency Medicine 37 (2019) 762793

Suspected lower GI bleeding in ED: from bleeding symptoms to diagnosis

lower gastrointestinal bleeding (LGIB) is a common medical problem in emergency medicine. The few existing data concern LGIB in patients hospitalized in gastroenterology departments (GED) or after endoscopy [1-6]. These patients represent only a part of LGIB cases managed in emer- gency departments (EDs). We aimed to describe the epidemiologic char- acteristics and management of patients with suspected LGIB in EDs.

We performed an observational, multicentric, prospective study during 4 consecutive days in November 2013. This study was performed simultaneously and with a similar method to another one that assessed upper gastrointestinal bleeding in EDs [7]. The 110 EDs participating in the French Emergency Medicine Research [IRU] network, coordinated by the French Society of Emergency Medicine [SFMU], contributed to the study [7,8]. All adult patients with suspected LGIB were included. LGIB was defined as externalisation of red blood by the rectum, includ- ing bloody stools. Patient’s characteristics, clinical presentation includ- ing severity signs and hemoglobinemia level, medical history and usual treatments were collected. Treatments in EDs, endoscopy and computed tomography (CT) data were noted, such as outcomes (hospi- talized or discharged patients) and when hospitalized, final diagnosis, length of stay and hospital deaths. The analysis was mostly descriptive. Ethics committees approved the study.

During the study, 149 patients with suspected LGIB were included (0.32% of 46,190 ED’s visits). The estimated incidence was 93/100,000 in- habitants. The main patient characteristics are shown in Table 1. Forty-

two (28%) were discharged from ED. Among the 107 hospitalized pa- tients, 75 (70%) underwent endoscopy, 44 colonoscopy, 20 colonoscopy and Upper endoscopy, and 11 only upper endoscopy. A haemorrhagic le- sion was identified for 92/99 (93%) hospitalized patients (Table 2). Di- verticulosis and colitis (infectious, inflammatory and ischemic) were the main lesions, 22/99 (22%) and 28/99 (28%) respectively. Anorectal le- sions concerned 17/99 (17%) patients. For 12/99 (12%) patients, the final diagnosis was upper gastrointestinal bleeding. Thirty patients (20%) had at least one clinical severity sign (Table 1), and 4 (3%) were hospitalized in an intensive care unit. For 9, the haemoglobin level was b7 g/dL (6%) and 30 received a blood transfusion (20%). The median hospitalization stay was 4.5 days [Q1-Q3 2-10]. The hospitalization mortality rate was 5% (n = 7). Mortality was significantly higher among patients with high heart rate (p = 0.024), altered mental status (p = 0.011) and low haemoglobin level (p = 0.013) as well as exteriorized bleeding in the ED (p = 0.042) (Table 3). Mortality was also associated with receiving fluids (p = 0.029), transfusion (p = 0.004), catecholamines (p = 0.048) or vitamin K antagonist reversal (p = 0.037), and hospitalization in an intensive care unit (p = 0.0003).

The calculated incidence of LGIB seems higher than in the literature [1,3,9] and may be related to the fact that included patients presented all types of bleeding, among which weak bleeding due to anorectal le- sions. Moreover, LGIB incidence has tended to increase this last decade due to the aging of the population and the increased use of antithrom- botic treatments [2,3,9-12]. Almost one third of bleeding occurred in pa- tients presenting no severity criteria and who were discharged from ED. These patients were younger, used less antithrombotics, less presented melena, and bleeding was less often seen in the ED. The remaining bleeding concerned hospitalized patients, mainly with colonic lesions.

Table 1

General characteristics and treatments of patients presenting lower gastrointestinal bleeding in emergency departments.

Total

Hospitalized patients

Discharged patients

P value

n = 149

n = 107

n = 42

Age (median [Q1-Q3])

67 [47-80]

74 [54-85]

49 [32-64]

b0.0001

Sex (men; n, %)a

73 (49)

52 (49)

21 (50)

1

initial symptoms, n (%) Hematochezia

149 (100)

107 (100)

42 (100)

1

Melena

Medical history and treatment, n (%)b

19 (13)

18 (17)

1 (2)

0.015

Known cirrhosis

9 (8)

7 (8)

2 (10)

Known ulcer

12 (11)

12 (14)

0 (0)

Non-steroidal anti-inflammatory drugs

8 (7)

5 (6)

3 (15)

0.16

antithrombotic agents

48 (44)

46 (52)

2 (10)

0.0004

Comorbidity

41 (38)

36 (41)

5 (25)

0.21

Exteriorized bleeding in the ED, n (%)a

89 (60)

