1. Journal of the Neurological Sciences 208 (2003) 25 – 29
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Predictors of gastrointestinal bleeding in acute intracerebral haemorrhage
U.K. Misra a,*, J. Kalita a, S. Pandey a, S.K. Mandal b
a
Department of Neurology, Sanjay Gandhi PGIMS, Rae Bareily Road, Lucknow 226014, India
b
Department of Biostatistics, Central Drug Research Institute, Lucknow, India
Received 3 June 2002; received in revised form 23 September 2002; accepted 22 October 2002
Abstract
Background: Gastrointestinal (GI) haemorrhage is an important and sometimes serious complication in critically ill neurological patients
who suffered from stroke and head injury and those in intensive care. There is no study evaluating frequency, severity and risk factors of GI
haemorrhage in patients with primary intracerebral haemorrhage (ICH). Aims: To evaluate the frequency, severity and predictors of GI
haemorrhage in patients with ICH. Methods: In a prospective hospital-based study, consecutive CT-proven ICH patients within 10 days of
the ictus were included. The patients with history of peptic ulcer, GI haemorrhage, liver and kidney disease, bleeding diathesis and those on
antiplatelet, anticoagulant or nonsteroidal antiinflammatory drugs (NSAIDS) were excluded. A detailed neurological evaluation was carried
out. Glasgow coma scale (GCS) was used for assessment of consciousness level and Canadian neurological scale (CNS) for severity of
stroke. The haematomas were classified into small ( < 20 ml), medium (20 – 40 ml) and large ( > 40 ml). The occurrence of GI haemorrhage
during 14 days of ictus was considered due to ICH. To evaluate the predictors of GI haemorrhage, various clinical and CT scan findings
were evaluated by univariate followed by multivariate logistic regression analysis. Results: Fifty-one patients with ICH were included
whose age ranged between 30 and 80 years and 14 were female. The mean GCS score was 8.9 (3 – 15) and CNS score was 2.2 (2 – 4).
Haematoma was small ( < 20 ml) in 11 patients and medium (20 – 40 ml) and large (>40 ml) in 20 patients each. Evidences of septicemia
were present in 20 patients. Gastric haemorrhage (GH) was noted in 15 patients which was more than 40 ml in 4 patients and one of these
patients needed blood transfusion. On univariate analysis, the size of haematoma, septicemia, motor signs on the nonhemiplegic side and
pupillary asymmetry were significantly related to GI haemorrhage. On multivariate analysis, the best set of predictors of gastric
haemorrhage included size of haematoma, septicemia and GCS score. Conclusion: GI haemorrhage is more likely present in patients with
larger haematoma having septicemia. Our study highlights the importance of septicemia, which is an important and modifiable risk factor
for GI bleeding in ICH patients.
D 2002 Elsevier Science B.V. All rights reserved.
Keywords: Gastric haemorrhage; Intracerebral haemorrhage; Septicemia; CT scan
1. Introduction reported to be low and usually does not contribute to
increased morbidity and mortality [5 – 7]. In a study, GI
Cushing [1] reported 11 patients with either gastrointes- haemorrhage was noted in 0.1% of patients with stroke; 14
tinal (GI) ulceration, perforation or haemorrhagic erosion in of these patients had ischaemic stroke, 2 patients had
his postoperative brain tumour patients. Subsequently, all GI subdural haematoma and 1 patient had haemorrhagic stroke
lesions associated with intracranial disease are known as [5]. In another study, patients with severe stroke, especially
Cushing’s ulcer. Gastrointestinal bleeding occurs frequently those with Glasgow coma scale (GCS) score below 10 had
in intensive care unit patients who have intracranial dis- higher frequency of GI haemorrhage [6]. In this study, we
eases. Following head injury, endoscopic evidence of have evaluated the frequency, severity and factors respon-
mucosal lesion can appear within 24 h and 17% of patients sible for GI haemorrhage in patients with primary intra-
with GI haemorrhage may present clinically with significant cerebral haemorrhage (ICH).
bleeding [2]. Mortality in patients with GI haemorrhage may
be as high as 50% [3,4]. GI haemorrhage in stroke has been
2. Subjects and methods
* Corresponding author. Fax: +91-522-440017, +91-522-440973.
