Comparison of 3 scoring systems to predict mortality from unstable upper gastrointestinal bleeding in cirrhotic patients

Objective

We aimed to compare the performance of Glasgow-Blatchford, preendoscopic Rockall, and model for end-stage liver disease (MELD) scores in cirrhotic patients with unstable upper gastrointestinal bleeding (UGIB) in the emergency department (ED).

Methods

This was a retrospective cohort study conducted at a university-affiliated teaching hospital. Adult cirrhotic patients who presented with acute UGIB and unstable vital signs (heart rate > 100 beats/min or systolic blood pressure < 100 mm Hg) between January 2009 and February 2011 were included. Patients who were transferred from another hospital, received no emergency endoscopy study, or had incomplete medical records were excluded. Data were retrieved from the admission list of the ED critical zone using international classification of disease code via computer registration.

Results

Among enrolled visits, the initial median hemoglobin level was 8.6 (interquartile range, 7.2-10.1) mg/dL in the ED. The median heart rate and systolic blood pressure were 111.0 beats/min and 94.0 mm Hg, respectively. The endoscopic diagnosis of variceal bleeding accounted for 86.6% of the events. The mortality rate was 16.0% (19/119). Model for end-stage liver disease score performed better with an area under the curve (AUC) of 0.736 (95% confidence interval [CI], 0.629-0.842; P = .001) compared with other scoring systems (Glasgow-Blatchford score: AUC, 0.527; 95% CI, 0.393-0.661; P = .709; preendoscopic Rockall score: AUC, 0.591; 95% CI, 0.465-0.717; P = .208).

Conclusion

Model for end-stage liver disease score performed better in terms of predicting mortality of unstable UGIB in cirrhotic patients compared with Glasgow-Blatchford and preendoscopic Rockall scores in the ED.     

Massive transfusion in upper gastrointestinal bleeding: a new scoring system

Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization.

Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24?h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy.

Results: Five characteristics were independently associated (p?<?.001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100?mmHg (shock), haemoglobin <8.0?g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827–0.836; AUROC: 0.822, 95% CI: 0.817–0.826, respectively).

Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well.

• Key messages

• Massive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented.

• Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion.

• A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.

     

Prediction of in-hospital mortality after acute upper gastrointestinal bleeding: cross-validation of several risk scoring systems

ObjectiveWe aimed to identify the clinical, biochemical, and endoscopic features associated with in-hospital mortality after acute upper gastrointestinal bleeding (AUGIB), focusing on cross-validation of the Glasgow-Blatchford score (GBS), full Rockall score (RS), and Cedars-Sinai Medical Center Predictive Index (CSMCPI) scoring systems.MethodsOur prospective cross-sectional study included 156 patients with AUGIB. Several statistical approaches were used to assess the predictive accuracy of the scoring systems.ResultsAll three scoring systems were able to accurately predict in-hospital mortality (area under the receiver operating characteristic curve [AUC] > 0.9); however, the multiple logistic model separated the presence of hemodynamic instability (state of shock) and the CSMCPI as the only significant predictive risk factors. In compliance with the overall results, the CSMCPI was consistently found to be superior to the other two systems (highest AUC, highest sensitivity and specificity, highest positive and negative predictive values, highest positive likelihood ratio, lowest negative likelihood ratio, and 1-unit increase in CSMCPI associated with 6.3 times higher odds of mortality), outperforming the GBS and full RS.ConclusionsWe suggest consideration of the CSMCPI as a readily available and reliable tool for accurately predicting in-hospital mortality after AUGIB, thus providing an essential backbone in clinical decision-making.     

Comparison of risk scoring systems in predicting clinical outcome at upper gastrointestinal bleeding patients in an emergency unit

Background

Admission Rockall score (RS), full RS, and Glasgow-Blatchford Bleeding Score (GBS) can all be used to stratify the risk in patients presenting with upper gastrointestinal bleeding (UGIB) in the emergency department (ED). The aim of our study was to compare both admission and full RS and GBS in predicting outcomes at UGIB patients in a Romanian ED.

Patients and Methods

A total of 229 consecutive patients with UGIB were enrolled in the study. Patients were followed up 60 days after admission to ED because of UGIB episode to determine cases of rebleeding or death during this period. By using areas under the curve (AUCs), we compared the 3 scores in terms of identifying the most predictive score of unfavorable outcomes.

