Gastrointestinal hemorrhage in the setting of gastrointestinal cancer: Anatomical prevalence, predictors, and interventions

Table 1 ICD-10-CM and PCS codes for diagnoses and procedures

Diagnosis	ICD-10-CM
GI hemorrhage	Upper: I85.x1; (K25-K28).0,2,4,6; K29.x1; K318.11 K31.82
	Lower: K50.x11; K51.x11; K55.21; K57.x1; K57.x3
	Total = upper + lower + K62.5; K92.0-2
GI cancer
Esophageal cancer	C15; C49.A1; D00.1
Upper third	C15.3
Middle third	C15.4
Lower third	C15.5
Other/unspecified	C15.8-9; C49.A1; D00.1
Gastric cancer	C16; C49.A2; D00.2
Cardia	C16.0
Fundus	C16.1
Body	C16.2
Pyloric antrum	C16.3
Pylorus	C16.4
GIST	C49.A2
Other/unspecified	C16.5-9; D00.2
Small bowel cancer	C17; C49.A3; D01.49
Duodenum	C17.0
Jejunum	C17.1
Ileum	C17.2
GIST	C49.A3
Other/unspecified	C17.3-9; D01.49
Liver cancer	C22; D01.5
Hepatocellular carcinoma	C22.0
Other primary liver	C22.2-8; D01.5
Biliary cancer	C22.1; C24
Intrahepatic	C22.1
Extrahepatic	C24.0
Ampulla of Vater	C24.1
Other/unspecified	C24.8-9
Gallbladder cancer	C23
Pancreatic cancer	C25
Head	C25.0
Body	C25.1
Tail	C25.2
Duct	C25.3
Endocrine	C25.4
Other/unspecified	C25.7-9
Colorectal cancer	C18; C19; C20; C26.0; C49.A4-5; D01.0-4
Cecum	C18.0
Appendix	C18.1
Ascending colon	C18.2
Hepatic flexure	C18.3
Transverse colon	C18.4
Splenic flexure	C18.5
Descending colon	C18.6
Sigmoid	C18.7
Rectosigmoid junction	C19
Rectum	C20
Other/unspecified	C188.9-9; C26.0; C49.A4-5; D01.0-4
Acute kidney injury	N17; N19; N99.0; O90.4
Chronic kidney disease	D63.1; (E08-E13).22; I12.0,9; I13.10,11,20; N18; R88.0; Z49
Congestive heart failure	I50; I97.13x; O29.12x; Z95.812; I09.81; I11.0; I13.0,2
Cirrhosis and liver failure	K70.4; K70.3; K72; K91.82; K71.7; K74; K76.(6,7); K65.2; I85
Radiation gastroenteritis/proctitis	K52.0; K62.7
Metastasis	C77; C78; C79; C80.0
Chemotherapy and immunotherapy	Z92.21; Z51.11-12; T45.1X; K12.31; D61.81; D64.81
Severe malnutrition and cachexia	E40-43; R64
Obesity	E66.01; E66.09; E66.(1,2,8,9); Z68.3-4
Palliative care	Z521.5
Aspirin/antiplatelets	Z79.82; Z79.02
Anticoagulants	Z79.01
Intestinal infection	A00-09; A18.32; A21.3; A22.2; B37.82; B25.8-9
Hypovolemic shock	R57.1
Procedures	ICD-10-PCS
Upper endoscopy	06L34CZ; 0D5(1-9)8ZZ; 0DB(1-9)8ZX; 0DB(1-9)8ZZ; 0DBA8ZX; 0DJ08ZZ; 0DQ(6,7,9)8ZZ; 3E0G8TZ
Colonoscopy	06LY4CC; 0D5(E-Q)8ZZ; 0DB(B-Q)8ZZ; 0DB(B-Q)8ZX; 0DJD8ZZ
Surgery	0D(1,5,B,J,T); 0F(5,B,T); OW(J,3) excluding endoscopic approach
Trans-arterial embolization	04(L,V)(1,2,3,5,6,7,9,B)3DZ
Radiation therapy	D(D,F,W)0(0-7)(0-6)Z(0,Z)

GI: Gastrointestinal; GIST: Gastrointestinal stromal tumor.

