Varis Dışı Üst Gastrointestinal Sistem Kanaması ile Yatan Hastalarda 2 Skorlama Sisteminin Retrospektif Analizi
Abstract
Üst gastrointestinal kanama (ÜGK), Treitz ligamentine kadar olan proksimal duodenum ile üst özofagus sfinkteri arasında lümen içine olan kanamayı ifade eder. Şiddeti; subklinik gizli bir kanamadan abondan kanamaya, kronik anemiden akut hipovolemik şoka kadar değişebilen geniş bir spektrumu kapsar. Sıklığı yılda 103/100.000'dir. ABD'de yılda 300.000 hastaneye yatış nedenidir ve tüm hastaneye yatışların yaklaşık %1'ini teşkil eder. Farmakolojik ve girişimsel tedavi yöntemlerindeki tüm gelişmelere rağmen mortalite %2-10 arasındadır. Mortalite oranı yaşla yakından ilişkilidir. Öyle ki, 60 yaşın altında mortalite %8 iken, 60 yaşın üstünde bu oran %13'e çıkmaktadır. Mortaliteyle ilişkili diğer faktörler nüks kanama, yandaş hastalık varlığı (kardiyak hastalık, kronik karaciğer hastalığı, solunum sistemi veya merkezi sinir sistemi hastalığı, renal yetersizlik), peptik ülser veya geçirilmiş cerrahi girişim öyküsü, hematemezle prezentasyon, hipotansiyon gelişimi ve özofagus varis kanamasıdır. ÜGK'ların yaklaşık %50'sinin nedeni peptik ülserdir. Hastaların %30-50'sinde non-steroid antiinflamatuvar ilaç (NSAİİ) kullanımı mevcuttur. Özellikle yaşlı hastalarda NSAİİ'lara bağlı ÜGK riski yüksektir. Çoğunlukla kanamalar spontan olarak durur. Kanamanın devam ettiği olgularda endoskopik tedaviyle hemostaz sağlanabilir. Hemodinamik stabilitenin ve kanama kontrolünün sağlanamadığı veya nüks kanaması olan riskli olgular cerrahiye adaydır. Son yıllarda hastaları risk gruplarına göre sınıflandırmak için birçok skorlama geliştirilse de en çok kullanılan iki puanlama sistemi; pre-endoskopik ve endoskopik bileşenleri içeren ve mortaliteyi öngörmede kullanılan Rockall skoru (RS) sistemi ile sadece klinik ve laboratuvar bulguları ile müdahale gerekmeyen düşük riskli hastaları tahmin etmede kullanılan Glasgow-Blatchford skorlama (GBS) sistemidir. Bu çalışmada Üst Gis Kanamalı hastalarda endoskopi yapılma süresi, helikobakter pilori pozitifliği, forrest sınıflaması, cerrahi ihtiyacı gibi parametrelerle beraber Rockal ve Glasgow-Blachford skorlarının mortalite üzerine etkisi değerlendirilecektir. Böylece, helikobakter pilori pozitifliğinin mortalite üzerine etkisi ne kadardır? endoskopi yapılma süresinin mortalite üzerine etkisi ne kadardır? Rockal ve Glasgow-Blachford skorlarının mortalite üzerine etkisi ne kadardır? gibi sorulara yanıt bulmak amaçlanmıştır. Gereç ve Yöntem: Bu çalışma rutin tetkik ve tedavi işlemleri sırasında elde edilmiş materyallerle yapılacak çalışma olarak planlandı. Çalışmaya 45 kadın, 155 erkek hasta olmak üzere toplam 200 gönüllü alındı. Çalışmada 18-99 yaş aralığındaki üst gis kanaması olan ve helikobakteri pilori durumuna bakılan, forrest düzeyine bakılan ve Rockal ve GlasgowBlachford skorları incelendi. Araştırma Ocak 2013'ten sonra Van YYÜ Dursun Odabaş Tıp Merkezi, İç Hastalıkları servisi, Gastroenteroloji servisi İç Hastalıkları Yoğun Bakım servisi, Genel Cerrahi servisi, Genel Cerrahi Yoğun Bakım servisi ve Anestezi ve Reaminasyon Yoğun Bakım servisinde üst gis kanamalı hastalarda Rockal ve Glasgow-Blachford skorları istatistiksel olarak değerlendirilmesi planlandı. Çalışmanın örneklem genişliğini hesaplamada, her değişken için Power (Testin Gücü) en az %80 ve Tip-1 hata %5 