Predictors of Non-Significant Endoscopic Findings in Patients with Suspected Upper Gastrointestinal Tract Hemorrhage Preeda Sumritpradit MD*, Suwat Tangkittimasak MD*, Panuwat Lertsithichai MD* * Department of Surgery, Ramathibodi Hospital and Medical School, Mahidol University Objectives: The objective of the present study was to determine pre-endoscopic predictive factors of non- significant endoscopic findings in patients with suspected upper gastrointestinal tract hemorrhage (UGIH). Material and Method: Medical records of 187 patients admitted with the primary diagnosis of UGIH were reviewed. Non-significant endoscopic findings were defined as “normal”, “mild gastritis” or unspecified gastritis with a hospital stay of two days or less. Possible predictors of non-significant endoscopic findings included pertinent history, physical examination, nasogastric tube aspirate, routine laboratory findings, and units of infused packed red cells (PRC). Multiple logistic regression analysis was used to determine signifi- cant predictors. Results: Predictors of non-significant endoscopic findings included the absence of comorbid diseases (OR: 6.4; 95%CI: 3.0-13.6), higher platelet count (OR: 1.7 per 100,000 increase; 95%CI: 1.1-2.5) and less PRC infusion (OR: 1.9 per unit decrease; 95%CI: 1.3-2.7). Conclusion: Patients with UGIH who may have a negative EGD can be identified prior to endoscopy. Keywords: Predictors, Non-significant findings, Endoscopy, Upper gastrointestinal hemorrhage J Med Assoc Thai 2005; 88 (9): 1207-13 Full text. e-Journal: http://www.medassocthai.org/journal Acute upper gastrointestinal tract hemorrhage reducing hospitalization costs(6,12). For example, many (UGIH) remains a major cause of morbidity and mor- patients are hospitalized while awaiting EGD. The tality(1,2). Urgent esophagogastroduodenoscopy (EGD) ability to recognize patients who may or may not need is widely recommended for patients presenting with urgent EGD should reduce some of these costs(12). It acute UGIH in the emergency department. EGD can can be further proposed that a subgroup of these provide definitive diagnoses of the cause of UGIH as patients may not need EGD at all. These patients in- well as treatment for actively bleeding lesions(3,4). How- clude those diagnosed as having suspected UGIH but ever, 80% of UGIH patients have an uncomplicated with normal EGD findings or other “non-significant” course(5). If it is possible to identify these patients prior findings such as “mild gastritis” or “mild duodenitis”. to EGD, then a less costly or less risky level of care can The objective of the present study was to be provided without compromising outcome(6-8), for determine which pre-endoscopic predictive factors can example by foregoing urgent EGD. be used to distinguish between acute UGIH patients There is some evidence that 20% to 30% of who do not have significant EGD findings and those patients presenting with UGIH can be safely managed who do. in an outpatient setting(9-11). Studies have been con- ducted to identify such patients with the hope of Material and Method Medical charts of patients who were admitted Correspondence to : Lertsithichai P, Department of Surgery, to the authors’ hospital with the primary diagnosis of Ramathibodi Hospital and Medical School, Mahidol University, Bangkok 10400, Thailand. Phone: 0-2201-1315, Fax: 0-2201- UGIH during the period between May 2003 and July 1316, E-mail: [email protected] 2004 were reviewed. Patients were included if they J Med Assoc Thai Vol. 88 No.9 2005 1207 underwent urgent EGD (within 24 - 48 hrs after admis- deviation, 17.9 years). Potential predictive factors for sion). Patients were excluded if they were hospitalized non-significant EGD findings are presented in Table 1, for other illnesses, if they had severe cardiopulmonary separately for patients with non-significant EGD find- diseases, severe hematologic derangement and ings and for those with significant findings. Fifty-five advanced cancer. A total of 187 patients were enrolled. patients (29%) were found to have non-significant Data on pre-endoscopic predictive factors EGD findings. Details of the EGD findings are shown in potentially able to help discriminate between UGIH Table 2. The most common EGD finding was gastritis patients without significant EGD findings and those (38%). with such findings were abstracted. These factors On bivariable analysis, sex, history associated included age and sex, history associated with the cur- with current UGIH episode, history of previous UGIH rent bleeding episode, documented history of comorbid episodes and concomitant drug use, with the excep- diseases and medications used, results of pertinent tion of aspirin, were not associated with EGD findings. physical