Table 2 Comparison of gastrointestinal hemorrhage between inpatients who have and do not have gastrointestinal cancer

		GI cancer				Total
		No		Yes
		Count	Within GI cancer (%)	Count	Within GI cancer (%)	Count	Within total (%)
GI bleeding	No	17242568	96.6	291115	90.5	17533683	96.5
	Yes	609695	3.4	30507	9.5	640202	3.5
	Total	17852263	100	321622	100	18173885	100

P < 0.001. GI: Gastrointestinal.

Table 3 Tabulated representation of data of Figure 1 which shows to the prevalence of gastrointestinal hemorrhage according to the anatomic location of gastrointestinal cancer

Anatomic location of cancer		GI hemorrhage
		No		Yes
	n	Count	Row (%)	Count	Row (%)
Esophagus	23674	21508	90.90	2166	9.10
Upper third	773	725	93.80	48	6.20
Middle third	1467	1349	92.00	118	8.00
Lower third	6540	5843	89.30	697	10.70
Other/unspecified	15161	13842	91.30	1319	8.70
Stomach	27409	23103	84.30	4306	15.70
Cardia	6829	5815	85.20	1014	14.80
Fundus	471	351	74.50	120	25.50
Body	1284	1004	78.20	280	21.80
Pyloric antrum	1881	1561	83.00	320	17.00
Pylorus	398	325	81.70	73	18.30
GIST	2477	2060	83.20	417	16.80
Other/unspecified	14410	12256	85.10	2154	14.90
Small bowel	6469	5646	87.30	823	12.70
Duodenum	3270	2760	84.40	510	15.60
Jejunum	513	456	88.90	57	11.10
Ileum	540	509	94.30	31	5.70
GIST	872	737	84.50	135	15.50
Other/unspecified	1322	1228	92.90	94	7.10
Liver	33452	29111	87.00	4341	13.00
HCC	27601	23877	86.50	3724	13.50
Other primary liver	5988	5357	89.50	631	10.50
Bile ducts	18706	17577	94.00	1129	6.00
Intrahepatic	12515	11749	93.90	766	6.10
Extrahepatic	2749	2608	94.90	141	5.10
Ampulla of Vater	2143	2008	93.70	135	6.30
Other/unspecified	1464	1368	93.40	96	6.60
Gallbladder	4268	4049	94.90	219	5.10
Pancreas	63636	59063	92.80	4573	7.20
Head	17643	16469	93.30	1174	6.70
Body	3077	2882	93.70	195	6.30
Tail	3892	3630	93.30	262	6.70
Ducts	774	718	92.80	56	7.20
Endocrine	589	548	93.00	41	7.00
Other/unspecified	38379	35489	92.50	2890	7.50
Colon and rectum	148943	135410	90.90	13533	9.10
Cecum	12171	10863	89.30	1308	10.70
Appendix	3967	3835	96.70	132	3.30
Ascending	16104	14458	89.80	1646	10.20
Hepatic flexure	3280	2916	88.90	364	11.10
Transverse	7439	6687	89.90	752	10.10
Splenic flexure	2033	1851	91.00	182	9.00
Descending	4239	3862	91.10	377	8.90
Sigmoid	17602	15976	90.80	1626	9.20
Rectosigmoid	17199	15527	90.30	1672	9.70
Rectum	29634	26730	90.20	2904	9.80
Other/unspecified	40531	37341	91.50	3190	8.50

GI: Gastrointestinal; GIST: Gastrointestinal stromal tumor; HCC: Hepatocellular carcinoma.

