Ege Üniversitesi Tıp Fakültesi Acil Servis'ine üst gastrointestinal sistem kanaması ile başvuran hastaların glasgow-blatchford skoru ve rockall skorlarının prediktif değerlerinin retrospektif değerlendirilmesi
Retropective evalution of predictive values of glasgow-blatchford and rockall scores in patients referred to emergency department of Ege University Medical Faculty with bleeding in upper gastrointestinal system
Yazar: KEMAL GÖKÇEK
Danışman: DOÇ. DR. MURAT ERSEL
Ege Üniversitesi / Tıp Fakültesi / Acil Tıp Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2013
Konu: İlk ve Acil Yardım = Emergency and First Aid
Dizin: Endoskopi-gastrointestinal = Endoscopy-gastrointestinal ; Gastrointestinal hemoraji = Gastrointestinal hemorrhage ; Hemorajiler = Hemorrhage ; Mortalite = Mortality ; Retrospektif çalışmalar = Retrospective studies ; Ölçekler = Scales

Özet:
Giriş ve Amaç: Üst gastrointestinal sistem kanaması önemli morbidite ve mortalitesi olan tıbbi bir sorundur. Bu çalışmadaki amacımız; sıklıkla kullanılan Rockall ve Blatchford skorlama sistemlerinin ve şok indeksinin üst gastrointestinal sistem kanamalarında endoskopi ve hospitalizasyon ihtiyaci ile mortalite olasılıklarını tahmin etmedeki başarısını kendi hastalarımız için ölçerek, bu skorlama sistemlerinin pratikte güvenli şekilde kullanımını sağlamak ve düşük riskli hastaların güvenli bir şekilde erken taburcu edilip, ayaktan tedavi ve takip edilebileceklerini göstermektir. Materyal ve Metod: Retrospektif tanımlayıcı nitelikteki bu çalışmada Ege Üniversitesi Tıp Fakültesi Hastanesi Acil Servisine 01/09/2010-31/08/2012 tarihleri arasında üst gastrointestinal sistem kanaması ile başvuran 18 yaş üstü hastalar geriye dönük olarak incelenmiştir. Bu yıllarda acil servise başvuran ve üst gastrointestinal sistem kanaması olabilecek İCD kodları ile çıkışı yapılan hastaların protokol numaralarına ulaşıldı. Bu hastaların protokol numaraları ile acil servis arşivinden dosyalarına ulaşılan 423 hasta çalışmaya alındı. Hastaların Pre-Rockall, Rockall ve Blatchford skorları hesaplandı. PreRockall skorunda 0 düşük risk 1 ve üzeri yüksek risk; Rockall risk sınıflamasında toplam skoru 0-2 olan hastalar düşük risk grubu, 3-4 olan hastalar orta risk grubu ve ? 5 olan hastalar yüksek risk grubu olarak ayrıldı. Güvenilirlik testlerinde Rockall skoru 0-2 olan hastalar düşük risk grubu, 3 ve üzeri olan hastalar yüksek risk grubu olarak değerlendirildi. Blatchford skorlamasında ise 0-2 düşük risk grubu, ?3 yüksek risk grubu olarak kabul edildi. Çalışmamızda standart veri toplama formu oluşturuldu. Veriler analiz için gruplara ayrıldı. İstatistik değerlendirmede veriler SPSS 16.0 programına yüklenerek gerekli analizler yapıldı. Bulgular: Çalışmaya alınan 423 hastanın 130'u (%30.7) kadın, 293'ü (%69.3) erkek olup genel yaş ortalaması 63.67±15.69 olarak saptandı. Hastaların 330'u (%78) melena, 210'u (%49.6) hematemez, 51'i (%12.1) senkop nedeniyle acil servise başvurduğu saptandı. Hastaların vital bulguları incelendiğinde ortalama sistolik basıncı 118.20±23.65 mmHg, diyastolik basınç 67.31±14.07 mmHg , ortalama nabız sayısı 94.30±18.72/dk olarak saptandı. Hastaların ortalama şok indeksi ise 0.82±0.24 idi. Hastaların Pre-Rockall skoru ortalaması 3.15±1.61, Rockall skoru ortalaması 5.05±2.13, Blatchford skoru ortalaması 10.19±3.78 olarak saptandı. Pre-Rockall, Rockall ve Blatchford Skorlarının ERT gereksinim tahmini için x

Abstract:
Introduction and Objective: Upper gastrointestinal bleeding is a serious problem with important morbidity and mortality. In this study our aim is to measure the success of frequently used Rockall and Blatchford scoring systems and shock index in estimating the endoscopy and hospitalization needs and the possibilities of mortality in upper gastrointestinal bleedings and apply it to our patients, to enable safe use of this scoring systems in practice, to demonstrate that patients with lower risk could be discharged early and safely and be treated and followed-up as outpatient. Materials and Methods: In this retrospective descriptive type of study the patients over 18 years of age who referred to Emergency Department of Ege University Medical Faculty with upper gastrointestinal bleeding between 01 September 2010 and 31 August 2012 were examined. The protocol numbers of those patients who referred to emergency department and discharged with ICD codes