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Clinical Scoring Systems in Predicting the Outcomes of Small Bowel Bleeding

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Clinical Scoring Systems in Predicting the Outcomes of Small Bowel Bleeding 32 6 Clinical Scoring Systems Predicting Small Bowel Bleeding ORIGINAL ARTICLE GASTROINTESTINAL TRACT Su et al. Clinical Scoring Systems in Predicting the Outcomes of Small Bowel Bleeding Su Shuai1, Zhang Zhifang2, Wang Yuming1, Jin Hong1, Sun Chao1, Jiang Kui1, Wang Bangmao1 1Department of gastroenterology and hepatology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China 2Department of Neurology, Tianjin Xiqing Hospital, Tianjin, People’s Republic of China Cite this article as: Su S, Zhang Z, Wang Y, et al. Clinical scoring systems in predicting the outcomes of small bowel bleeding. Turk J Gastroenterol. 2021; 32(6): 493-499. ABSTRACT Background: The aim was to assess the clinical Glasgow–Blatchford score (GBS), Rockall score (CRS), and AIMS65 score in predicting outcomes (rebleeding, need for intervention, and length of stay) among patients with small bowel hemorrhage. Methods: We conducted a retrospective study of patients with small bowel bleeding (SBB). Rebleeding, need for intervention, and length of stay was investigated by 3 scoring systems. The area under the receiver operator characteristic curve was used to analyze the perfor- mance of 3 scoring systems. Results: Among 162 included patients, the scores of rebleeding, intervention, and length of stay ≥10 days groups were higher than no rebleeding, non-intervention, and length of stay <10 days groups, respectively (P < .05). The CRS, GBS, and AIMS65 scoring systems dem- onstrated statistically significant difference in predicting rebleeding (AUROC 0.693 vs. 0.790 vs. 0.740; all P < .01), intervention (AUROC: 0.726 vs. 0.825 vs. 0.773; all P < .01) and length of stay (AUROC 0.651 vs. 0.631 vs. 0.635; all P < .05). Higher cut-off scores achieved better sensitivity/specificity [rebleeding (CRS > 2, GBS > 7, AIMS65 > 0); need for intervention (CRS > 2, GBS > 7, AIMS65 > 0); length of stay (CRS > 0, GBS > 7, AIMS65 > 1)] in the risk stratification. Conclusions: The GBS system is reliable to be recommended for routine use in predicting rebleeding and the need for intervention for early decision making in patients with SBB. The 3 scoring systems are poorly useful in predicting length of stay. Keywords: Glasgow–Blatchford score, clinical Rockall score, AIMS65 score, small bowel bleeding, ROC curve INTRODUCTION bowel rebleeding in patients with SBB, but there were Small bowel bleeding (SBB) remains a relatively uncom- limitations for them.5-7 For example, no risk score was mon event in gastrointestinal (GI) bleeding.1,2 It can be a designed to distinguish between high-risk and low-risk severe and potentially life-threatening condition, which patients with SBB after the first investigation and making is difficult to be resolved. Capsule endoscopy (CE) and early decisions such as the timing of intervention(blood double-ballon enteroscopy(DBE) could be used to detect transfusion, endoscopic, or surgical therapy) and time and treat small bowel-specific bleeding lesions. However, of discharge in patients. Therefore, it is useful to find a rebleeding has still been reported in 13-20% of cases clinical prognosis score for the identification of high-risk after cessation of small bowel bleeding.3,4 It is valuable to patients with small bowel hemorrhage, such as rebleed- find high-risk patients with rebleeding and quickly treat ing, to determine who requires early intervention. them in these situations. For upper gastrointestinal bleeding (UGIB), some clinical The risk scores are reported to be useful for GI bleed- prognosis scores are used to predict the risk of rebleed- ing patient risk stratification, triage, and management. ing, need for intervention, and length of stay in clinical The “PRSBB” score, comorbidity Index, and ORBIT score practice, such as Glasgow–Blatchford score (GBS), clini- (Older age, Reduced hemoglobin/hematocrit, Bleeding cal Rockall score (CRS), and AIMS65 score.8,9 Whether history, Insufficient kidney function and Treatment with the 3 scoring systems could be used for SBB is still antiplatelets) were once used for the prediction of small unknown. There are several risk factors in common Corresponding author: Wang Bangmao, e-mail: [email protected]. Received: June 24, 2019 Accepted: November 19, 2019 Available Online Date: July 30, 2021 © Copyright 2021 by The Turkish Society of Gastroenterology • Available online at turkjgastroenterol.org DOI: 10.5152/tjg.2020.19458 493 Turk J Gastroenterol 2021; 32(6): 493-499 Su et al. Clinical Scoring Systems Predicting Small Bowel Bleeding between SBB and UGIB.5,6,7,10 For example, risk fac- Statistical Analysis tors for SBB include age, the pulse rate and systolic All data were identified