Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Original Article

Volume 12, Number 1, February 2019, pages 1-7

Lactic Acid Is an Independent Predictor of Mortality and Improves the Predictive Value of Existing Risk Scores in Patients Presenting With Acute Gastrointestinal Bleeding

Figure 1. ROC curves comparing the original and modified Blatchford scores (top panel), Rockall pre-endoscope score (middle panel), and Rockall post endoscopic (complete) scores (bottom panel).

**Table 1.** Baseline Demographic Characteristics and Test Result of Patients With Acute Gastrointestinal Bleeding According to In-Patient Mortality Status
	Survivors (n = 336)	Non-survivors (n = 30)	All (366)	P value
Age (years)
Mean (SD)	70.5 (15.9)	76.6 (16.2)	70.9 (16)	0.021
Median (IQR)	72 (20)	80 (21)	73 (21)
Gender	148 (44%)	14 (46.7%)	162 (44.3%)	0.782
Female, n (%)
Systolic blood pressure (mm Hg), mean (SD)	127.3 (27)	116.0 (28.6)	123.4 (27.5)	0.035
Heart rate (beats/min), mean (SD)	89.5 (21.3)	86.7 (26.7)	89.3 (21.8)	0.747
Melena	127 (37.8%)	12 (40%)	139 (38%)	0.812
Syncope in last 7 days	19 (5.7%)	5 (16.7%)	24 (6.6%)	0.037
Altered mentation	24 (7.1%)	7 (23.3%)	31 (8.5%)	0.008
Comorbidities
No major comorbidity	65 (19.3%)	2 (6.7%)	67 (18.3%)	< 0.0001
Renal failure, liver failure, and/or disseminated malignancy	120 (35.7%)	22 (73.3%)	142 (38.8%)
Any comorbidity except renal failure, liver failure, and/or disseminated malignancy	151 (44.9%)	6 (20.0%)	157 (42.9%)
Congestive heart failure	74 (22%)	10 (33.3%)	84 (23%)	0.158
Hepatic disease	43 (12.8%)	8 (26.7%)	51 (13.9%)	0.05
Albumin < 3g/dL	55 (16.4%)	15 (50%)	70 (19.1%)	< 0.0001
INR > 1.5	73 (21.7%)	5 (16.7%)	78 (21.3%)	0.487
Lactic acid , peak (mmol/L), mean (SD)	2.2 (1.7)	5.8 (5.5)	2.4 (2.2)	< 0.0001
Hemoglobin(g/dL), mean (SD)	10.4 (3)	9.7 (2.7)	10.3 (3)	0.295
BUN(mg/dL), mean (SD)	33.3 (22)	41.5 (27)	33.8 (22.8)	0.058
Endoscopic diagnosis (n = 188)
No lesion or stigmata of recent bleed	41 (23.6%)	2 (14.3%)	43 (22.9%)	0.316
Malignancy of upper GI tract	3 (1.7%)	1 (7.1%)	4 (2.1%)
All other diagnosis	130 (74.7%)	11 (78.6%)	141 (75%)
Hemorrhage stigmata (n = 189)	67 (38.3%)	11 (78.6%)	78 (41.3%)	0.003

Table 1. Baseline Demographic Characteristics and Test Result of Patients With Acute Gastrointestinal Bleeding According to In-Patient Mortality Status

Survivors (n = 336)

Non-survivors (n = 30)

All (366)

P value

Age (years)

Mean (SD)

70.5 (15.9)

76.6 (16.2)

70.9 (16)

0.021

Median (IQR)

72 (20)

80 (21)

73 (21)

Gender

148 (44%)

14 (46.7%)

162 (44.3%)

0.782

Female, n (%)

Systolic blood pressure (mm Hg), mean (SD)

127.3 (27)

116.0 (28.6)

123.4 (27.5)

0.035

Heart rate (beats/min), mean (SD)

89.5 (21.3)

86.7 (26.7)

89.3 (21.8)

0.747

Melena

127 (37.8%)

12 (40%)

139 (38%)

0.812

Syncope in last 7 days

19 (5.7%)

5 (16.7%)

24 (6.6%)

0.037

Altered mentation

24 (7.1%)

7 (23.3%)

31 (8.5%)

0.008

Comorbidities

No major comorbidity

65 (19.3%)

2 (6.7%)

67 (18.3%)

< 0.0001

Renal failure, liver failure, and/or disseminated malignancy

120 (35.7%)

22 (73.3%)

142 (38.8%)

Any comorbidity except renal failure, liver failure, and/or disseminated malignancy

151 (44.9%)

6 (20.0%)

157 (42.9%)

Congestive heart failure

74 (22%)

10 (33.3%)

84 (23%)

0.158

Hepatic disease

43 (12.8%)

8 (26.7%)

51 (13.9%)

0.05

Albumin < 3g/dL

55 (16.4%)

15 (50%)

70 (19.1%)

< 0.0001

INR > 1.5

73 (21.7%)

5 (16.7%)

78 (21.3%)

0.487

Lactic acid , peak (mmol/L), mean (SD)

2.2 (1.7)

5.8 (5.5)

2.4 (2.2)

< 0.0001

Hemoglobin(g/dL), mean (SD)

10.4 (3)

9.7 (2.7)

10.3 (3)

0.295

BUN(mg/dL), mean (SD)

33.3 (22)

41.5 (27)

33.8 (22.8)

0.058

Endoscopic diagnosis (n = 188)

No lesion or stigmata of recent bleed

41 (23.6%)

2 (14.3%)

43 (22.9%)