E-mail addresses: ukmisra@sgpgi.ac.in, ukmisra@indiatimes.com This study was conducted in a tertiary care teaching
(U.K. Misra). institute in India. Fifty-one patients with CT-proven
0022-510X/02/$ - see front matter D 2002 Elsevier Science B.V. All rights reserved.
doi:10.1016/S0022-510X(02)00415-X

2. 26 U.K. Misra et al. / Journal of the Neurological Sciences 208 (2003) 25–29
intracerebral haemorrhage within 10 days of ictus who 2.1. Statistical analysis
were managed by us during 2000 –2001 were included in
the present study. Patient’s consciousness was evaluated To study the variables contributing to the occurrence of
by Glasgow coma scale (GCS) and severity of stroke by GI haemorrhage, a number of clinical (age, sex, CNS score,
Canadian neurological scale (CNS) score [8]. Presence of GCS score, diabetes, NSAIDS, pupillary asymmetry, decere-
hyperventilation, pupillary asymmetry and motor signs on bration, motor signs on nonhemiplegic side and presence of
the nonhemiplegic side were recorded. The diagnosis of septicemia) and radiological (site, size, intraventricular
septicemia was considered if at least two of the follow- extension of haematoma) details were analysed by employ-
ing features were present: (1) temperature>38 jC or ing univariate logistic regression, followed by multiple
below 36 jC, (2) heart rate>90/min, (3) respiratory logistic regression analysis. The independent variables were
rate>20/min or pa CO 2 < 32 Torr, and (4) leucocyte categorised as sex (male = 1, female = 2), diabetes, septice-
counts>12 000/mm3 or < 4000/mm3 or more than 10% mia, NSAIDS use, hyperventilation, pupillary asymmetry,
band forms [9]. Presence of Fibrin degradation product motor signs on nonhemiplegic side and decerebration
(FDP) was also noted. History of peptic ulcer, diabetes, (present = 1, absent = 2), size of haematoma (large = 1,
alcoholism, smoking and use of nonsteroidal antiinflam- medium = 2, small = 3), and intraventricular extension
matory drugs (NSAIDS) during hospital stay were (present = 1, absent = 2). The raw score of age, GCS score
recorded. Hemoglobin, full blood count, hematocrit, and CNS score were analysed. The dichotomous-dependent
serum chemistry, prothombin time and activated pro- variable (GI haemorrhage = y) was assigned the value 1 when
thrombin time, radiograph of chest and electrocardiogram GI haemorrhage was absent and 0 when it was present. If x1,
were carried out in all the patients. Noncontrast cranial x2, x3. . ., xp were the characteristics relating to the occurrence
CT scan was carried out on a third generation CT of GI haemorrhage, then the logistic regression model
scanner and 10-mm axial section was obtained parallel specified the conditional probability of GI haemorrhage as
to orbitomeatal line. On CT scan, the location of hae- follows:
matoma, its size, ventricular extension and midline shift
were noted. The size of haematoma was calculated by
ABC/2, where A = largest diameter of haematoma in Pðy ¼ 1=x1 ; x2 ; x3 ; . . . xp Þ
" !#
centimeter, B = diameter in centimeter in 90j to A and X
P
C = number of parenchymal haemorrhage seen in 1 – 0.5 ¼ 1=1 þ exp À A þ ÀBj Xj ð1Þ
J ¼1
cm slice. The haematomas were classified into small ( < 20
ml), medium (20 – 40 ml) and large (>40 ml). Patients
were managed conservatively. Mannitol was given to the The multivariate logistic risk factors were formulated
patients with clinical signs of raised intracranial pressure as Eq. (1), where Bj was the logistic coefficient and A
(i.e. pupillary asymmetry, hyperventilation, decrebration or was constant. The parameters of the model were obtained
decorticaltion and pyramidal signs on nonhemiplegic side). by maximum likelihood ration [10]. Initially, all the
Corticosteroids were not given in any patient. Antihyper- variables were included for the analysis but later, the
tensive was prescribed if blood pressure was more than best model was obtained using stepwise logistic regres-
180/110 mm Hg in acute stage. None of the patients sion in which the parameters with the lowest weight
underwent surgical evacuations of haematoma. Occurrence (Coefficient) was removed sequentially till the best model
of GI haemorrhage during first 14 days of ictus was was arrived at.
