背景:急性胃肠道(GI)出血是急诊就诊和住院的主要原因之一。CT血管造影(CTA)在急性消化道出血的评估中发挥了越来越大的作用,广泛可用,相当敏感,并在阳性时提供精确的定位。我们试图确定预测CTA结果的患者和临床特征,以帮助指导急性胃肠道出血患者使用这种方式。
方法:在这项回顾性研究中,我们分析了2019年10月至2020年3月期间在杜克大学医疗保健系统中用于评估胃肠道出血的所有CTA.我们捕获了患者特征,包括年龄,性别,生命体征,血红蛋白,血小板,PT/INR,和抗凝状态。研究适应症按可疑出血来源进行分组:上消化道出血(呕血或咖啡粉呕吐)、小肠出血(黑便或“黑便”)、下消化道出血(便血或直肠鲜红血液(BRBPR))。卡方,Wilcoxon,t测试,和多变量逻辑回归用于描述和评估患者特征与研究结果之间的关系(表1).表1通过CT血管造影结果对患者特征的单变量分析通过GI出血的CT阳性患者特征否(N=274)是(N=43)总计(N=317)p值性别0.451女性138(50.4%)19(44.2%)157(49.5%)男性136(49.6%)24(55.8%)160(50.5%)年龄,中位数(Q1,Q3)65(51,75)70(62,80)66(52,76)<0.012心率,中位数(第一季度,第三季度)86(74,100)89(72,98)86(74,99)0.782MAP,平均(SD)87.32(15.52)81.72(16.53)86.560.033冲击指数,中位数(Q1,Q3)0.70(0.58,0.85)0.78(0.55,1.00)0.71(0.58,0.85)0.352血红蛋白0.332N27343316中位数(Q1,Q3)8.50(6.90,11.00)7.70(6.50,11.30)8.45(6.90,11.00)基线血红蛋白0.70(Q1,0.85)0.20N,0.40血红蛋白(9.40,0.001.60)1.60中位数(Q1,Q3)219.5(141,301)183(139,246)217(139,246)0.102INR0.272N26342305中位数(Q1,Q3)1.10(1.00,1.30)1.20(1.00,1.30)抗凝0.131否155(56.6%)19(44.2%)19(54.9%)2020年3月)43.1%0.58%无出血(448%54.943例患者(13.6%)的活动性出血CTA阳性。多变量logistic回归分析显示,在控制年龄后,平均动脉压(MAP)和指征,只有血红蛋白从基线下降与CTA阳性显著相关.血红蛋白从患者基线每下降1g/dL,CT阳性的几率增加1.17(OR1.1795%CI1.00-1.36,p=0.04)。年纪(OR1.0295%CI0.99-1.04,p=0.06)与便血/BRBPR(OR2.0995%CI0.94-4.64,p=0.07)接洽有统计学意义。
结论:在出现消化道出血的患者中,CTA可能是一种有用的分诊工具,对怀疑下消化道出血的老年患者最有用,血红蛋白从基线下降。其他临床因素包括MAP和抗凝剂的使用不能预测CTA阳性。
Acute gastrointestinal (GI) bleeding is one of the leading causes of emergency department visits and hospital admissions. CT angiography (CTA) has had an expanding role in the evaluation of acute GI bleeding because it is rapidly performed, widely available, reasonably sensitive and provides precise localization when positive. We attempted to identify patient and clinical characteristics that predict CTA results in order to help guide the utilization of this modality in patients with acute GI bleeding.
In this retrospective
study, we analyzed all CTAs performed for the evaluation of GI bleeding in the Duke University healthcare system between October 2019 and March 2020. We captured patient characteristics including age, sex, vital signs, hemoglobin, platelets, PT/INR, and anticoagulation status.
Study indications were grouped by suspected source of bleeding: upper GI bleeding (
hematemesis or coffee-ground emesis) vs small bowel bleeding (melena or \"dark stools\") vs lower GI bleeding (hematochezia or bright red blood per rectum (BRBPR)). Chi-square, Wilcoxon, t test, and multivariate logistic regression were used to describe and assess the relationship between patient characteristics and
study outcomes (Table 1). Table 1 Univariate analysis of patient characteristics by CT angiography outcome Patient Characteristics by Positive CT for GI Bleed No (N = 274) Yes (N = 43) Total (N = 317) p value Gender 0.451 Female 138 (50.4%) 19 (44.2%) 157 (49.5%) Male 136 (49.6%) 24 (55.8%) 160 (50.5%) Age, median (Q1,Q3) 65 (51,75) 70 (62,80) 66 (52, 76) < 0.012 Heart rate, median (Q1,Q3) 86 (74,100) 89 (72,98) 86 (74, 99) 0.782 MAP, mean (SD) 87.32 (15.52) 81.72 (16.53) 86.56 0.033 Shock index, median (Q1,Q3) 0.70 (0.58, 0.85) 0.78 (0.55, 1.00) 0.71 (0.58, 0.85) 0.352 Hemoglobin 0.332 N 273 43 316 Median (Q1, Q3) 8.50 (6.90, 11.00) 7.70 (6.50, 11.30) 8.45 (6.90, 11.00) Baseline hemoglobin 0.202 N 258 39 297 Median (Q1, Q3) 11.20 (9.40, 13.00) 12.00 (9.40, 14.00) 11.20 (9.40, 13.00) Hemoglobin drop from baseline 0.062 N 258 39 297 Median (Q1, Q3) 2.10 (0.60, 3.70) 2.70 (1.20, 4.80) 2.20 (0.70, 3.80) Platelets, median (Q1, Q3) 219.5 (141, 301) 183 (139, 246) 217 (139, 282) 0.102 INR 0.272 N 263 42 305 Median (Q1, Q3) 1.10 (1.00, 1.30) 1.20 (1.00, 1.30) 1.10 (1.00, 1.30) Anticoagulation 0.131 No 155 (56.6%) 19 (44.2%) 174 (54.9%) Yes 119 (43.4%) 24 (55.8%) 143 (45.1%) Upper GI bleeding 0.401 No 251 (91.6%) 41 (95.3%) 292 (92.1%) Yes 23 (8.4%) 2 (4.7%) 25 (7.9%) Small Bowel bleeding 0.761 No 216 (78.8%) 33 (76.7%) 249 (78.5%) Yes 58 (21.2%) 10 (23.3%) 68 (21.5%) Lower GI bleeding 0.091 No 134 (48.9%) 15 (34.9%) 149 (47.0%) Yes 140 (51.1%) 28 (65.1%) 168 (53.0%) 1Chi-Square 2Wilcoxon 3Equal Variance T-Test RESULTS: A total of 317 patients underwent CTA between October 2019 and March 2020. Forty-three patients (13.6%) had a CTA positive for active bleeding. Multivariable logistic regression showed that after controlling for age, mean arterial pressure (MAP) and indication, only a hemoglobin drop from baseline was significantly associated with a positive CTA. For each 1 g / dL drop in hemoglobin from the patient\'s baseline, the odds of a positive CT increased by 1.17 (OR 1.17 95% CI 1.00 - 1.36, p = 0.04). Age (OR 1.02 95% CI 0.99 - 1.04, p = 0.06) and hematochezia / BRBPR (OR 2.09 95% CI 0.94-4.64, p = 0.07) approached statistical significance.
In patients who present to the hospital with GI bleeding, CTA can be a helpful triage tool that is most helpful in older patients with suspected lower GI bleeding with a drop in hemoglobin from baseline. Other clinical factors including MAP and the use of anticoagulants were not predictive of a positive CTA.