and entered into computer data blood pressure, comorbidities, sex, hemoglobin lev- files by experienced data managers. Statistical analysis els, INR, medication use on admission, melena, and was performed using SPSS19.0. Baseline characteristics so on.10 The risk factors in SBB are also shared by and outcomes were summarized by frequency tabulation UGIB.5-7 Furthermore, the risk factors included in SBB and means with standard deviations as appropriate. The are similar to risk factors that included in CRS, GBS, and discriminative ability of the scoring systems for predicting AIMS65 score.5,6,7,10 Therefore, we aimed to determine outcomes was evaluated by receiver–operator character- 3 different prognosis scores designed for UGIB could be istic curve analysis. The area under the receiver–operating used in small bowel hemorrhage to estimate the risk of characteristic curve the area under the receiver-oper- rebleeding and make further decisions for intervention ating characteristic curve (AUROC) was calculated and and length of stay . compared for all scores using the DeLong test. A cut-off point was selected according to the maximal sum of each score’s sensitivity and specificity. METHODS Study Design and Setting Estimates of sensitivity and specificity were calculated We conducted a retrospective study in patients who for each score. Comparison between rebleeding/inter- suffered SBB between January 1, 2016 and January 31, vention/length of stay ≥ 10 days groups and no rebleed- 2019 at our academic medical center. The medical center ing/non-intervention/length of stay <10 days groups for is a 2468-bed urban academic, tertiary care, and univer- each score was performed using the chi-square test and sity hospital. Ethics committee approval was received for Fisher’s exact test as appropriate. All statistical compari- this study from the Ethics Committee of the academic sons were 2 tailed, with P value <.05 considered statisti- medical center. Written informed consent was neces- cally significant. sary to be signed for the patients who participated in this study. RESULTS Population Characteristics Selection of Participants In this study, 162 patients with SBB were identified and In this study, 162 patients hospitalized with SBB were suitable for our study to be analyzed. The median age of retrospectively analyzed. All patients 18 years of age or the patients was 56 years. Of these patients, 104 (64.81%) older were necessary for the study. Upper endoscopy were males. At admission, melena or/and hematochezia and colonoscopy were negative in patients who got GI were the most common presentation of SBB. The most bleeding with signs (melena/hematochezia, hypoten- common comorbidities were hypertension (37.0%) and sion, shock, orthostatic changes in systolic blood pres- cardiovascular disease (18.5%). Regarding medication, 46 sure and/or pulse, or repeated bleeding). For patients (28.4%) patients were taking non-steroidal anti-inflam- to be enrolled, they needed to have performed exami- matory drugs when the bleeding episode occurred. Blood nations of CE or/and DBE. The patients with preg- transfusion was required in nearly half of the patients nant and unable to be performed with CE or DBE were (48.1%), while endoscopic therapy was required in almost excluded. 1/10 patients. Only 2 patients (2.5%) required surgery as rescue therapy. Rebleeding was observed in 76 patients (46.9%) over a median follow-up period of 4 weeks. Two Rebleeding is defined as bleeding again after 24 h of ces- patients died because of small bowel malignant tumor. The sation of bleeding in the small bowel, including melena or/ baseline demographic and clinical characteristics of these and hematochezia, a decrease of >2 g/dL in hemoglobin patients according to in-patient status are shown in Table 1. value, or need of a transfusion. One hundred sixty-two cases involved in SBB were diag- Scores nosed by small bowel capsule endoscopy (SBCE) and/or The 3 scoring systems (GBS, CRS, and AIMS65 score) chosen DBE. Of all the patients who experienced SBB, 48 (29.63%) for SBB were independent from endoscopy. The clinical had lesions detected by SBCE, while 82 (87.23%) were or laboratory findings were the basement of the 3 scoring detected by DBE. Twenty-eight (66.7%) lesions were systems. The Blatchford score, CRS, and AIMS65 score found in both SBCE/DBE. Patients performed by SBCE/ were calculated from clinical or laboratory variables.11-13 DBE can be found in Figure 1. 494 Su et al. Clinical Scoring Systems Predicting Small Bowel Bleeding Turk J Gastroenterol 2021; 32(6): 493-499 Table 1. Baseline Characteristics and Outcomes of Patients Characteristics of Patients at Baseline Age (mean ± SD) (years) 56.27 ± 18.92 Male/female 104/58 Length of stay (days) 12.14 ± 6.40 Mean course (months) (mean± SD) 12.84 ± 27.27 Previous bleeding, n (%) 38 (23.5%)
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