A Clinical-Endoscopic Risk Score To Predict Outcome In Acute Lower Intestinal Bleeding (Lib)

Introduction: Few prognostic models based on clinical variables have been developed to predict outcome in LIB. It is conceivable that the inclusion of endoscopic variables in the prognostic models will improve their predictive value. Objective: To develop a risk score that associates clinical and endoscopic variables, to predict outcome in patients with LIB. Patients and Methods: Design: Prospective, cohort study. Patients: Patients admitted to our hospital with the diagnosis of LIB and evaluated by means of early colonoscopy (<24 hours) from April 2005 to April 2007. Variables: The outcome variable was severe bleeding defined as decrease in hematocrit of ≥20% within the first 24 hours, and/or recurrent bleeding (rectal bleeding together with decrease in hematocrit of ≥20% and/or additional blood transfusions, and/or readmission due to the same condition within 1 week of discharge), need of surgery or death. The variables evaluated were age, comorbid conditions, blood pressure, heart rate, hematocrit, antiaggregant and anticoagulant treatment, abdominal tenderness, rectum bleeding during the first 4 hours of medical evaluation, presence of red blood at early colonoscopy exam, and ulcerative mucosal lesions (ischemic colitis, neoplasm, ulcers). Univariate logistic regression was used to select variables to be included in multiple logistic regression analysis. Results: A total number 179 patients were included. Independent predictive factors for severe LIB were: rectum bleeding within the first 4 hours after admission, OR 3 (95% CI, 1.27-7.06; p = 0.01); presence of red blood at early colonoscopy exam, OR 4 (95% CI, 1.65-9.43; p = 0.002); and absence of ulcerative mucosal lesions OR 3 (95% CI, 1.13-8.06; p = 0.02). When patients were classified according to the number of present risk factors, we found that severe LIB occurred in 19/132 (14%) patients with 0 or1 risk factors; in 17/36 (46%) with 2 risk factors; and in 8/11 (72%) with 3 risk factors. The area under the ROC curve for the prediction of severe bleeding was 0.72. With regard specifically to the prediction of recurrent bleeding we found that recurrence occurred in 0/56 (0%) patients with no risk factors; 5/81 (6%) with 1 risk factor; 7/32 (22%) with 2 risk factors; and 5/10 (50%) with 3 risk factors. The area under the ROC curve for the prediction of recurrent bleeding was 0.83. Conclusion: Our clinical-endoscopic risk score can identify patients with severe LIB and those at high risk for recurrent bleeding. This risk score, once prospectively validated, could be used to guide the management of patients with LIB. Endoscopic variables have a high predictive value as occurs in upper gastrointestinal bleeding.