0.316

Malignancy of upper GI tract

3 (1.7%)

1 (7.1%)

4 (2.1%)

All other diagnosis

130 (74.7%)

11 (78.6%)

141 (75%)

Hemorrhage stigmata (n = 189)

67 (38.3%)

11 (78.6%)

78 (41.3%)

0.003

**Table 2.** Clinical Risk Scores According to Inpatient Mortality Status
Risk scores	Survivors (n = 336)	Non-survivors (n = 30)	P value
*Values are mean score (SD).
Blatchford score	8 (4.6)	10.7 (4.3)	0.002
Rockall-pre-endoscopy	3.6 (1.5)	4.6 (1.3)	0.001
Rockall-complete*	5.3 (2.1)	6.9 (1.3)	0.004
AIMS65	1.87 (0.8)	1.9 (0.8)	0.683

Table 2. Clinical Risk Scores According to Inpatient Mortality Status

Risk scores

Survivors (n = 336)

Non-survivors (n = 30)

P value

*Values are mean score (SD).

Blatchford score

8 (4.6)

10.7 (4.3)

0.002

Rockall-pre-endoscopy

3.6 (1.5)

4.6 (1.3)

0.001

Rockall-complete*

5.3 (2.1)

6.9 (1.3)

0.004

AIMS65

1.87 (0.8)

1.9 (0.8)

0.683

**Table 3.** Binary Logistic Regression for the Prediction of In-Patient Mortality in Patients With Acute Gastrointestinal Bleeding
	Odds ratio (OR)	95% Confidence interval for OR	P value
Age	1.07	1.02	1.11	< 0.0001
BP	1.01	0.99	1.03	0.37
Hepatic disease	0.41	0.09	1.87	0.25
Charlson score
(0) Reference				0.04
(2)	0.55	0.09	3.23	0.51
(3)	2.48	0.45	13.54	0.3
Syncope in last 7 days	0.9	0.19	4.41	0.9
Altered mentation	3.4	0.98	11.78	0.05
Lactic acid level, peak	1.51	1.26	1.82	< 0.0001
BUN	0.99	0.97	1.01	0.39
Albumin	0.28	0.12	0.64	< 0.0001

Table 3. Binary Logistic Regression for the Prediction of In-Patient Mortality in Patients With Acute Gastrointestinal Bleeding

Odds ratio (OR)

95% Confidence interval for OR

P value

Lower

Upper

Age

1.07

1.02

1.11

< 0.0001

1.01

0.99

1.03

0.37

Hepatic disease

0.41

0.09

1.87

0.25

Charlson score

(0) Reference

0.04

(2)

0.55

0.09

3.23

0.51

(3)

2.48

0.45

13.54

0.3

Syncope in last 7 days

0.9

0.19

4.41

0.9

Altered mentation

3.4

0.98

11.78

0.05

Lactic acid level, peak

1.51

1.26

1.82

< 0.0001

BUN

0.99

0.97

1.01

0.39

Albumin

0.28

0.12

0.64

< 0.0001

**Table 4.** Comparison Between Original Clinical Risk Scoring Systems and Modified Scoring System Incorporating Points (1, 2, or 3) for Lactic Acid ≥ 2.75 mmol/L
Score	Area	P value	95% Confidence interval	P value
Blatchford score	0.652	0.006	0.557	0.747	Blatchford score vs.
L1-Blatchford	0.669	0.002	0.578	0.760	0.005
L2-Blatchford	0.688	0.001	0.600	0.775	0.004
L3-Blatchford	0.706	0.000	0.621	0.792	0.003
Rockall Pre-Endoscopy	0.675	0.001	0.586	0.765	Rockall pre-endoscopy vs.
L1-Rockall pre-endoscopy	0.733	0.000	0.649	0.818	0.003
L2-Rockall pre-endoscopy	0.762	0.000	0.680	0.844	0.007
L3-Rockall pre-endoscopy	0.774	0.000	0.694	0.854	0.012
Rockall Score-complete	0.742	0.003	0.633	0.850	Rockall score-complete vs.
L1-Rockall-complete	0.780	0.000	0.677	0.883	0.040
L2-Rockall-complete	0.801	0.000	0.698	0.904	0.078
L3-Rockall-complete	0.808	0.000	0.703	0.913	0.129

Table 4. Comparison Between Original Clinical Risk Scoring Systems and Modified Scoring System Incorporating Points (1, 2, or 3) for Lactic Acid ≥ 2.75 mmol/L

Score

Area

P value

95% Confidence interval

P value

Lower bound

Upper bound

Blatchford score

0.652

0.006

0.557

0.747

Blatchford score vs.

L1-Blatchford

0.669

0.002

0.578

0.760

0.005

L2-Blatchford

0.688

0.001

0.600

0.775

0.004

L3-Blatchford

0.706

0.000

0.621

0.792

0.003

Rockall Pre-Endoscopy

0.675

0.001

0.586

0.765

Rockall pre-endoscopy vs.

L1-Rockall pre-endoscopy

0.733

0.000

0.649

0.818

0.003

L2-Rockall pre-endoscopy

0.762

0.000

0.680

0.844

0.007

L3-Rockall pre-endoscopy

0.774

0.000

0.694

0.854

0.012

Rockall Score-complete

0.742

0.003

0.633

0.850

Rockall score-complete vs.

L1-Rockall-complete

0.780

0.000

0.677

0.883

0.040

L2-Rockall-complete

0.801

0.000

0.698

0.904

0.078

L3-Rockall-complete

0.808

0.000

0.703

0.913

0.129