alınarak Standart Etki Büyüklüğü 0,61 olarak belirlenmiştir. Her bir gruba n=42 vaka alınması yeterlidir. Çalışmada her bir grup için 3 er vaka rezerv alındı. Bütün verilere ulaşılmaya çalışıldı. Elde edilen tüm bilgiler bilgisayar ortamına taşındı. Verilerin analizinde tanımlayıcı istatistikler kullanıldı. Verilerin tanımlayıcı istatistiklerinde ortalama, standart sapma, medyan en düşük, en yüksek, frekans ve oran değerleri kullanılmıştır. Değişkenlerin dağılımı kolmogorov simirnov test ile ölçüldü. Nicel bağımsız verilerin analizinde bağımsız örneklem t test, mann-whitney u test kullanıldı. Bağımlı nicel verilerin analizinde eşleştirilmiş örneklem t test, wilcoxon testi kullanıldı. Nitel bağımsız verilerin analizinde ki-kare test, ki-kare test koşulları sağlanmadığında fischer test kullanıldı. Analizlerde SPSS 28.0 programı kullanılmıştır. Anlamlılık düzeyi için p <0.05 değeri anlamlı kabul edildi. II Bulgular: Çalışmaya toplam 200 hasta (155 erkek, 45 kadın) dahil edilmiş olup, mortalite oranı %38.5 olarak saptanmıştır. Yapılan normal dağılım analizleri sonucunda yalnızca yaş değişkeninin parametrik dağılım gösterdiği, diğer tüm skorlar ve inflamatuvar belirteçlerin nonparametrik dağıldığı belirlenmiştir. Mann-Whitney U testine göre mortal olan hastaların Glasgow-Blatchford skoru, Rockall skoru, CRP/Alb oranı, NLR, PLR ve SII değerlerinin sağ kalan hastalara göre anlamlı derecede yüksek olduğu gözlenmiştir (p<0.05). Cinsiyet ile sağkalım arasında yapılan ki-kare testinde, erkeklerin sağ kalım oranının kadınlara göre daha yüksek olduğu, bu farkın istatistiksel olarak anlamlı olduğu bulunmuştur (p=0.010). ROC analizi sonuçlarına göre Glasgow-Blatchford Skoru (AUC: 0.801) en yüksek ayırt ediciliğe sahip parametre olarak belirlenmiş, onu sırasıyla NLR (0.761), PLR (0.732), Rockall skoru (0.742) ve CRP/Alb oranı (0.726) izlemiştir. Ayrıca Forrest sınıflamasına göre Ia–Ib grubundaki hastalarda mortalite oranının %27,6 ile en yüksek düzeyde olduğu, Helicobacter pylori negatif hastalarda ise mortalite oranının %21,5 olduğu saptanmıştır. Endoskopi süresi 12 saatten fazla olan hastalarda mortalite oranı belirgin şekilde artmıştır. Sonuç: Bu retrospektif analizde, üst gastrointestinal sistem kanaması olan hastalarda kullanılan Rockall ve Glasgow-Blatchford skorlama sistemlerinin mortalite öngörüsünde etkin araçlar olduğu belirlenmiştir. Özellikle Glasgow-Blatchford Skoru'nun yüksek AUC değeri ile klinik kullanıma uygunluğu desteklenmiştir. İlaveten, inflamatuvar belirteçlerin (CRP/Alb, NLR, SII, PLR) de mortalite ve yeniden kanama açısından anlamlı öngörü gücüne sahip olduğu gösterilmiştir. Kadın hastalarda mortalite oranlarının daha yüksek olması, cinsiyete dayalı farklı risk profillerinin var olabileceğini düşündürmektedir. Forrest sınıflamasının ileri evresinde yer alan hastalarda ölüm oranlarının artması, endoskopik sınıflamanın klinik gidişatı öngörmede önemli olduğunu göstermektedir. Helicobacter pylori pozitif hastalarda mortalite oranının daha düşük olması, bu enfeksiyonun sistemik etkilerinin beklenenden farklı olabileceğini düşündürmektedir. Bu doğrultuda, ÜGK hastalarının erken dönemde risk skorlamaları ile değerlendirilmesi, inflamatuvar parametrelerin izlenmesi ve endoskopik sınıflandırmanın dikkate alınması; tedavi sürecinin etkinliğini artırarak mortalite ve komplikasyonları azaltabilir.
