Admission Hypocalcemia and the Need for Endoscopic and Clinical Interventions among Patients with Upper Gastrointestinal Bleeding.

INTRODUCTION: Calcium is an essential co-factor in the coagulation cascade and hypocalcemia is associated with adverse outcomes in bleeding patients, including trauma patients, women with postpartum hemorrhage, and patients with intracranial hemorrhage. In this retrospective, single-center, cohort study, we aimed to determine whether admission ionized calcium (Ca++) is associated with higher rates of therapeutic interventions among patients presenting with acute non-variceal upper gastrointestinal bleeding (NV-UGIB).

METHODS: Adult patients admitted due to NV-UGIB between 1/2009-4/2020 were identified. The primary outcome was defined as a need for clinical intervention (two or more packed cell transfusions, need for endoscopic, surgical, or angiographic intervention). Univariate and multivariable logistic regression analyses were performed to determine whether Ca++ was an independent predictor of the need for therapeutic interventions. Propensity score matching was performed to adjust the imbalances of covariates between the groups.

RESULTS: A total of 434 patients were included, of whom 148 (34.1%) had hypocalcemia (Ca++<1.15mmol/L). Patients with hypocalcemia were more likely to require therapeutic interventions than those without hypocalcemia (48.0% vs. 18.5%, p<0.001). Specifically, patients with hypocalcemia were more likely to require endoscopic intervention for control of bleeding (25.0% vs. 15.7%, p=0.03) and require multiple packed cell transfusions (6.8% vs. 0.3%, p<0.001). Additionally, they had significantly longer hospital stay (5.0 days [IQR 3.0-8.0] vs. 4.0 days [IQR 3.0-6.0], p=0.01). After adjusting for multiple covariates, Ca++ was an independent predictor of the need for therapeutic intervention (aOR 1.62, 95% CI 1.22-2.14, p<0.001). The addition of Ca++ to Modified Glasgow Blatchford score improved its accuracy in the prediction of therapeutic intervention from AUC of 0.68 (95% CI 0.63-0.72) to 0.72 (95% CI 0.67-0.76), p=0.02. After incorporation of the propensity score, the results did not change significantly.

CONCLUSION: These findings suggest that hypocalcemia is common and is associated with an adverse clinical course in patients with NV-UGIB. Measurement of Ca++ on admission may facilitate risk stratification in these patients. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.