Table 4 Bivariate analysis comparing various factors based on gastrointestinal hemorrhage status in a population of inpatients with gastrointestinal cancer

Inpatients with GI cancer		No GI hemorrhage		GI hemorrhage		P value
		n = 291115		n = 30507
		Count/mean	Column%/SD	Count/mean	Column%/SD
Demographic factors
Age (yr)		66.2	± 12.8	68.2	± 13.2	< 0.001
Female		125898	43.30	11543	37.80	< 0.001
Race	White	192544	68.30	18633	63.00	< 0.001
	Black	37986	13.50	4727	16.00	< 0.001
	Hispanic	29010	10.30	3462	11.70	< 0.001
	Asian or Pacific Islander	11482	4.10	1562	5.30	< 0.001
	Native American	1494	0.50	189	0.60	0.015
	Other	9345	3.30	999	3.40	0.543
Socioeconomic factors
Insurance	Medicare	161272	55.50	18371	60.30	< 0.001
	Medicaid	33523	11.50	3859	12.70	< 0.001
	Private	81599	28.10	6483	21.30	< 0.001
	Self-pay	6348	2.20	894	2.90	< 0.001
	No charge	628	0.20	71	0.20	0.544
	Other	7379	2.50	799	2.60	0.373
Median household income for patient ZIP Code	1st quartile	78840	27.60	8905	29.70	< 0.001
	2nd quartile	73759	25.80	7733	25.80	0.965
	3rd quartile	69806	24.40	7072	23.60	0.003
	4th quartile	63693	22.30	6241	20.80	< 0.001
Comorbidities
Acute kidney injury		55007	18.90	7849	25.70	< 0.001
Chronic kidney disease		38425	13.20	5766	18.90	< 0.001
Heart failure		8704	3.00	1289	4.20	< 0.001
Cirrhosis and liver failure		32194	11.10	6154	20.20	< 0.001
Intestinal infection		6694	2.30	753	2.50	0.06
Cancer related
Metastasis		125345	43.10	12120	39.70	< 0.001
Chemo and Immunotherapy		57005	19.60	4314	14.10	< 0.001
Radiation gastroenteritis/proctitis		849	0.30	189	0.60	< 0.001
Palliative care		38129	13.10	5318	17.40	< 0.001
Nutritional status
Severe malnutrition and cachexia		41008	14.10	4952	16.20	< 0.001
Obesity		32691	11.20	3127	10.30	< 0.001
Use of antithrombotic/anticoagulants
Aspirin/antiplatelets		30778	10.60	3605	11.80	< 0.001
Anticoagulants		22753	7.80	3345	11.00	< 0.001

Bold values represent a statistically significant higher column proportion. GI: Gastrointestinal.

Table 5 The results of multivariate analysis showing the predictors of gastrointestinal hemorrhage in a population of patients with gastrointestinal cancer