Upper gastrointestinal bleeding (UGIB) refers to bleeding into the lumen between the proximal duodenum up to the ligament of Treitz and the upper esophageal sphincter. Its severity covers a wide spectrum ranging from subclinical occult bleeding to subcutaneous bleeding, from chronic anemia to acute hypovolemic shock (1). The incidence is 103/100.000 per year. It is the cause of 300,000 hospitalizations per year in the USA and constitutes approximately 1% of all hospitalizations. Despite all the advances in pharmacologic and interventional treatment methods, mortality is between 2-10% (2). Mortality rate is closely related to age. In fact, while mortality is 8% below the age of 60 years, this rate increases to 13% above the age of 60 years (2). Other factors associated with mortality include recurrent bleeding, presence of comorbidities (cardiac disease, chronic liver disease, respiratory or central nervous system disease, renal failure), history of peptic ulcer or previous surgical intervention, presentation with hematemesis, development of hypotension and esophageal variceal bleeding (3). Peptic ulcer is the cause of approximately 50% of UICs. Non-steroidal anti-inflammatory drug (NSAID) use is present in 30-50% of patients. Especially in elderly patients, the risk of NSAID-related UICs is high (4). Mostly bleeding stops spontaneously. In cases where bleeding continues, hemostasis can be achieved with endoscopic treatment. Risky cases in whom hemodynamic stability and bleeding control cannot be achieved or who have recurrent bleeding are candidates for surgery. Although many scoring systems have been developed in recent years to classify patients according to risk groups, the two most commonly used scoring systems are the Rockall score (RS) system, which includes pre-endoscopic and endoscopic components and is used to predict mortality, and the Glasgow-Blatchford scoring (GBS) system, which is used to predict low-risk patients who do not require intervention based only on clinical and laboratory findings. (5, 6) In this study, the effect of Rockal and GlasgowBlachford scores on mortality in patients with Upper GI bleeding together with parameters such as duration of endoscopy, helicobacter pylori positivity, forrest classification and need for surgery will be evaluated. Thus, what is the effect of helicobacter pylori positivity on mortality, what is the effect of duration of endoscopy on mortality? What is the effect of Rockal and Glasgow-Blachford scores on mortality? Materials and Methods: This study was planned as a study with materials obtained during routine examination and treatment procedures. A total of 200 volunteers, 45 female and 155 male patients, were included in the study. In the study, patients between the ages of 18-99 with upper gastrointestinal bleeding who were examined for helicobacterium pylori status, forrest level, Rockal and Glasgow-Blachford scores were analyzed. The study was planned to statistically evaluate Rockal and Glasgow-Blachford scores in patients with upper gastric bleeding in Van YYÜ Dursun Odabaş Medical Center, Internal Medicine service, Gastroenterology service, Internal Medicine Intensive Care service, General Surgery service, General Surgery Intensive Care service and Anesthesia and Reamination Intensive Care service after January 2013. In calculating the sample size of the study, the Standard Effect Size was determined as 0.61 by taking the Power (Power of the Test) at least 80% and Type-1 error 5% for each variable. It is sufficient to include n=42 cases in each group. In the study, 3 cases were reserves for each group. All data were tried to be accessed. All the information obtained was computerized. Descriptive statistics were used to analyze the data. Mean, standard deviation, median, minimum, maximum, frequencies and ratios were used in the descriptive statistics of the data. The distribution of variables was measured using the Kolmogorov-Simirnov test. Independent samples t-test, Mann-Whitney u-test were used to analyse independent quantitative data. Paired sample t-test and Wilcoxon test were used to analyse dependent quantitative data. The chi-square test was used in the analysis of independent IV qualitative data, and the fischer test was used when the conditions for the chi-square test were not met. SPSS 28.0 was used for analyses. A value of p < 0.05 was considered significant. Results: A total of 200 patients (155 males and 45 females) were included in the