# Diagnostic performance of the blood urea/creatinine ratio in the diagnosis of occult upper gastrointestinal hemorrhage in the ICU

Keyvan Meghdadi, Hervé Kpeglo, My Linh Tran Minh, Romain Barthelemy, Benjamin Chousterman, Charles de Roquetaillade

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## To cite this version:

Keyvan Meghdadi, Hervé Kpeglo, My Linh Tran Minh, Romain Barthelemy, Benjamin Chousterman, et al.. Diagnostic performance of the blood urea/creatinine ratio in the diagnosis of occult upper gastrointestinal hemorrhage in the ICU. Critical Care, 2025, 29 (1), pp.527. 10.1186/s13054-025-05750-8. inserm-05503540

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# Diagnostic performance of the blood urea/creatinine ratio in the diagnosis of occult upper gastrointestinal hemorrhage in the ICU

Keyvan Meghdadi¹, Hervé Kpeglo¹,<fnref n="2" />, My Linh Tran Minh<fnref n="3" />, Romain Barthelemy¹,<fnref n="2" />, Benjamin Chousterman¹,<fnref n="2" /> and Charles de Roquetaillade¹,<fnref n="2" />*

Dear Editor,

Upper gastrointestinal hemorrhage (UGIH) is a common condition in intensive care unit (ICU), associated with significant morbidity and mortality [1]. ICU patients are exposed to metabolic stress, which compromises mucosal defense mechanisms and predisposes to ulceration and UGIH. The incidence of occult UGIH in ICU patients is challenging to determine but has been reported to range from 5% to 30%, with many cases likely remaining undiagnosed [2]. The gold standard for diagnosing UGIH is esophagogastroduodenoscopy (EGD). However, EGD carries inherent risks and significant human and financial costs. It is therefore essential to identify patients in whom the suspicion of occult UGIH justifies performing EGD [3]. Blood urea, creatinine concentrations, and the urea-to-creatinine ratio (UCR) have been proposed biomarkers in emergency department settings to better target patients at risk of rebleeding. To our knowledge, the utility of this biomarker has never been studied in the ICU context [4]. Given its widespread availability in critically ill patients, UCR could serve as a simple, readily available, and cost-effective tool to guide the indication for EGD in this high-risk population. We thus aimed to analyze the performance of UCR in predicting a positive EGD in ICU patients with suspected occult UGIH.

Over a five-year period, we reviewed cases of critically ill adults admitted to a tertiary medical ICU who developed occult UGIH and subsequently underwent EGD. Occult UGIH was defined by a decrease in hemoglobin of ≥1 g/dL within 72 h prior to EGD. Patients with overt hemorrhage and stage 3 acute kidney injury were excluded. The index test was UCR measured on the day of EGD. A positive EGD was defined as the presence of hemorrhagic lesions (Forrest Ib or II) or the requirement for a hemostatic procedure.

Among 384 EGDs performed, 139 patients met inclusion criteria (Flow-Chart in Supplementary material). 38 patients (27%) had endoscopically confirmed UGIH. The population had a median age of 62 [IQR 49–72] years, with a predominance of men (59%), motives of admission were mostly acute brain injury (54.7%) or sepsis (23%). Most patients were under mechanical ventilation (87.1%) and 48.9% required vasopressors. The vast majority were receiving proton pump inhibitors (70.5%) and enteral feeding (73.3%) at the time bleeding was suspected (Supplementary Table 1).

The median UCR on the day of EGD was 37.7 [26.2–48.4] in patients with confirmed bleeding and 34.2 [24.2–44]) in those without (p = 0.284) (Fig. 1A). When evaluated as a diagnostic test, UCR yielded an area under the ROC curve of 0.58 [0.46–0.69] (Fig. 1B). A threshold

<footnote>*Correspondence:
Charles de Roquetaillade
charles.de-roquetaillade@aphp.fr
¹Department of Anesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France, Paris, France</footnote>

<footnote n="2">²Université de Paris, INSERM, U942 MASCOT, F-75006, Paris, France, Paris, France</footnote>