75 (71)

14 (33)

b 0.0001

Clinical features of severity, n (%)

Heart rate N 100 bpm

15 (10)

15 (14)

0 (0)

0.006

Systolic arterial pressure b 90 mm Hg

18 (12)

17 (16)

1 (2)

0.024

Marbling

4 (3)

4 (4)

0 (0)

0.58

Altered mental status

4 (3)

4 (4)

0 (0)

0.58

Haemoglobin level, n (%)c b7 g/dL

9 (6)

8 (8)

1 (3)

b0.0001

7-10 g/dL

39 (28)

38 (37)

1 (3)

N10 g/dL

91 (65)

57 (55)

34 (94)

Treatments in ED, n (%)

nasogastric tube

6 (4)

6 (6)

0 (0)

0.18

Fluid administration

29 (19)

28 (26)

1 (2)

0.0004

Transfusion

30 (20)

29 (27)

1 (2)

0.0004

proton pump inhibitors

47 (32)

47 (44)

0 (0)

b0.0001

Vasopressors

4 (3)

4 (4)

0 (0)

0.32

Catecholamines

1 (1)

1 (1)

0 (0)

1

Antibioticsd (excluding erythromycin)

9 (6)

9 (8)

0 (0)

0.06

Vitamin K antagonist reversal

7 (5)

7 (7)

0 (0)

0.19

Erythromycin

1 (1)

1 (1)

0 (0)

1

Upper endoscopy in ED, n (%)d

8 (5)

8 (7)

0 (0)

0.11

Computed tomography in ED, n (%)d

21 (14)

21 (20)

0 (0)

0.0005

ED = emergency department.

a For 148 patients.

b For 108 patients.

c For 139 patients

d For 147 patients.

Correspondence / American Journal of Emergency Medicine 37 (2019) 762793 773

Table 2

Final diagnosis (hospitalized patients).

Diagnosis n = 99a

Diverticulosis 22 (22)

Colitis 28 (28)

Angiodysplasia 4 (4)

Cancer 9 (9)

Anorectal lesions 17 (17)

Upper gastrointestinal bleeding 12 (12)

None 7 (7)

a 8 missing data.

However, patients characteristics are similar to those observed in studies from GED, as melena frequency [3,12-18]. The diagnostic performance of endoscopy for LGIB was good as previously reported (68% to 97%) [1,14,19]. The etiological distribution of hospitalized LGIB patients is in accordance with recent literature [3,6,13-15]. Diverticular and colitis bleeding are the most common causes and angiodysplasia seems rare. Patients suspected of LGIB could have upper gastrointestinal bleeding, as observed in previous studies, justifying upper endoscopy in patients with significant rectal hemorrhage [1,16]. The severity and mortality

rates are close to those observed in previous studies [3-6,13-15,18,19]. Death is not often related to bleeding itself but rather to co- morbidities. The main factors associated with mortality found in the lit- erature are age, male sex, presence of co-morbidities, anticoagulant therapy, initial signs of severity and the need for transfusion [6,11,12,14,17,19-22]. Our data confirm a significant association with clinical severity signs, lower haemoglobin level, as well as management elements related to the initial severity. The number of transfusions sug- gests that the restrictive transfusion policy is not yet followed [13,23,24]. Our study main limitations are the short inclusion period of 4 days, the number of included patients (n = 149) and the few number of de- ceased patients that did not allow us to perform a multivariate analysis. epidemiological data of LGIB has never been studied in EDs. Almost 1/3 of patients with suspected LGIB were discharged from ED. Divertic- ulosis and colitis were the main lesions in hospitalized patients, but an

upper bleeding must not be missed.

Funding

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

Table 3

Patient characteristics by survival status.

Survivors n = 139a

Non-survivors n= 7a

P value

Age (median [Q1-Q3])

67

67 [57-89]

0.30

Sex (men; n, %)b

[46-80]

69 (50)

4 (57)

1

Initial symptoms, n (%)

Medical history and treatment, n (%)c

Melena

17 (12)

2 (29)

0.23

Known cirrhosis

6 (6)

2 (29)

0.087

Known ulcer

11 (11)

1 (14)

0.58

Non-steroidal anti-inflammatory drugs

5 (5)

1 (14)

0.34

Antithrombotic agents

44 (44)

4 (57)

0.70

Comorbidity

38 (38)

3 (43)

1

Exteriorized bleeding in the ED, n (%)b

80 (58)

7 (100)

0.042

Clinical features of severity, n (%)

Heart rate N 100 bpm

12 (9)

