HYPOTENSION AND ENDOSCOPIC STIGMATA OF RECENT HEMORRHAGE IN BLEEDING PEPTIC-ULCER - RISK MODELS FOR REBLEEDING AND MORTALITY

Clinical and endoscopic data were collected prospectively in 1050 patients with bleeding peptic ulcer admitted between September 1985 and July 1989 to the care of one surgical team. Seventy-nine patients underwent therapeutic endoscopy soon after admission and in 129 patients either immediate or early elective surgery was performed. Eight hundred and forty-two patients, in whom therapeutic endoscopy was not performed at any stage, underwent initial conservative management and data from this latter group are now presented. Shock on admission was defined as systolic blood pressure (BP) less-than-or-equal-to 100 mmHg on presentation. There were 10 deaths of 147 shocked patients (6.8%) compared with only 25 deaths of 695 patients (3.6%) not in shock (P < 0.08). Bleeding recurred in 30 patients (20.4%) shocked on presentation but in only 96 (13.8%) with a BP > 100 mmHg (P < 0.05). Twenty-one of 358 patients (5.9%) with endoscopic stigmata of recent haemorrhage (ESRH) died, but only 14 of 484 patients (2.9%) without such stigmata (P < 0.05) died. In shocked patients rebleeding was evident in 21 of 73 (28.8%) cases with ESRH but in only 9 of 74 (12.2%) patients in whom ESRH were absent (P < 0.02). In the absence of fresh blood at endoscopy rebleeding occurred in 22 of 124 (17.8%) shocked patients and only 74 of 629 (11.8%) of those not shocked on presentation (P < 0.07). When ulcer size was documented rebleeding rates for ulcers less-than-or-equal-to 1 cm, less-than-or-equal-to 2 cm and > 2 cm in size were 54 of 485 (11.1%), 30 of 142 (21.2%) and 12 of 44 (27.3%) respectively. In shocked patients rebleeding occurred in 7 of 73 (9.6%) patients with an ulcer less-than-or-equal-to 1 cm in size but in 17 of 44 (38.6%) patients in whom ulcer size was > 1 cm (P < 0.001). When admission BP was > 100 mmHg corresponding rebleeding rates for ulcers less-than-or-equal-to 1 cm and > 1 cm size were 47 of 412 (11.4%) and 25 of 142 (17.6%) (P < 0.06). Shock, large ulcer size and ESRH were each related to rebleeding, the highest rebleeding rates being seen with a combination of shock and ulcer size > 1 cm or ESRH.