Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage

doi:10.1016/S0016-5107(04)01524-X

Gastrointestinal Endoscopy

Volume 60, Issue 1, July 2004, Pages 9-14

https://doi.org/10.1016/S0016-5107(04)01524-X Get rights and content

Abstract

Background

Risk scores for triage of patients with acute upper-GI hemorrhage that incorporate endoscopic variables (e.g., the complete Rockall Score) may have better test characteristics for identification of “low-risk” bleeding episodes than those (e.g., Blatchford Score, clinical Rockall Score) that rely solely on clinical variables. An endoscopy-based risk score was compared with two clinically based risk scores in a large cohort of patients hospitalized for treatment of acute upper-GI hemorrhage to quantify the incremental value of endoscopy in the identification of low-risk bleeding.

Methods

ICD-9-CMcodes for discharge diagnosis were used to identify a cohort of patients (n = 175) hospitalized at a university medical center with acute non-variceal upper-GI hemorrhage. Medical record data were abstracted by two data abstractors blinded to the study intent by using a standardized data collection instrument. Blatchford and Rockall Scores were generated for each case. Low risk was defined as a Blatchford Score of 0, a clinical Rockall Score of 0, or complete Rockall Score of 2 or less.

Results

The Blatchford Score risk stratified only 14 of 175 (8%) patients with acute, non-variceal upper-GI hemorrhage as “low risk,” while the clinical Rockall Score identified 12%. However, the complete Rockall Score identified the greatest number of low-risk cases, 53/175 (30%) (p < 0.0001), when compared with either the Blatchford or clinical Rockall Score.

Conclusions

The complete Rockall Score identified significantly more low-risk patients with acute upper-GI hemorrhage than either the clinical Rockall Score or the Blatchford Score. Identification of additional low-risk patients via this endoscopy-based score could lead to decreases in the use of hospital-based services, iatrogenic complications, and time lost from work or usual activity, while improving quality of care. Use of the clinical and complete Rockall Scores sequentially, with consideration of outpatient care for patients at identified as low risk, is recommended.

Section snippets

Patients and methods

An historical cohort study was conducted by using existing medical record data for patients admitted to a tertiary care, university affiliated hospital with acute UGIH. The office for the protection of research subjects of our university approved the study. Potential cases were identified via an electronic search of an administrative database containing data on all consecutive adult patients (>18 years of age) hospitalized during calendar years 1997 and 1998. These years were chosen because

Results

A total of 175 adult patients (mean age 62 [19] years) with acute, non-variceal UGIH were identified during the study period; 54% (95/175) were men. Almost half (46%) were actively taking non-steroidal anti-inflammatory drugs (NSAID), including aspirin, at the time of hospital admission. The most common endoscopic diagnoses were gastric ulcer (40 patients, 23%) and duodenal ulcer (23 patients, 13%) (Fig. 1). Two thirds of all patients and 72% of those with a complete Rockall Risk Score of less

Discussion

With continued increases in the cost of health care, the appropriateness of expensive in-hospital treatment has come under growing scrutiny by health care policy planners. As a result, the delivery of health care by gastroenterologists is increasingly being shifted to the outpatient setting. A key concern for health care providers is that efforts to decrease inappropriate use of services do not inadvertently place restrictions on access to necessary care. Because acute UGIH is among the most

Acknowledgments

We wish to thank Tommy T. Oei, MD, and Dong Chang, MD, for assistance with data collection.

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Citation Excerpt :
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A total of 96,887 discharges with PUB as a diagnosis were identified—3574 with PUB and cirrhosis and 93,313 with PUB alone without cirrhosis. Mortality of PUB with concomitant cirrhosis was higher than in the control group without cirrhosis (5.5% vs 2%; P = .01); decompensated cirrhosis had higher mortality than did compensated cirrhosis (6.6% vs 3.9%; P = .01). In multivariate analysis, the presence of cirrhosis independently increased mortality (adjusted odds ratio (aOR) 3.3; 95% confidence interval [CI], 2.2-4.9). Stratified analysis showed that decompensated cirrhosis (aOR 4.4; 95% CI, 2.6-7.3) had higher mortality than compensated cirrhosis (aOR 1.9; 95% CI, 1.04-3.6). There was no difference in the proportion of patients who underwent endoscopy within 24 hours (51.9% vs 51.1%; P = .68) between those with cirrhosis and controls. Patients with cirrhosis received less surgical intervention (aOR 0.8; 95% CI, 0.6-0.9) compared with controls. Hospitalization costs also were increased in patients with decompensated cirrhosis.
Administrative data set.
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^☆: Dr. Gralnek is supported by a VA HSR&D Advanced Research Career Development Award and VA HSR&D IIR 01-191-1. Dr. Dulai is supported by an NIH/NCRR K23 Career Development Award 1618801.

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Original ArticlesIncremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage☆

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Discussion

Acknowledgments

Lancet

Lancet

Lancet

Lancet

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Original Articles
Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage☆