study, and the mortality rate was found to be 38.5%. Normality tests revealed that only the age variable showed a parametric distribution, while all scoring systems and inflammatory markers followed non-parametric distributions. According to the Mann-Whitney U test, the Glasgow-Blatchford score, Rockall score, CRP/Alb ratio, NLR, PLR, and SII values were significantly higher in deceased patients compared to survivors (p<0.05). The Chi-square test for gender and survival showed that male patients had a significantly higher survival rate than females (p=0.010). In ROC analysis, the Glasgow-Blatchford Score (AUC: 0.801) demonstrated the highest discriminatory power, followed by NLR (0.761), PLR (0.732), Rockall Score (0.742), and CRP/Alb ratio (0.726). Furthermore, the Forrest classification showed that patients in the Ia–Ib group had the highest mortality rate at 27.6%, while Helicobacter pylori-negative patients had a mortality rate of 21.5%. Mortality was significantly higher in patients who underwent endoscopy after more than 12 hours. Conclusion: In this retrospective analysis, the Rockall and Glasgow-Blatchford scoring systems were found to be effective tools in predicting mortality among patients with upper gastrointestinal bleeding. The Glasgow-Blatchford Score, in particular, was supported for clinical use due to its high AUC value. Additionally, inflammatory markers such as CRP/Alb ratio, NLR, SII, and PLR demonstrated significant predictive power for both mortality and rebleeding. The higher mortality rate observed in female patients suggests that gender-based risk profiles may exist. The increased mortality in advanced stages of Forrest classification underscores the importance of endoscopic classification in predicting clinical outcomes. Interestingly, lower mortality rates among Helicobacter pylori-positive patients may indicate that the systemic effects of this infection differ from expected patterns. Therefore, early risk stratification using scoring systems, monitoring of inflammatory parameters, and the use of endoscopic classification may enhance treatment effectiveness and reduce mortality and complications in UGIB patients.
Upper gastrointestinal bleeding (UGIB) refers to bleeding into the lumen between the proximal duodenum up to the ligament of Treitz and the upper esophageal sphincter. Its severity covers a wide spectrum ranging from subclinical occult bleeding to subcutaneous bleeding, from chronic anemia to acute hypovolemic shock (1). The incidence is 103/100.000 per year. It is the cause of 300,000 hospitalizations per year in the USA and constitutes approximately 1% of all hospitalizations. Despite all the advances in pharmacologic and interventional treatment methods, mortality is between 2-10% (2). Mortality rate is closely related to age. In fact, while mortality is 8% below the age of 60 years, this rate increases to 13% above the age of 60 years (2). Other factors associated with mortality include recurrent bleeding, presence of comorbidities (cardiac disease, chronic liver disease, respiratory or central nervous system disease, renal failure), history of peptic ulcer or previous surgical intervention, presentation with hematemesis, development of hypotension and esophageal variceal bleeding (3). Peptic ulcer is the cause of approximately 50% of UICs. Non-steroidal anti-inflammatory drug (NSAID) use is present in 30-50% of patients. Especially in elderly patients, the risk of NSAID-related UICs is high (4). Mostly bleeding stops spontaneously. In cases where bleeding continues, hemostasis can be achieved with endoscopic treatment. Risky cases in whom hemodynamic stability and bleeding control cannot be achieved or who have recurrent bleeding are candidates for surgery. Although many scoring systems have been developed in recent years to classify patients according to risk groups, the two most commonly used scoring systems are the Rockall score (RS) system, which includes pre-endoscopic and endoscopic components and is used to predict mortality, and the Glasgow-Blatchford scoring (GBS) system, which is used to predict low-risk patients who do not require intervention based only on clinical and laboratory findings. (5, 6) In this study, the effect of Rockal and GlasgowBlachford scores on mortality in patients with Upper GI bleeding together with parameters such as duration of endoscopy, helicobacter pylori positivity, forrest classification and need for surgery will be evaluated. Thus, what