considered due to ICH. Gastric haemorrhage was defined
as gross blood or coffee ground substance in nasogastric
aspirate or hematochesia, hematemesis or malena. Gastro- 3. Result
intestinal endoscopic study was not possible in any as
patients were in altered sensorium and noncooperative for Fifty-one consecutive patients with ICH were included
this study. The GI haemorrhage was considered severe if whose age ranged between 30 and 80 (mean 56.76) years
there was hypotension and/or need for blood transfusion. and 14 were females. The location of haematoma was
The exclusion criteria included: (1) use of anticoagulants putaminal in 38 patients, thalamic in 11 patients, and
or antiplatelet drugs in preceeding 7 days; (2) history of caudate and pontine in 1 patient each. Twenty patients
coagulation disorder, purpura, chronic liver or kidney had septicemia, of whom fibrin degradation product was
disease or acid peptic disease or history of hematemesis, present in four patients. Gastrointestinal haemorrhage was
malena or oesopharyngeal varices. All the patients present in 15 patients which exceeded 50 ml in 4 patients
received sucralfate suspension 1 g every 6 h for 3 weeks and blood transfusion was needed in 1 patient. The clinical
and H2-receptor blockers or proton pump inhibitiors in details of the patients are given in Table 1.
standard dose except one patient. The patients were fol- On univariate logistic regression analysis, the significant
lowed at the end of 1 month. The end point was 1-month parameters related to GI haemorrhage included size of
mortality. haematoma (Z = 2.74), septicemia (Z = 3.8), nonhemiplegic

3. U.K. Misra et al. / Journal of the Neurological Sciences 208 (2003) 25–29 27
Table 1 Table 3
Clinical features of patients with intracerebral haemorrhage Best predictors of gastric haemorrhage in patients with intracerebral
No. of patients haemorrhage in multivariate logistic regression analysis
Parameters Coefficient Odd’s ratio Z
History of hypertension 16
Diabetes mellitus 4 Lower Upper
Smoking 6 Size of À 2.2177 0.0135 0.876 2.08*
Alcohol 4 haematoma
GCS score Septicemia À 3.6374 0.0031 0.223 3.34*
<6 9
GCS score 0.2048 0.8810 1.841 0.99
6 – 12 33 Constant 6.2313 3.28
>12 9
CNS score Likelihood ratio statistics, 27.868; df = 3.
< 3.5 43 * P < 0.05.
z 3.5 8
Signs of raised ICP 33
Haematoma size nificantly related to the 1-month mortality of ICH patients
Small 11 (X2 = 4.34, df = 1, P < 0.05).
