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T A Rockall

Publications and source records attributed to T A Rockall.

13 recordsLinked to original sources
PubMed2006

Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin.

Several commonly prescribed antibiotics are known to interact with warfarin, increasing its anticoagulant effect by different mechanisms. Retroperitoneal bleeding with consequent haematoma is recognised as a complication of over-anticoagulation. Consequences, which are potentially fatal, include hypovolaemic shock and compression of retroperitoneal structures such as the ureter and inferior vena cava.

Aged↗
PubMed1999

Carcinoembryonic antigen: its value in the follow-up of patients with colorectal cancer.

We examined the value of carcinoembryonic antigen (CEA) monitoring for detecting treatable recurrence of colorectal carcinoma. CEA assays were undertaken in 193 patients over a 2-year period. The levels in 34 patients were raised in one or more assays above the laboratory-defined upper limit of normal; 31 cases were reviewed retrospectively. In 10% of patients there were Dukes' A lesions at the initial resection, in 39% Dukes' B, and in 52% Dukes' C1 or C2. Tumours were rectal in 61%. Median follow-up was 3 years (range, 16 years-2 months). In 23 of 31 (74%) there were symptoms or signs of recurrent disease prior to or simultaneously with an observed rise in CEA; in 8 the CEA rise preceded the onset of symptoms or the appearance of signs. Of the 31 cases 26 underwent investigation for recurrent disease, but in only 6 of these was the investigation driven by the observed rise in CEA rather than the onset of symptoms or presence of signs. Three of these six were false-positive results (50%), one has been lost to follow-up, and two had confirmed recurrence. Neither of the two with recurrence had operable disease. One of the two had no further treatment, and one underwent laparotomy at which multiple peritoneal seedlings were found. In both of the two cases going to laparotomy, one of which was prompted by a high CEA, widely disseminated disease was found. Over a 2-year period, serial CEA measurement thus yielded no patient benefit.

Carcinoembryonic Antigen↗
PubMed1998

Management and outcome of patients undergoing surgery after acute upper gastrointestinal haemorrhage. Steering Group for the National Audit of Acute Upper Gastrointestinal Haemorrhage.

Most patients with acute upper gastrointestinal haemorrhage are managed conservatively or with endoscopic intervention but some ultimately require surgery to arrest the haemorrhage. We have conducted a population-based multicentre prospective observational study of management and outcomes. This paper concerns the subgroup of 307 patients who had an operation because of continued or recurrent haemorrhage or high risk of further bleeding. The principal diagnostic group was those with peptic ulcer. Of 2071 patients with peptic ulcer presenting with acute haemorrhage, 251 (12%) had an operative intervention with a mortality of 24%. In the non-operative group mortality was 10%. The operative intervention rate increased with risk score, ranging from 0% in the lowest risk categories to 38% in the highest. Much of the discrepancy between operative and non-operative mortality was explainable by case mix; however, for high-risk cases mortality was significantly higher in the operated group. In 78% of patients who underwent an operation for bleeding peptic ulcer there had been no previous attempt at endoscopic haemostasis. For patients admitted to surgical units, the operative intervention rate was about four times higher than for those admitted under medical teams. In patients with acute upper gastrointestinal haemorrhage operative intervention is infrequent and largely confined to the highest-risk patients. The continuing high mortality in surgically treated patients is therefore to be expected. The reasons for the low use of endoscopic treatment before surgery are not revealed by this study, but wider use of such treatments might further reduce the operative intervention rate. Physicians and surgeons have not yet reached consensus on who needs surgery and when.

Endoscopy, Gastrointestinal↗
PubMed1997

Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Steering Committee of the National Audit of Acute Upper Gastrointestinal Haemorrhage.