is the effect of helicobacter pylori positivity on mortality, what is the effect of duration of endoscopy on mortality? What is the effect of Rockal and Glasgow-Blachford scores on mortality? Materials and Methods: This study was planned as a study with materials obtained during routine examination and treatment procedures. A total of 200 volunteers, 45 female and 155 male patients, were included in the study. In the study, patients between the ages of 18-99 with upper gastrointestinal bleeding who were examined for helicobacterium pylori status, forrest level, Rockal and Glasgow-Blachford scores were analyzed. The study was planned to statistically evaluate Rockal and Glasgow-Blachford scores in patients with upper gastric bleeding in Van YYÜ Dursun Odabaş Medical Center, Internal Medicine service, Gastroenterology service, Internal Medicine Intensive Care service, General Surgery service, General Surgery Intensive Care service and Anesthesia and Reamination Intensive Care service after January 2013. In calculating the sample size of the study, the Standard Effect Size was determined as 0.61 by taking the Power (Power of the Test) at least 80% and Type-1 error 5% for each variable. It is sufficient to include n=42 cases in each group. In the study, 3 cases were reserves for each group. All data were tried to be accessed. All the information obtained was computerized. Descriptive statistics were used to analyze the data. Mean, standard deviation, median, minimum, maximum, frequencies and ratios were used in the descriptive statistics of the data. The distribution of variables was measured using the Kolmogorov-Simirnov test. Independent samples t-test, Mann-Whitney u-test were used to analyse independent quantitative data. Paired sample t-test and Wilcoxon test were used to analyse dependent quantitative data. The chi-square test was used in the analysis of independent IV qualitative data, and the fischer test was used when the conditions for the chi-square test were not met. SPSS 28.0 was used for analyses. A value of p < 0.05 was considered significant. Results: A total of 200 patients (155 males and 45 females) were included in the study, and the mortality rate was found to be 38.5%. Normality tests revealed that only the age variable showed a parametric distribution, while all scoring systems and inflammatory markers followed non-parametric distributions. According to the Mann-Whitney U test, the Glasgow-Blatchford score, Rockall score, CRP/Alb ratio, NLR, PLR, and SII values were significantly higher in deceased patients compared to survivors (p<0.05). The Chi-square test for gender and survival showed that male patients had a significantly higher survival rate than females (p=0.010). In ROC analysis, the Glasgow-Blatchford Score (AUC: 0.801) demonstrated the highest discriminatory power, followed by NLR (0.761), PLR (0.732), Rockall Score (0.742), and CRP/Alb ratio (0.726). Furthermore, the Forrest classification showed that patients in the Ia–Ib group had the highest mortality rate at 27.6%, while Helicobacter pylori-negative patients had a mortality rate of 21.5%. Mortality was significantly higher in patients who underwent endoscopy after more than 12 hours. Conclusion: In this retrospective analysis, the Rockall and Glasgow-Blatchford scoring systems were found to be effective tools in predicting mortality among patients with upper gastrointestinal bleeding. The Glasgow-Blatchford Score, in particular, was supported for clinical use due to its high AUC value. Additionally, inflammatory markers such as CRP/Alb ratio, NLR, SII, and PLR demonstrated significant predictive power for both mortality and rebleeding. The higher mortality rate observed in female patients suggests that gender-based risk profiles may exist. The increased mortality in advanced stages of Forrest classification underscores the importance of endoscopic classification in predicting clinical outcomes. Interestingly, lower mortality rates among Helicobacter pylori-positive patients may indicate that the systemic effects of this infection differ from expected patterns. Therefore, early risk stratification using scoring systems, monitoring of inflammatory parameters, and the use of endoscopic classification may enhance treatment effectiveness and reduce mortality and complications in UGIB patients.
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İç Hastalıkları, Internal Diseases
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