3 (43)

0.024

Systolic arterial pressure b 90 mmHg

15 (11)

2 (29)

0.19

Marbling

3 (2)

1 (14)

0.18

Altered mental status

2 (1)

2 (29)

0.011

Haemoglobin level, n (%)d

b7 g/dL

8 (6)

1 (14)

0.013

7-10 g/dL

33 (26)

5 (71)

N10 g/dL

88 (68)

1 (14)

Treatments in ED, n (%)

Nasogastric tube

5 (4)

1 (14)

0.26

Fluid administration

25 (18)

4 (57)

0.029

Transfusion

25 (18)

5 (71)

0.004

Proton pump inhibitors

42 (30)

4 (57)

0.21

Vasopressors

3 (2)

1 (14)

0.18

Catecholamines

0 (0)

1 (14)

0.048

Antibioticse (excluding erythromycin)

9 (7)

0 (0)

1

Vitamin K antagonist reversal

5 (4)

2 (29)

0.037

Erythromycin

1 (1)

0 (0)

1

Hospitalization in intensive care unit, n (%)

1 (1)

3 (43)

0.0003

Final diagnosis, n (%)f (hospitalized patients)

Diverticulosis

21 (23)

1 (14)

0.45

Colitis

25 (27)

3 (43)

Angiodysplasia

4 (4)

0 (0)

Cancer

7 (8)

2 (29)

Ano-rectal lesions

17 (18)

0 (0)

Upper gastrointestinal

11 (12)

1 (14)

bleeding

None

7 (8)

0 (0)

ED = emergency department.

a 3 missing data.

b For 145 patients.

c For 106 patients.

d For 136 patients.

e For 144 patients.

f For 99 patients.

774 Correspondence / American Journal of Emergency Medicine 37 (2019) 762793

Declarations of interest

None.

Pierre-Clement Thiebaud

Hreinsson JP, Gumundsson S, Kalaitzakis E, Bjornsson ES. Lower gastrointestinal bleeding: incidence, etiology, and outcomes in a population-based setting. Eur J Gastroenterol Hepatol 2013;25:37-43. https://doi.org/10.1097/MEG. 0b013e32835948e3.
  • Gayer C, Chino A, Lucas C, Tokioka S, Yamasaki T, Edelman DA, et al. Acute lower gas- trointestinal bleeding in 1,112 patients admitted to an urban emergency medical center. Surgery 2009;146:600-6 discussion 606-7 https://doi.org/10.1016/j.surg.
  • 2009.06.055.

    Whelan CT, Chen C, Kaboli P, Siddique J, Prochaska M, Meltzer DO. Upper versus

    Emergency Department, Hopital Saint-Antoine, Assistance Publique-

    Hopitaux de Paris, Paris, France Initiatives de Recherche aux Urgences, SFMU, French Society of Emergency

    Medicine, France Corresponding author at: Service des Urgences, Hopital Saint Antoine, Assistance Publique-Hopitaux de Paris, 184 rue du Faubourg St-Antoine,

    75012 Paris, France.

    E-mail address: [email protected].

    Youri Yordanov

    Emergency Department, Hopital Saint-Antoine, Assistance Publique-

    Hopitaux de Paris, Paris, France Sorbonne Universites, Paris, France INSERM U1153, Statistic and epidemiologic research Center Sorbonne Paris Cite (CRESS), METHODS Team, Hotel-Dieu Hospital, Paris, France

    Jacques-Emmanuel Galimard INSERM U1153, Statistic and Epidemiologic Research Center Sorbonne Paris Cite (CRESS), METHODS Team, Hotel-Dieu Hospital, Paris, France

    Diane Naouri Dominique Pateron

    Emergency Department, Hopital Saint-Antoine, Assistance Publique-

    Hopitaux de Paris, Paris, France Sorbonne Universites, Paris, France

    Fabien Brigant

    Emergency Department, Hopital Saint-Antoine, Assistance Publique-

    Hopitaux de Paris, Paris, France

    Jennifer Truchot

    Initiatives de Recherche aux Urgences, SFMU, French Society of Emergency

    Medicine, France Emergency Department, Hopital Lariboisiere, Assistance Publique-Hopitaux

    de Paris, Paris, France

    Fares Moustafa

    Initiatives de Recherche aux Urgences, SFMU, French Society of Emergency

    Medicine, France Emergency Department, Hopital Gabriel-Montpied, Clermont-Ferrand,

    France

    The Initiatives de Recherche aux Urgences Group

    24 July 2018

    https://doi.org/10.1016/j.ajem.2018.08.053

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