Diagnosis and treatment of patients with recurrent gastroduodenal hemorrhage - Shaprynskyi V.O. 2009

Predicting the recurrence of bleeding of ulcer etiology

For a surgeon, the possibility of recurrent bleeding in a patient remains a constant concern. Even after achieving apparently stable endoscopic hemostasis and initiating conservative therapy, patients with PEPTIC ULCER DISEASE frequently experience rebleeding. Naturally, clinicians are faced with the question of whether a particular patient will suffer a recurrence of bleeding, and how to predict it. Therefore, assessing the risk of potential rebleeding, particularly its early and proactive Prevention, is of paramount importance in the clinical practice of every surgeon.

An analysis of domestic and foreign literature reveals various clinical Methods FOR STUDYING risk factors and statistical techniques for their analysis. Most studies describe associations between risk factors that are typically statistically insignificant, thereby requiring validation through large-scale observational studies to ensure quantitative and qualitative representativeness.

Upon admission to the hospital, it is advisable to assess the risk of recurrent bleeding in all patients with gastrointestinal Hemorrhage to determine further management strategies. Consequently, several prognostic scoring systems have been proposed.

To risk-stratify patients into high- and low-risk groups directly in the emergency department, the Blatchford score (2000) was developed. Based solely on clinical and laboratory findings, it does not require prior endoscopic examination to assess the risk of bleeding, making it highly practical for use in hospitals lacking an experienced endoscopist or an available emergency endoscopy service (Table 6.1.).

Class="center">Table 6.1. The Blatchford score.

The Rockall score (Table 6.2) has been widely adopted abroad to assess the risk of recurrent bleeding and potential mortality.

Table 6.2. The Rockall score.

It was developed based on a study of patients treated for gastrointestinal bleeding in the United Kingdom. Through statistical analysis, significant risk factors for recurrent bleeding and mortality were identified. The most prominent among these were age, the presence of shock on admission, the severity of comorbidities, and specific endoscopic findings. However, as other researchers point out, this scoring system cannot be utilized prior to endoscopy, which is its major limitation. A total score greater than 7 indicates a high risk of recurrent bleeding.

The diagnostic sensitivity and Specificity of this score for predicting recurrent bleeding proved to be low; however, it demonstrated the highest accuracy among the evaluated systems for predicting mortality.

A team of clinicians at Addenbrooke's Hospital (Cambridge, UK) developed their own scoring system to assess the risk of recurrent bleeding, mortality, and The Need for urgent invasive intervention. This score was established based on a prospective study of patients to identify prognostic factors. The system stratifies patients into three risk categories: high, moderate, and low. A patient is assigned to one of these risk groups if they meet at least one of the specified criteria (Table 6.3.).

Table 6.3 Scale for predicting recurrent bleeding, mortality, and the need for urgent invasive Treatment (Addenbrooke's Hospital, Cambridge, UK)

V.K. Gostishchev (2003) formulated METABOLISM/2.html">THE CONCEPT OF the risk level of recurrent bleeding, which is based on clinical and endoscopic criteria and determines further treatment strategy. An identified grade III recurrence risk indicates the inevitable development of bleeding in the first hours after hemostasis and serves as a basis for emergency Surgical treatment. Grade II risk indicates the possibility of recurrent bleeding within 24-48 hours from the moment of hemostasis.

I.Ya. Dziubanovskyi et al. (2006) studied the factors of early recurrent bleeding based on endoscopic and immunomorphological monitoring, investigating the severity of duodenal mucosal damage. The authors evaluated the prognosis of ulcer disease, taking into account the onset time of recurrent bleeding: early recurrence within 6-12 hours, delayed recurrence within 12-24 hours, and late recurrence more than 24 hours after the initial bleeding episode.

In recent years, several prognostic scales have been developed by Ukrainian researchers. Thus, P.D. Fomin et al. propose determining the risk of recurrent bleeding using the following formula:

Risk of RUB = 3 x X1 + 2 x X2 + X3 + X4, where X1-X4 are variables whose values are assigned based on clinical and endoscopic data obtained during the initial examination (Table 6.4). The state of hemostasis was determined According to the Forrest Classification, and the severity of bleeding according to the classification of V.D. Bratus.

Table 6.4. Characteristics of discriminant variables.

When calculated using the specified equation, the total score for patients with a low risk of RUB recurrence was <10, for moderate risk - from 10 to 16, and for high risk - more than 16.

V.O. Shaprynskyi and I.V. Pavlyk (2007) proposed an easy-to-calculate and user-friendly scale for predicting the recurrence of gastrointestinal bleeding of ulcer Etiology (Table 6.5).

Table 6.5. Scale for predicting the recurrence of gastrointestinal bleeding in patients with gastric and duodenal ulcers.

The presence of any single factor listed above, as well as their combination, allows for the Assessment of the risk level of recurrent gastrointestinal bleeding in patients with peptic ulcer disease. The Use of this scale does not require complex mathematical calculations, is easy to use, and can be applied by a wide range of surgeons. The diagnostic sensitivity and specificity of this scale are very high, allowing for an accurate prediction in almost 91% of cases.

In light of the above and based on our own research findings, we recommend the Shaprynskyi V. O. and Pavlyk I. V. scale for widespread use in predicting recurrent bleeding, and the Rockall et al. score for predicting potential mortality, as these systems demonstrated the best performance in a comparative Analysis of the scales.