AIMS: To assess changes in practice and outcome in acute upper gastrointestinal haemorrhage following the feedback of data, the reemphasis of national guidelines, and specific recommendations following an initial survey. DESIGN: A prospective, multicentre, audit cycle. Forty five hospitals from three health regions participated in two phases of the audit cycle. PATIENTS: Phase I: 2332 patients with acute upper gastrointestinal haemorrhage; phase II: 1625 patients with upper gastrointestinal haemorrhage. METHODS: Patients were evaluated with respect to management (with reference to the recommendations in the national guidelines), mortality, and length of hospital stay. RESULTS: Following the distribution of data from the first phase of the National Audit and the formulation of specific recommendations for improving practice, the proportion of hospitals with local guidelines or protocols for the management of upper gastrointestinal haemorrhage rose from 71% (32/45) to 91% (41/45); 12 of the 32 hospitals with guidelines during the first phase revised their guidelines following the initial survey. There was a small but significant increase in the proportion of all patients who underwent endoscopy (from 81% to 86%), the proportion who underwent endoscopy within 24 hours of admission (from 50% to 56%), and the use of central venous pressure monitoring in patients with organ failure requiring blood transfusion or those with profound shock (from 30% to 43%). There was, however, no change in the use of high dependency beds or joint medical/surgical management in high risk cases. There was no significant change in crude or risk standardised mortality (13.4% in the first phase and 14.4% in the second phase). CONCLUSIONS: Although many of the participating hospitals have made efforts to improve practice by producing or updating guidelines or protocols, there has been only a small demonstrable change in some areas of practice during the National Audit. The failure to detect any improvement in mortality may reflect this lack of change of practice, but may also reflect the fact that a large proportion of the deaths in this unselected study are not preventable; only a very large study could hope to demonstrate a significant change out of the context of a clinical trial.

Acute Disease↗
PubMed1996

Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage.

BACKGROUND: Acute upper gastrointestinal haemorrhage is a common medical emergency and hospital admission has usually been regarded as obligatory until the risk of further haemorrhage has receded. This policy means that some patients at low risk stay in hospital for longer than is necessary especially when diagnostic endoscopy is delayed. We attempted to identify patients who had negligible risk of further bleeding or death and for whom early discharge or even outpatient management would be possible with no adverse effect on standards of care. METHODS: We used a validated risk scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), diagnosis (0-2), and endoscopic stigmata of recent haemorrhage (0-2); the maximum possible score was 11. We studied patients identified through the UK national Audit of acute upper gastrointestinal haemorrhage; they had been admitted with upper gastrointestinal haemorrhage to hospitals in the UK during 4 months of 1993. This analysis was based on the 2531 patients from the national audit who underwent endoscopy after an acute admission. FINDINGS: 744 (29.4%) of the 2531 patients scored 2 or less on the risk score. Of these patients only 32 (4.3% [95% Cl 3.0-6.0] rebled and only one (0.1% [0.006-0.75] died). Thus, the risk score identifies patients at low risk of rebleeding or death. The median hospital stay increased with risk score. Within risk score categories of 5 or less, there was a trend of increasing hospital stay as the time between admission and endoscopy increased. INTERPRETATION: Our risk score identifies a large proportion of patients with acute upper gastrointestinal haemorrhage who are at low risk of further bleeding or death. Early endoscopy and discharge of such patients could allow substantial resource savings.

Acute Disease↗
PubMed1996

Risk assessment after acute upper gastrointestinal haemorrhage.

The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage, and to formulate a simple numerical scoring system that categorizes patients by risk. A prospective, unselected, multicentre, population based study was undertaken using standardised questionnaires in two phases one year apart. A total of 4185 cases of acute upper gastrointestinal haemorrhage over the age of 16 identified over a four month period in 1993 and 1625 cases identified subsequently over a three month period in 1994 were included in the study. It was found that age, shock, comorbidity, diagnosis, major stigmata of recent haemorrhage, and rebleeding are all independent predictors of mortality when assessed using multiple logistic regression. A numerical score using these parameters has been developed that closely follows the predictions generated by logistical regression equations. Haemoglobin, sex, presentation (other than shock), and drug therapy (non-steroidal anti-inflammatory drugs and anticoagulants) are not represented in the final model. When tested for general applicability in a second population, the scoring system was found to reproducibly predict mortality in each risk category. In conclusion, a simple numerical score can be used to categorize patients presenting with acute upper gastrointestinal haemorrhage by risk of death. This score can be used to determine case mix when comparing outcomes in audit and research and to calculate risk standardised mortality. In addition, this risk score can identify 15% of all cases with acute upper gastrointestinal haemorrhage at the time of presentation and 26% of cases after endoscopy who are at low risk of rebleeding and negligible risk of death and who might therefore be considered for early discharge or outpatient treatment with consequent resource savings.

Acute Disease↗
PubMed1995

Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage.