of upper gastrointestinal bleeding between these years were accessed. A total of 423 patients whose files in archive of emergency department were accessed through the protocol numbers were included in study. In our study a standard data collection form was developed. Data were divided into groups for analysis. In statistical evaluation the data were loaded into SPSS 16.0 program and necessary analyses were performed. Findings: Of the 423 patients included in study, 130 (30.7%) were women, 293 (69.3%) were males, mean age was 63.67 ± 15.69 years. Of the patients, 330 (78%) were referred to emergency department with melena, 210 (49.6%) with haematemesis, 51 (12.1%) with syncope. When patients' vital findings were examined the mean systolic pressure was 118.20 ± 23.65 mmHg, diastolic pressure was 67.31 ± 14.07 mmHg, the mean pulse count was 94.30 ± 18.72/min. Their mean shock index was 0.82 ± 0.24. Their mean score of Pre-Rockall was found as 3.15 ± 1.61, the mean score of Rockall as 5.05 ± 2.13, the mean score of Blatchford as 10.19 ± 3.78. When the reliability of Pre-Rockall, Rockall and Blatchford scores in estimating the ERT need was evaluated, Pre-Rockall score's sensitivity value was established as 94.9 %, specificity value as 10.5%, PPD as 52.1% and NPD as 66.7%. Rockall score's sensitivity value was 88.8%, specificity value was 14.4%, PPD was 51.5% and NPD was 55.6%. Blatchford score's sensitivity value was 100%, specificity value was 6.2%, PPD was 52.2% and NPD was 100%. Shock index's sensitivity value was 37.8%, specificity value was xi75.6%, PPD was 61.3% and NPD was 54.3%. A significant relationship could not be found between Rockall risc score and ERT transfusion. When the reliabilities of Pre-Rockall ve Blatchford scores for estimating the necessity of endoscopy were evaluated Pre-Rockall score's sensitivity value was detected as 94.1%, specificity value as 11.2%, PPD as 65.4% and NPD as 51.5%. Blatchford score had a sensitivity value of 100%, specificity value of 8.6%, PPD of 66.1% and NPD of 100%. When Pre-Rockall, Rockall, Blatchford scores and shock index were evaluated for estimating the patients with higher risk, Blatchford sensitivity and NPD were found to be the highest score. Blatchford score's sensitivity value was 100%, specificity value was 16%, PPD was 83.4% and NPD was 100%. Pre-Rockall score's sensitivity value was 93.6%, specificity value was 13.6%, PPD was 82.1% and NPD was 33.3%. When we evaluated the Rockall score we found its sensitivity value as 92.7%, specificity value as 35.8%, PPD as 85.9% and NPD as 53.7%. Shock index's sensitivity value was 33.9%, specificity value was 80.3%, PPD was 87.8% and NPD was 22.3%. When the mean scores of dead and living cases were compared, all of the three scores were found statistically significant (P<0.001). When the reliability of Pre-Rockall, Rockall and Blatchford scores in estimating the mortality was evaluated, Pre-Rockall score's sensitivity value was 100%, specificity value was 8.3%, PPD was 6.2% and NPD was 100%. Rockall score's sensitivity value was calculated as 100%, specificity value as 13.5%, PPD as 6.5% and NPD as 100%. When the Blatchford score was examined its sensitivity value was 100%, specificity value was 3.3%, PPD was 5.9% and NPD was 100%. Shock index's sensitivity was found as 54.1%, specificity as 70.2%, PPD as 9% and NPD as 96%. Discussion and Conclusion: In our study the Blatchford score was found to be the most significant score in estimating the blood transfusion needs of patients and the necessity of endoscopic intervention. Both Rockall score and Blatchford score were found very useful in estimating the higher-risk groups that require hospitalization. Rockall and Blatchford scores were more useful than Pre-Rockall score in terms of mortality. Shock index was also a good indicator to be calculated at the early referral in estimating the blood transfusion need and mortality and its PPD and specificity were found higher than risk scores. In our study limited number of cases and the absence of clinic data at the posthospitalization period hindered us to make a net comment related to the long term effectiveness and reliability of risk scores; thus this must be tested with further prospective studies that will develop these findings. Keywords: upper gastrointestinal system bleeding; risk score; endoscopy; mortality