examination, results of nasogastric (NG) tube Younger age was, however, associated with non- aspirates, basic laboratory investigations, and units of significant findings. Almost all comorbid diseases were blood components infused. Details of these factors significantly associated with significant EGD findings. and their measures are presented in Table 1. A variable defined by the absence of any comorbid The primary outcome of the present study diseases was most significantly associated with non- was the EGD findings. These findings were abstracted significant EGD findings. from endoscopic report forms available both electroni- Interestingly, blood pressure at presentation cally and in the medical charts. “Non-significant” EGD was not associated with EGD findings although there findings were defined as either “normal” EGD findings, was a tendency for patients with non-significant EGD or findings of “mild gastritis”, “mild duodenitis”, “gas- findings to have higher blood pressure. Most of the tritis” along with a hospital stay no longer than 48 hrs. patients in the present study were hemodynamically Other EGD findings were considered “significant”. stable on presentation (66% and 60% of patients had “Bivariable” association between each pre- a systolic and diastolic blood pressure greater than dictive factor and the EGD finding of non-significant 100 and 60 mmHg, respectively). Physical findings of or significant lesions was tested using the t-test, chronic liver disease, anemia and melena were asso- Wilcoxon ranksum test, or chi-square test (including ciated with significant EGD findings, as was a bloody Fisher’s exact test) as appropriate(13). Factors found aspirate from the NG tube. to be significantly associated with EGD findings on Blood counts were not associated with EGD bivariable analysis were entered in a multiple logistic findings, with the exception of platelet counts. Bio- regression model. Factors remaining statistically sig- chemical renal function tests were not associated EGD nificant in the model were retained in the final model. findings, although abnormal liver function tests were The discriminatory ability of the final multiple logistic associated with significant EGD findings. Finally, the regression model was measured using the Area Under number of units of packed red cells (PRC) infused were the receiver operating characteristic Curve (AUC)(14). significantly associated with EGD findings. Cross-validity of the model was assessed using the On multivariable analysis, the only remaining jackknife method(13). Statistical significance was defined significant predictors of non-significant EGD findings as a test p-value of 0.05 or less. were the absence of comorbid diseases or conditions, A simple clinical prediction rule was created higher platelet counts and less PRC infusions (Table 3). based on the multiple logistic regression model, It is interesting to note that physical findings, NG tube emphasizing high specificity. This was because in aspirates, and other routine laboratory tests were no order not to perform an EGD, the clinician must be able longer significant in the multiple logistic regression to predict with near certainty that the EGD findings will model. The AUC of the model was 0.83, and the jack- be non-significant. Hence the prediction rule must be knife AUC was 0.81. highly specific. A simple clinical prediction rule was created, by which a clinician might exclude a UGIH patient from Results undergoing urgent EGD or not to undergo EGD at all. Data were available for all 187 patients iden- Based on the multiple logistic regression model, the tified. There were 118 men (63%) and 69 women (37%) simplest rule with the highest specificity was “the in the cohort. The mean age was 53.5 years (standard absence of comorbid diseases, with a platelet count 1208 J Med Assoc Thai Vol. 88 No.9 2005 Table 1. Predictive factors for “non-significant” EGD findings Predictive factors Total (n = 187) Significant EGD Non-significant EGD p-values findings (n = 132) findings (n = 55) Age (years): mean (sd) 53.5 (17.9) 57.3 (16.8) 44.2 (17.1) <0.001 a Sex (male): number (%) 118/187 (63) 86/132 (65) 32/55 (58) 0.368 b History Coffee ground emesis: number (%) 59/187 (32) 41/132 (31) 18/55 (33) 0.823 b Hematemesis: number (%) 53/187 (28) 37/132 (28) 16/55 (29) 0.883 b Melena: number (%) 129/187 (69) 95/132 (72) 34/55 (62) 0.171 b Syncope: number (%) 93/187 (50) 67/132 (51) 26/55 (47) 0.664 b Peptic ulcer disease: number (%) 66/187 (35) 45/132 (34) 21/55 (38) 0.594 b First bleeding episode (yes): number (%) 121/187 (65) 81/132 (62) 40/55 (73) 0.138 b Medications and substances NSAIDS use (yes): number (%) 42/187 (22) 27/132 (20) 16/55 (29) 0.161 b ASA use (yes): number (%) 31/187 (17) 27/132 (20) 4/55 (7) 0.027 b