Medium 20
Large 20
Mortality at 1 month 14
4. Discussion
In our study, 30% of patients with ICH had GI haemor-
motor signs (Z = 2.68) and pupillary asymmetry (Z = 2.92). rhage and the best predictors of GI bleeding by multivariate
The variables which were not found to be significantly logistic regression analysis included septicemia, size of
related to GI haemorrhage included age (Z = 0.32), sex haematoma and GCS score. In the available literature, we
(Z = 1.9), decerebration (Z = 1.99), hyperventilation have not come across any study evaluating the predictors of
(Z = 2.51), GCS score (Z = 2.24), CNS score (Z = 1.76), GI haemorrhage in ICH patients. In a retrospective analysis
NSAIDS (Z = 0.12), diabetes (Z = 2.55), site of haematoma of 16,672 stroke patients, 17 had GI haemorrhage, high-
(Z = 1.51) and intraventricular extension of haematoma lighting the rarity of GI bleeding in stroke. Interestingly, the
(Z = 2.06). The clinical and radiological features of the majority of these patients had ischaemic stroke and the
patients with ICH having GI haemorrhage as well as those strokes were mild enough for these patients to undergo GI
without it are summarised in Table 2. endoscopy that needs patient’s cooperation. Only one
On multivariate logistic regression analysis, the best set patient in this study had ICH and two had subdural
of predictors for occurrence of GI haemorrhage included haematoma. In this study, history of NSAIDS, aspirin and
size of haematoma, presence of septicemia and GCS score. corticosteroid therapy and H. pylori infection were found to
The statistical findings are presented in Table 3. At the end be contributing to GI haemorrhage [7]. The higher fre-
of 1 month, 14 patients died and 8 patients of whom had GI quency of GI haemorrhage in our patient may be due to
haemorrhage. The occurrence of GI haemorrhage was sig- more severe stroke and presence of septicemia. All our
patients had intracerebral haemorrhage, 78% of them had
medium- or large-size haematoma resulting in raised intra-
Table 2 cranial pressure, herniation and altered sensorium. Upper
Important predictors of gastric haemorrhage (GH) in patients with gastrointestinal endoscopy was not possible in our patients
intracerebral haemorrhage (ICH) in univariate logistic regression analysis
because of more severe stroke, resulting in variable extent of
Variables Level (no.) ICH Z altered sensorium. We have excluded the patients on long-
With Without term use of NSAIDS, aspirin, anticoagulant and cortico-
GH GH steroid therapy.
Size Small (11) 1 10 2.74* In an unconscious patient, septicemia may occur follow-
Medium (20) 3 17 ing catheterisation, IV cannulation, endotracheal intubation
Large (20) 11 9
Septicemia Present (20) 13 7 3.80*
and pneumonia. In our study, 65% of patients with septice-
Absent (31) 2 29 mia had GI haemorrhage. Septicemia may result in reduc-
NHM signs Present (22) 11 11 2.68* tion of gastric blood flow leading to mucosal ischaemia. The
Absent (29) 4 25 mucous layer can be disrupted by ischaemic insults to the
Pupillary Present (15) 9 6 2.92* underlying mucosa leading to change in mucosal permi-
asymmetry Absent (36) 6 30
GCS score < 6 (9) 5 4 2.24
ability. Subsequently, an unrestricted influx of hydrogen
6 – 12 (33) 9 24 ions can damage gastric mucosa [11,12]. In critically ill
>12 (9) 1 8 patients in intensive care unit, several studies have high-
NMH = nonhemiplegic motor, GCS = Glasgow coma scale. lighted the importance of septicemia in producing GI
* P < 0.05. haemorrhage [13 – 15]. Although we have excluded the

4. 28 U.K. Misra et al. / Journal of the Neurological Sciences 208 (2003) 25–29
patients on anticoagulant and antiplatelet therapy, septice- From this multivariate logistic regression analysis, it can
mia itself can result in coagulation abnormality, which may be concluded that the size of haematoma, septicemia and
also contribute to GI haemorrhage. In a metaanalysis of GCS score are the best predictors of GI haemorrhage in ICH
critically ill intensive care unit patients, prophylaxis against patients. Our study highlights the importance of septicemia
stress-related upper GI haemorrhage was recommended in in ICH, which is not only an important but also a modifiable
patients with coagulopathy and respiratory failure [14]. In risk factor for GI haemorrhage in ICH patients.
our study, of 13 patients having septicemia and GI haemor-
rhage, 7 patients had abnormal coagulation profile and 4
patients were positive for fibrin degradation product. Acknowledgements
Size of haematoma determines the clinical picture and
outcome of ICH patients [16]. A large haematoma may We gratefully acknowledge Mr. Rakesh Kumar Nigam
result in uncal or transtentorial herniation, which may be for secretarial help.
associated with excessive autonomic discharge due to hypo-
thalamic or brainstem insult. In stroke, excessive sympa-
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