A stitch in time: predicting long-term survival after acute gastrointestinal hemorrhage.

Since the advent of endoscopic imaging technology, a large literature has accrued regarding its impact on the diagnosis and treatment of acute gastrointestinal hemorrhage (AGIH). Attempts to distill this vast body of information into a format allowing simple and accurate categorization of re-bleeding risk and short- and long-term mortality has been difficult. In fact, though much has been written on short- and long-term rebleeding risk and mortality in AGIH, little information is available to guide the clinician seeking an understanding of long-term mortality associated with these events. (1,2)

In this issue of the Journal, Gopalswamy et al (3) present an interesting data set on the seven-year mortality of a cohort of patients admitted to intensive care units for an episode of AGIH. Their attempt to associate clinical and endoscopic measures of disease acuity with long-term mortality highlights the difficulties involved in such prognostication. Their data further support a conclusion that the burden of comorbid disease in which bleeding occurs, and not the clinical features of the hemorrhage itself, has the highest correlation with long-term survival.

The authors retrospectively recorded measurement of illness acuity through calculation of APACHE III and their own "Bleeding" score, and calculated the underlying burden of chronic illness through the previously validated Charlson Comorbidity index. (4) Sixty-six patients, mean age 58.6 [+ or -] 16 years, who were admitted directly or transferred to an intensive care unit for AGIH (upper, lower, or unknown site) comprised the cohort, and the authors' tabulation of cumulative mortality is quite striking. Over half of this relatively young cohort (53%) had died within the follow-up period. Although the authors used only county death certificate review to ascertain mortality and cause of death (as opposed to chart review or telephone follow-up), and did not specify criteria used to attribute death "directly or indirectly" to AGIH, (2,5) they nonetheless concluded that only a minority of patients died as a result of causes attributable to their AGIH. This finding is in agreement with other published data. (2) Nonetheless, the authors' data suggests that AGIH portends a rapid rise in overall mortality, their 53% mortality rate being much higher than the 21.5% mortality at approximately 3 years reported by Longstreth. (2)

While perhaps not intuitively obvious, it is not surprising that multivariable measures of disease acuity, shown elsewhere to correlate well with short-term AGIH-associated mortality, (1,5,6) do not fare as well in predicting long-term survival. Numerous confounders are introduced into these scoring systems related to the differing demographics, pathophysiology, and natural history of the diseases associated with the broad categories of upper and lower gastrointestinal bleeding. (2,7) For decades it has been pointed out that exsanguination per se is rarely the cause of death in AGIH, and though it is an oft-repeated dictum that overall mortality in AGIH has changed little in the last 50 years, (1) it is likely this is due to a shift toward increasing age-related mortality associated with an increasing burden of comorbid illness in the elderly. (2,6,7) The current paper, demonstrating lower than historical short-term mortality and correlating increased Charlson score to long-term mortality, further supports such an analysis.

Thus, while medical advances have improved our ability to successfully intervene in AGIH, a troubling dichotomy exists between studies showing relatively low and perhaps decreasing short-term mortality in AGIH, and our rudimentary understanding of specific factors influencing the substantial longer-term mortality in AGIH survivors. The results of the work by Gopalswamy and his colleagues further the conclusion that these factors are best explained by an increasing burden of concurrent illness, along with increasing age, in this cohort.

Clinicians await, then, the development and validation of a scoring system that can combine increasingly trustworthy markers of acute mortality with appropriate weighting of comorbidities, allowing reliable prognostication of long-term survival in individual patients presenting with AGIH. Armed with previously published data and the contribution of the current study, physicians can approach this cohort with a clearer understanding of their long-term survival prospects, but when counseling patients and their families, cannot yet dispense with the art of medicine in favor of the science.

Once you eliminate the impossible, whatever remains, no matter how
improbable, must be the truth.
--Sherlock Holmes

Accepted December 12, 2003.

Please see "Long-term Mortality of Patients Admitted to Intensive Care Unit for Gastrointestinal Bleeding" on page 955 of this issue.

References

1. Hussain H, Lapin S, Cappell MS. Clinical scoring systems for determining the prognosis of gastrointestinal bleeding. Gastro Clin North Am 2000;29:445-464.

2. Longsreth GF. Epidemiology of hospitalization for acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastro 1997;92:419-424.

3. Gopalswamy N, Malhotra V, Reddy N, et al. Long-term mortality of patients admitted to intensive care unit for gastrointestinal bleeding. South Med J 2004;97:955-958.

4. Charlson M, Szatrowski TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin Epid 1994;47:1245-1251.

5. Kollef M, O'Brien JD, Zuckerman GR, et al. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med 1997;25:1125-1132.

6. Rockall TA, Logan RFA, Devlin HB, et al. Incidence of and mortality from acute upper gastrointestinal hemorrhage in the United Kingdom. BMJ 1995;311:222-226.

7. Elta GH. Approach to the patient with gross gastrointestinal hemorrhage, in Yamada T, et al (eds): Textbook of Gastroenterology. Philadelphia, Lippincott Williams & Wilkins, 2003, ed 4, pp 698-723.

Ronald A. Leo, MD

From the Baton Rouge General Health System, and Gastroenterology Associates, LLC, Baton Rouge, LA.

Reprint requests to Ronald A. Leo, MD, Section Chief-Gastroenterology, Baton Rouge General Health System, 8150 Jefferson Highway, Baton Rouge, LA 70809.