Results

Rebleeding rate was 40.2% (92 patients), and mortality rate was 18.7% (43 patients). For the prediction of mortality, full RS was superior to GBS (AUC, 0.825 vs 0.723; P = .05) and similar to admission RS (AUC, 0.792). Glasgow-Blatchford Bleeding Score had the highest accuracy in detecting patients who needed transfusion (AUC, 0.888) and was superior to both the admission RS and full RS (AUC, 0.693 and 0.750, respectively) (P < .0001). In predicting the need for intervention, the GBS was superior to both the admission RS and full RS (AUC, 0.868, 0.674, and 0.785, respectively) (P < .0001 and P = .04, respectively).

Conclusions

The GBS can be used to predict need for intervention and transfusion in patients with UGIB in our ED, whereas full RS can be successfully used to stratify the mortality risk in these patients.     

Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

Background

Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB.

Methods

International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients.

Results

The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score (P < .0001) or with the complete Rockall score (P < .0001).In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion.

Conclusions

The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.     

Rockall评分系统在急性非静脉曲张性上消化道出血患者中的应用

目的探讨Rockall危险积分在急性非静脉曲张性上消化道出血患者中的应用,评估其对死亡及再出血的预测能力准确性。方法回顾性分析上海浦东医院消化科ANVUGIB患者474例,按年龄段分为〈40岁组、40～59岁组、60～79岁组和／〉80岁组,应用Rockall评分系统进行评分,采用受试者工作特征曲线（ROC）下面积（AUC）评估其对ANVUGIB再出血及死亡的预测能力。结果474例ANVUGIB患者中男性与女性之比约为2．36：1,死亡22例（4．64％）,再出血54例（11．39％）。Rockalli~分系统预测死亡的AUC=0．849（P〈0．05）,预测再出血的AUC=0．675（P〉0．05）。各组再出血率分别为10％、7．53％、12．58％、19．58％。Rockall评分系统评估各组再出血率AUC分别为0．610、0．740、0．632、0．727。各组死亡率分别为0％、5．48％、2．65％、10．3％。结论Rockall评分系统对ANVUGIB死亡的预测能力良好。Rockall评分系统对40～59岁组、≥80岁组ANVUGIB患者再出血预测价值较高。     

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) remains an important cause of morbidity and mortality. The etiological role and the relative risk of nonsteroidal anti-inflammatory drugs (NSAIDs) in association with other clinical factors are the focus of several papers published in the last year. Data from studies that evaluate the interaction of NSAIDs with Helicobacter pylori suggest that there is a clear role for eradication in aspirin-related bleeding. Although the benefit of H. pylori eradication in nonaspirin NSAID-related bleeding is being debated, they should both be eliminated given their relative contribution to the causation of peptic ulcer hemorrhage. The search for reliable and accurate tools to predict outcomes after NVUGIB continues. Recent important contributions in this area of research are the use of a clinical prediction guide to identify patients who are likely to require endoscopic intervention, and the use of Doppler ultrasound examination of the ulcer base to predict rebleeding. The role of antisecretory therapy in the setting of acute NVUGIB has been revisited in two meta-analyses and one randomized, placebo-controlled trial of omeprazole as an adjunct to endoscopic intervention. Until more definitive data are available, it appears that the effect of acid-decreasing medications is more important when endoscopic therapy is not provided than when effective endoscopic intervention is instituted. With regard to therapeutic endoscopy for upper gastrointestinal bleeding, the few randomized trials that have been published in full form in the last year focus on the use of mechanical methods of hemostasis for peptic ulcer bleeding and other etiologies such as Mallory-Weiss tears and Dieulafoy lesions.     

Nonvariceal upper gastrointestinal bleeding

Gastroduodenal ulcerations still account for the majority of nonvariceal gastrointestinal hemorrhage. The causative roles of Helicobacter pylori and nonsteroidal anti-inflammatory drugs (NSAIDs) are still being discussed, but the role of H. pylori appears less significant in the complicated ulcers, while NSAIDs are increasingly implicated. The two factors do not appear to potentiate each other, and some data suggest that H. pylori should not be eradicated in the context of an NSAID-related ulcer hemorrhage. The role of triage and risk assessment was highlighted in several of last year's publications, and increasing attention has been given to the cost aspects of peptic ulcer bleeding. There have been few comparative therapeutic trials, but several reports from Japan make a case for ethanol injection as an alternative to other injection agents. However, a randomized comparative trial is needed to further define the role of this technique. Radiological embolization techniques and minimally invasive surgery are increasingly becoming viable options in patients with complex cases, and a multidisciplinary approach is perhaps even more crucial today than ever before.     