Hospital mortality after acute upper gastrointestinal haemorrhage varies widely. In a population-based, multi-centre, prospective survey of the management and outcome of unselected cases of acute upper gastrointestinal haemorrhage, we have assessed the effect of risk standardisation on this variation. We collected data from 74 acute hospitals in four health regions in the UK on patients aged 16 years and over who presented with acute upper gastrointestinal haemorrhage during 4 months in 1993 (3981 cases) and 3 months in 1994 (1584 cases). The overall mortality was 14.3% (798/5565). Crude mortality in individual hospitals ranged from 0% to 29%, and differed significantly from the overall rate in eight. Risk-standardised mortality ratios were calculated with a risk score derived from well-established risk factors. Only two hospitals had standardised mortality ratios significantly different from the reference value. When hospitals were ranked in order of increasing mortality, risk standardisation for age, shock, and comorbidity resulted in 21 of the 74 hospitals changing ranks by ten or more places. After further standardisation for diagnosis, endoscopic stigmata of recent haemorrhage, and rebleeding, 32 hospitals moved ten or more places from their original rank; one hospital moved 45 places. Risk standardisation to correct for variation in case mix results in apparently significant differences in mortality rates becoming non-significant. The current state of routine data collection does not allow for anything but the most basic case-mix adjustment to be made. Simple league tables of crude mortality are misleading in this disorder and cannot be regarded as a reflection of the quality of health care.

Acute Disease↗
PubMed1995

Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage.

OBJECTIVE: To describe the current epidemiology of acute upper gastrointestinal haemorrhage. DESIGN: Population based, unselected, multicentre, prospective survey. SETTING: 74 hospitals receiving emergency admissions in four health regions in the United Kingdom. SUBJECTS: 4185 cases of acute upper gastrointestinal haemorrhage in which patients were aged over 16 years identified over four months. OUTCOME MEASURES: Incidence and mortality. RESULTS: The overall incidence of acute upper gastrointestinal haemorrhage in the United Kingdom is 103/100,000 adults per year. The incidence rises from 23 in those aged under 30 to 485 in those aged over 75. At all ages incidence in men was more than double that in women except in elderly patients. 14% of the haemorrhages occurred in inpatients already in hospital for some other reason. In 27% of cases (37% female, 19% male) patients were aged over 80. Overall mortality was 14% (11% in emergency admissions and 33% in haemorrhage in inpatients). In the emergency admissions, 65% of deaths in those aged under 80 were associated with malignancy or organ failure at presentation. Mortality for patients under 60 in the absence of malignancy or organ failure at presentation was 0.8%. CONCLUSIONS: The incidence of acute upper gastrointestinal haemorrhage is twice that previously reported in England and similar to that reported in Scotland. The incidence increases appreciably with age. Although the proportion of elderly patients continues to rise and mortality increases steeply with age, age standardised mortality is lower than in earlier studies. Deaths occurred almost exclusively in very old patients or those with severe comorbidity.

Acute Disease↗
PubMed1990

Scintigraphic evaluation of glomus tumours.

The current investigations of choice for a suspected glomus tumour are either direct or indirect angiography to include digital subtraction followed by computerized tomography (CT) or magnetic resonance imaging (MRI) or, if available, CT and MRI with gadolinium alone. Although these modalities confirm the diagnosis and give anatomical information to facilitate accurate staging, they do not provide functional data. The use of radionuclide scintigraphy can add an extra physiological dimension to glomus tumour imaging. Iodine-131/123 metaiodobenzylguanidine (MIBG) is a tumour imaging agent which has been used to diagnose head and neck neuroendocrine tumours to include paragangliomata and medullary carcinoma of the thyroid (MCT). However, it is expensive and the new head and neck tumour imaging agent technetium-99 m (Tc99m) (v) dimercaptosuccinic acid (DMSA) has superceded it as the imaging agent of choice to evaluate MCT. We report a patient with a glomus jugulare tumour which was evaluated with I131/I123-MIBG and Tc99m (v) DMSA. The tumour was functional and is the first reported case exhibiting positive accumulation of both I131-MIBG and Tc99m (v) DMSA. The patient was subsequently treated with a therapeutic dose of I131-MIBG. The significance of these results is discussed.

3-Iodobenzylguanidine↗