Predictors of GI hemorrhage
		aOR	95%CI	P value
Demographic factors
Age (yr)		1.01	(1.01-1.02)	< 0.001
Female		0.84	(0.81-0.86)	< 0.001
Race	White- Reference	1.00	-	-
	Black	1.27	(1.22-1.31)	< 0.001
	Hispanic	1.19	(1.14-1.24)	< 0.001
	Asian or Pacific Islander	1.42	(1.34-1.50)	< 0.001
	Native American	1.24	(1.06-1.46)	0.007
	Other	1.13	(1.05-1.21)	0.001
Socioeconomic factors
Insurance	Medicare- Reference	1.00	-	-
	Medicaid	1.17	(1.12-1.22)	< 0.001
	Private	0.91	(0.88-0.94)	< 0.001
	Self-pay	1.44	(1.34-1.56)	< 0.001
	No charge	1.21	(0.94-1.56)	0.148
	Other	1.03	(0.95-1.12)	0.468
Median household income for patient ZIP Code	1st quartile- Reference	1.00	-	-
	2nd quartile	0.98	(0.95-1.01)	0.246
	3rd quartile	0.96	(0.93-0.99)	0.022
	4th quartile	0.94	(0.90-0.97)	< 0.001
Comorbidities
Acute kidney injury		1.17	(1.13-1.20)	< 0.001
Chronic kidney disease		1.22	(1.18-1.26)	< 0.001
Heart failure		1.19	(1.12-1.27)	< 0.001
Cirrhosis and liver failure		1.84	(1.78-1.90)	< 0.001
Cancer related
Metastasis		0.93	(0.90-0.95)	< 0.001
Chemo and Immunotherapy		0.74	(0.72-0.77)	< 0.001
Radiation gastroenteritis/proctitis		2.39	(2.02-2.81)	< 0.001
Palliative care		1.21	(1.17-1.26)	< 0.001
Nutritional status
Severe malnutrition and cachexia		1.12	(1.08-1.15)	< 0.001
Obesity		0.94	(0.90-0.98)	0.001
Use of antithrombotic/anticoagulants
Aspirin/antiplatelets		1.09	(1.05-1.13)	< 0.001
Anticoagulants		1.48	(1.42-1.54)	< 0.001

Bold values represent a statistically significant odds ratio > 1 [in favor of gastrointestinal hemorrhage (GIH)]; multivariate logistic regression of outcome (GIH) was performed using the backward stepwise method to determine statistically significant factors; variables included in the analysis: Age, female, race, insurance, income, acute kidney injury, chronic kidney disease, heart failure, cirrhosis and liver failure, intestinal infection, metastasis, chemotherapy and immunotherapy, radiation gastroenteritis, palliative care, severe malnutrition and cachexia, obesity, aspirin/antiplatelet, and anticoagulant; intestinal infection was a statistically non-significant factor; GI: Gastrointestinal; CI: Confidence interval; OR: Odds ratio.

Table 6 The results of multivariate analysis showing the odds ratio of inpatient mortality associated with different interventions (endoscopy, surgery, embolization, radiation)

		GI bleeding patients with cancer
		All GI Ca	Esophageal Ca	Gastric Ca	Hepatic Ca	Biliary Ca	Gallbladder Ca	Pancreatic Ca	Small bowel Ca	Colorectal Ca
Mortality aOR (95%CI)	Endoscopy	0.42 (0.38-0.46)	0.42 (0.31-0.57)	0.42 (0.32-0.54)	0.36 (0.29-0.43)	0.43 (0.28-0.66)	0.71 (0.24-2.11)	0.36 (0.29-0.44)	1.19 (0.59-2.43)	0.45 (0.38-0.54)
	Surgery	0.97 (0.84-1.13)	-	1.73 (1.00-3.00)	1.30 (0.67-2.53)	-	-	0.85 (0.49-1.48)	2.26 (0.95-5.36)	1.33 (1.09-1.62)
	Trans-arterial embolization	1.35 (1.02-1.80)	-	1.46 (0.81-2.62)	1.12 (0.55-2.30)	-	-	0.98 (0.56-1.69)	-	2.52 (1.23-5.15)
	Radiation therapy	0.55 (0.29-1.05)	-	-	-	-	-	-	-	-

Bold values: Statistically significant (P < 0.05). Adjusted odds ratio with 95% confidence interval; empty cells indicate that analysis for the corresponding intervention was not performed due to the insufficient sample size; multivariate logistic regression of outcome (mortality) was performed using the backward stepwise method to determine statistically significant factors; variables included in the analysis: Age, female, race, income, acute kidney injury, chronic kidney disease, heart failure, cirrhosis and liver failure, intestinal infection, metastasis, chemotherapy and immunotherapy, radiation gastroenteritis, palliative care, hypovolemic shock, endoscopy, surgery, embolization, and radiation therapy. GI: Gastrointestinal. CI: Confidence interval; Ca: Cancer; OR: Odds ratio.