Predictors And Prognosis Of Stress Ulcer Bleeding In Acute Intracerebral Hemorrhage

Intracerebral Hemorrhage, ICH is a clinical commonly-seen and frequently-occurring disease. After the occurrence of the disease, the organism is usually in a stringent state. And gastrointestinal bleeding, pneumonia, heart symptom and water-electrolyte disorder occur in succession because of the damage of autonomic central nerve and the disorder of neurohumor adjustable function. The clinical process of these complications is very rapid and dangerous. The mortality is 35%-52% and the invalidity rate is 50%-85%. Among them, gastrointestinal bleeding is one of the most common complications and the rate of occurrence can reach 14% to 76%. The occurrence of this complication is always an indication of deterioration and prognosis mala.Gastrointestinal bleeding, i.e. stress ulcer bleeding, is mainly caused by stress reaction and diffuse gastric mucosa erosio and ulcer caused by neurotic trauma on certain parts of bodies. Neurotic fluid plays a dominant role in the process, and the inequilibrium between protective factors and destructive factors for gastric mucosa leads to the damage of gastric mucosa directly. SUB is caused by association of multiple factors. The symptoms of stress ulcer bleeding include vomiting gross blood or coffee ground substance and hematochezia, but in some patients only appear unobvious symptom like hematochezia. Stress ulcer bleeding probably occurs within severalhours after the onset of ICH, but most SUB happen 5-7 days after ICH, or even longer. Severe SUB can reduce circulation volume within bodies, then aggravate the damages done to brain and lead to failure of other vital organs, or even death.The prophylaxis of SUB positively is a key procedure in the process of improving the conditions of ICH patients. Studies show that application of prophylactic medicine to patients with high possibility of developing SUB can obviously reduce the occurrence of SUB,blood transfusion and the risk of reoccurrence of bleeding, and achieve a better effect. However, indiscriminate prophylactic treatment for SUB maybe increase the risk of developing clinical pneumonia. For the present, few researches on the factors contributing to SUB have been done. Studies at home are made from a single perspective and lack a consideration of interrelated factors which are bound to be defective. The study is based on the analysis of a variety of samples and factors, appraising the predictors and clinical features of SUB that occur in the early period of ICH, and provides a theoretical foundation for the choice of ideal time and reasonable and effective cure for SUB.ObjectTo discuss about the early predictors of SUB caused by ICH , to analyze occurrence time, clinical features of SUB and relationship between SUB and ICH, and provide theoretical references for the selection of potential patients and suitable juncture for cure.Methods373 cases of ICH that happened within 24 hours and treated in Neurology Department of the First Hospital of Jilin University from August of 2005 to August of 2006 were reviewed. The patients with history of peptic ulcer, coagulation disorders, chronic liver and kidney diseases and those on antiplatelet, anticoagulant or nonsteroidal antiinflammatory drugs (NSAIDS) or departed hospital without admissions were excluded. Patients'gender, age, history of high blood pressure, records of vomiting, GCS rating taken on admission, pupillary asymmetry, parameters of CT(location of ICH, amount of hemorrhage, intraventricular extension, and midline shift), unable independence eating, and minimally invasive evacuation of intracerebral hematomas are taken as independent variables and the occurence of SUB is made as dependent variables, and those were evaluated by univariate analysis followed by multivariate logistic regression analysis. Meanwhile, we observe the occurrence time of SUB, its duration, reoccurrence and mortality, and compare the mortality of ICH with SUB with that of ICH without SUB. The patients were followed at the end of 30 days. The end point was 30-day mortality.Results(1)Among the 373 cases of intracerebral hemorrhage, 45 cases are accompanied by stress ulcer bleeding, the rate is 12.06%. Four of them bleed again on the 12th day, the 15th day, the 22nd day and 42ndday respectively, and this takes 8.89%. Three of them are accompanied by serious stress ulcer bleeding and all are brainstem hemorrhage. One of them died because of gastrointestinal bleeding.(2)On univariate analysis, GCS score (P<0.01), pupillary asymmetry (P<0.01), the amount of intracerebral hemorrhage (P<0.01), middle line shift (P<0.01), ventricular extension (P<0.01) and unable independence eating (P<0.01) were significantly related to stress ulcer bleeding.(3)On multiplicity analysis, the independent predictors of stress ulcer bleeding included unable independence eating (OR=11.56), pupillary asymmetry (OR=3.62), brainstem hemorrhage (OR=3.35) and middle line shift (OR=2.54).(4)Stress ulcer bleeding most occur within the first week after intracerebral hemorrhage and this occupies 88.89%. One week later, the occurrence rate of stress ulcer bleeding dramatically decrease, it only occupies 11.11%. Most of them occure within the first day after the onset of the disease, altogether 23 cases and it occupies 51.11%. The occurrence within the first three days occupies 73.33%. The latest occurs at the 13th day. At most, the stress ulcer bleeding lasts for one day after medical treatment, altogether 34 cases takes 75.56%. The longest one lasts 6 days.(5)In the 45 cases of intracerebral hemorrhage with stress ulcer bleeding, 28 patients (62.22%) died. And among the 328 cases of intracerebral hemorrhage without SUB, 27 patients (18.23%) died.The mortality is significantly different in two groups (χ2=94.28, P<0.01).Conclusions( 1 ) In this study, unable independence eating, pupillary asymmetry, cerebral stem bleeding, middle line shift may be the independent predictive factors of acute intracerebral hemorrhage accompanied by stress ulcer bleeding.(2)Once SUB occurs, it often demonstrates of deterioration and bad consequence.(3)The symptoms of SUB are always lighter and the duration is shorter, so that it's often easy to be neglected. However, the emphasis on the early prophylactic is very important.(4)The prevention against the stress ulcer bleeding should be done earlier. We suggest that it start at the first day of onset of intracerebral hemorrhage, last for 3-5 days.