Advertisement

Digestive Diseases and Sciences

, Volume 61, Issue 9, pp 2732–2740 | Cite as

Origin, Clinical Characteristics and 30-Day Outcomes of Severe Hematochezia in Cirrhotics and Non-cirrhotics

  • Marine CamusEmail author
  • Vandana Khungar
  • Dennis M. Jensen
  • Gordon V. Ohning
  • Thomas O. Kovacs
  • Rome Jutabha
  • Kevin A. Ghassemi
  • Gustavo A. Machicado
  • Gareth S. Dulai
Original Article

Abstract

Background

The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia.

Methods

In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths.

Results

Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01–5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively.

Conclusions

Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.

Keywords

Cirrhosis Hematochezia Upper gastrointestinal bleeding Lower gastrointestinal bleeding 

Notes

Acknowledgments

The authors thank Jeff Gornbein DPH and Daniela Markovic, Ph.D. for their contributions to the statistical analyses, Mary Ellen Jensen, MLS and Nan Sun, M.S., for the management of the data, and Martha Carrico, RN as a research coordinator. This study was funded, in part, by a NIH41301 CURE Digestive Diseases Research Center Grant—Human Studies CORE, and a Veterans Affairs Clinical Merit Review Grant (Dennis M. Jensen, M.D., Principal Investigator). Marine Camus, M.D., received a grant from the Philippe Foundation in support of a research exchange program between France and the United States of America.

Compliance with ethical standards

Conflict of interest

The authors declare they have no competing interests.

References

  1. 1.
    Davila RE, Rajan E, Adler DG, et al. ASGE guideline: the role of endoscopy in the patient with lower-GI bleeding. Gastrointest Endosc. 2005;62:656–660.CrossRefPubMedGoogle Scholar
  2. 2.
    Zuccaro G Jr. Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol. 1998;93:1202–1208.CrossRefPubMedGoogle Scholar
  3. 3.
    Savides TJ, Jensen DM. GI bleeding. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management. 10th ed. Philadelphia: Saunders Elsevier Saunders; 2016:297–335.Google Scholar
  4. 4.
    Jensen DM. Management of patients with severe hematochezia—with all current evidence available. Am J Gastroenterol. 2005;100:2403–2406.CrossRefPubMedGoogle Scholar
  5. 5.
    González-González JA, García-Compean D, Vázquez-Elizondo G, Garza-Galindo A, Jáquez-Quintana JO, Maldonado-Garza H. Nonvariceal upper gastrointestinal bleeding in patients with liver cirrhosis. Clinical features, outcomes and predictors of in-hospital mortality. A prospective study. Ann Hepatol. 2011;10:287–295.PubMedGoogle Scholar
  6. 6.
    Lecleire S, Di Fiore F, Merle V, et al. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol. 2005;39:321–327.CrossRefPubMedGoogle Scholar
  7. 7.
    D’Amico G, De Franchis R. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology. 2003;38:599–612.CrossRefPubMedGoogle Scholar
  8. 8.
    Jensen DM, Machicado GA, Jutabha R, Kovacs TO. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000;342:78–82.CrossRefPubMedGoogle Scholar
  9. 9.
    Jensen DM, Machicado GA. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology. 1988;95:1569–1574.PubMedGoogle Scholar
  10. 10.
    Laine L, Shah A. Randomized trial of urgent vs. elective colonoscopy in patients hospitalized with lower GI bleeding. Am J Gastroenterol. 2010;105:2636–2641.CrossRefPubMedGoogle Scholar
  11. 11.
    Zuckerman GR, Prakash C. Acute lower intestinal bleeding. Part II: etiology, therapy, and outcomes. Gastrointest Endosc. 1999;49:228–238.CrossRefPubMedGoogle Scholar
  12. 12.
    Green BT, Rockey DC, Portwood G, et al. Urgent colonoscopy for evaluation and management of acute lower gastrointestinal hemorrhage: a randomized controlled trial. Am J Gastroenterol. 2005;100:2395–2402.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Marine Camus
    • 1
    • 2
    • 3
    Email author
  • Vandana Khungar
    • 4
  • Dennis M. Jensen
    • 1
    • 2
    • 5
  • Gordon V. Ohning
    • 1
    • 2
    • 5
  • Thomas O. Kovacs
    • 1
    • 2
    • 5
  • Rome Jutabha
    • 1
    • 2
  • Kevin A. Ghassemi
    • 1
    • 2
  • Gustavo A. Machicado
    • 1
    • 2
    • 5
  • Gareth S. Dulai
    • 1
    • 2
    • 5
  1. 1.Division of Digestive Diseases, David Geffen School of Medicine at UCLARonald Reagan UCLA Medical CenterLos AngelesUSA
  2. 2.CURE Hemostasis Research GroupCURE Digestive Diseases Research CenterLos AngelesUSA
  3. 3.Department of Gastroenterology, Cochin Hospital, APHPUniversity Paris 5ParisFrance
  4. 4.Department of Gastroenterology and HepatologyUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.Gastroenterology Section at VA GLAHCLos AngelesUSA

Personalised recommendations