Nonvariceal upper gastrointestinal bleeding

Although the incidence of nonvariceal upper gastrointestinal bleeding (NVUGIB) may be decreasing, the case fatality associated with it remains unchanged. What do the most recent studies tell us about medical and endoscopic therapy? Erythromycin is a potentially useful adjunct to endoscopy, and further data are needed to establish its role in the management of patients with NVUGIB. The use of proton-pump inhibitors in addition to combination endoscopic therapy appears to reduce the rebleeding rate consistently across different studies; the route of administration, dosage, and duration of treatment require further definition. Although two controlled studies suggest improved outcomes with clot removal and endoscopic therapy, the exact role of endoscopic treatment in the setting of overlying clots remains controversial. Hemoclips have not been found, in general, to be superior to the available endoscopic techniques. Currently, other hemostatic techniques such as injection and thermocoagulation - and in particular, combination therapy using both methods - are preferable. No major "breakthrough" endoscopic treatment has emerged. Newer endoscopic therapies such as cryotherapy are interesting, but have not had widespread application. Endoscopic suturing techniques, as used in the treatment of esophageal reflux and obesity, have not been adapted to the management of gastrointestinal bleeding.     

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.     

Hemodynamically stable upper gastrointestinal bleeding

This article is a prospective evaluation of 38 patients presenting to an emergency department (ED) with hematemesis but who were otherwise hemodynamically stable. Four patients were admitted, only one because of the development of hemodynamic instability. Thirty-three patients were discharged; on follow-up there was no evidence of major morbidity or mortality. Two patients were lost to follow-up, one who left against medical advice and one who lived in a county outside the service area of our hospital. Patients with hematemesis can be safely discharged from the ED after observation for 6 hours if they: (1) lack orthostatic vital sign changes; (2) lack associated significant underlying disease; (3) have a hemoglobin concentration greater than 10 gm/dL; (4) are less than 60 years of age; and (5) are thought to be reliable and compliant.     

The outcome of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study

BACKGROUND AND STUDY AIM: The aim was to evaluate the 30-day mortality after endoscopy for suspected upper gastrointestinal bleed, following the implementation of national audit guidelines at our hospital. PATIENTS AND METHODS: All patients with suspected upper gastrointestinal bleeding, referred for endoscopy to our teaching hospital between October 2001 and December 2003, were included in a prospective cohort study. RESULTS: A total of 716 patients with suspected upper gastrointestinal tract haemorrhage were referred for urgent endoscopy. The median age was 69 years (interquartile range 51 - 80 years). Bleeding from peptic ulcer remained the single most common endoscopic diagnosis (40 %). The overall re-bleeding rate for all patients with a gastrointestinal haemorrhage was 10 %. The overall 30-day mortality rate was 14.6 %. This was not significantly different from the mortality rate in 1995 of 10.5 % ( P = 0.11). Patients who died were significantly older (78 vs. 67 years, 95 %CI of the difference 5 to 12, P < 0.001). However, in only 29 % (30/105) was gastrointestinal haemorrhage stated in the death certificate as a factor which contributed to their death. CONCLUSIONS: Our results show that implementing the good practice guideline has a limited impact on overall mortality because of contributing factors that are beyond the control of clinicians.     

Management of non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a critical condition that demands a quick and effective medical management. Non-variceal UGIB, especially peptic ulcer bleeding is the most significant cause. Appropriate assessment and treatment have a major influence on the prognosis of patients with UGIB. Initial fluids resuscitation and/or transfusion of red blood cells are necessary in patients with clinical evidence of intravascular volume depletion. Endoscopy is essential for diagnosis and treatment of UGIB, and should be provided within 24 hours after presentation of UGIB. Pre-endoscopic use of intravenous proton pump inhibitor (PPI) can downstage endoscopic signs of hemorrhage. Post-endoscopic use of high-dose intravenous PPI can reduce the risk of rebleeding and further interventions such as repeated endoscopy and surgery. Eradication of Helicobacter pylori and withdrawal of non-steroidal anti-inflammatory drugs are recommended to prevent recurrent bleeding.