<footnote n="3">³Department of Gastroenterology, AP-HP, Hôpital Lariboisière, F-75010, Paris, France, Paris, France</footnote>
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<figure><img src="image_5.png" /><figcaption>**Fig. 1** (A) Boxplot of the urea creatinine ratio (UCR) at day 0. We found a median in the group no upper gastrointestinal hemorrhage (No UGIH) of 34.2 [24.2–44], vs. 37.7 [26.2–48.4] ($p$=0.284) in the upper gastrointestinal hemorrhage (UGIH) group. (B) ROC curve with the area under the curve (AUC) of the UCR at day 0. The AUC is equal to 0.58</figcaption></figure>

of 37.7 provided a sensitivity of 52% and a specificity of 68%, corresponding to likelihood ratios far too weak to influence clinical decision-making (LR 1.63). Analyses of urea or UCR values obtained up to three days before and 1 day after EGD led to similar conclusions, with no discriminative power (Supplementary Fig. 1). Clinical outcomes were not markedly different between groups: length of stay and mortality did not vary significantly according to whether occult UGIH was confirmed.

This study has several limitations. First, in emergency cohorts with overt bleeding, the intragastric blood volume is most likely substantial, which may be responsible for superior urea generation. In contrast, occult bleeding in ICU patients is often intermittent and smaller in volume. Second, critically ill patients are exposed to multiple metabolic perturbations, including increased catabolism, altered hepatic function, hypovolemia and variable renal clearance, all of which can confound interpretation of urea and creatinine levels [5].

Almost 60% of EGDs in this cohort revealed abnormal findings, although only 27% showed bleeding lesions (Supplementary Table 2). This highlights the frequent occurrence of endoscopic abnormalities in ICU patients, ranging from gastritis and esophagitis to non-bleeding ulcers, many of which may not explain the hemoglobin decline. This observation is in line with previous reports indicating that EGD in the ICU often yields equivocal results, even when performed for plausible indications.

These findings must be interpreted with caution given the retrospective and monocentric nature of our study, together with the relatively modest sample size. Only patients who underwent EGD were analyzed, which raises the possibility of verification bias. Nevertheless, the weak diagnostic performance observed for UCR

makes it very unlikely that a larger cohort would have substantially modified our conclusion.

In summary, in a mixt ICU population, analysis of UCR showed no meaningful ability to distinguish patients with occult UGIH from those without. Although attractive for its simplicity and physiological rationale, UCR cannot be recommended as a decision-making tool for EGD in this context. Future efforts to refine indications for endoscopy in critically ill patients should likely focus on multimodal approaches rather than isolated biochemical markers.

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s13054-025-05750-8.

Supplementary Material 1

### Acknowledgements

The authors thank the medical and nursing staff of the Lariboisière ICU and Gastroenterology Department for their support in patient care and data collection.

### Author contributions

KM and CdR designed the study, HK, KM and MTM collected the data. RB, CdR and KM performed the statistical analysis. BGC, RB, CdR, and KM interpreted the data. KM drafted the first version of the manuscript. All authors critically revised the manuscript for important intellectual content and approved the final version.

### Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

### Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.
Declarations

Consent for publication

Not applicable. The manuscript does not contain any individual person's data.

Competing interests

The authors declare no competing interests.

Ethical approval and consent to participate

This retrospective observational study was approved by the Research Ethics Committee under the authority of the GHU Paris Nord Ethics Committee. The requirement for written informed consent was waived due to the retrospective design of the study and the use of anonymized data (CER-2025-316).

Received: 1 October 2025 / Accepted: 29 October 2025

Published online: 19 December 2025

References

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2. Cook D, Guyatt G. Prophylaxis against Upper Gastrointestinal Bleeding in Hospitalized Patients. Longo DL, éditeur. N Engl J Med. 2018;378(26):2506-16.

3. Schulman AR, Popov V, Thompson CC. Randomized sham-controlled trials in endoscopy: a systematic review and meta-analysis of adverse events. Gastro-intest Endoscopy 1 déc. 2017;86(6):972-e9853.

4. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. Lancet. 2000; 14(9238):1318-21.

5. Gunst J, Kashani KB, Hermans G. The urea-creatinine ratio as a novel biomarker of critical illness-associated catabolism. Intensive Care Med déc. 2019;45(12):1813-5.

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