Original ContributionsRisk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding
Introduction
Upper gastrointestinal bleeding (UGIB) has an estimated incidence of about 102 in 100 000 people per year [1]. Upper gastrointestinal bleeding is a common medical emergency in clinical practice. There is no doubt that hospitalization is mandatory for variceal hemorrhage in cirrhotic patients. However, nonvariceal UGIB is highly inconstant in severity and outcome. Patients with UGIB may present with a wide range of clinical severity, ranging from insignificant bleeding to fatal outcomes [2]. Several systems have been designed to identify patients with high risks of adverse outcomes (commonly defined as a risk of recurrent bleeding of >5% and >1% mortality) and differentiate them from patients with lower risks [3], [4], [5], [6], [7], [8]. However, because clinical treatment aims to prevent patients from dying and complication, we believe that identifying which patients will require clinical intervention is more practical than identifying who may die or have recurrent bleeding.
The Blatchford score suggests that it be used to identify patients with acute UGIB who need clinical intervention before endoscopy. Patients with a Blatchford score of greater than 0 are considered to require clinical intervention [9]. The clinical Rockall score is calculated from routine clinical variables. Patients with a clinical Rockall score of greater than 0 are considered to be at high risk for adverse outcomes. Besides the clinical Rockall score, the complete Rockall score is calculated from clinical and endoscopic variables. Patients with a complete Rockall score of greater than 2 are considered to be at high risk for recurrent bleeding and death [2], [3], [10], [11].
Our study aims to compare the Blatchford score with the clinical Rockall score and the complete Rockall score in their utilities in assessing the need for clinical intervention in patients with acute nonvariceal UGIB.
Section snippets
Methods
An electronic search was made of all adult (>18 years of age) patients with acute UGIB admitted to the emergency department (ED) of Chang Gung Memorial Hospital (Taoyuan County, Taiwan)—a tertiary care, university-affiliated hospital—with an admission diagnosis of gastrointestinal (GI) bleeding (International Classification of Diseases, Ninth Revision codes 5780, 5781, and 5789). This search was made from our hospital's medical record database and began from January 2006 to July 2006. These
Results
Three hundred fifty-four patients with acute nonvariceal UGIB were enrolled and analyzed. Two hundred thirty-seven were men (66.9%) and 117 were women (33.1%). The mean age of total number of patients was 61.6 (16.2SD) years. About 42% (148/354) were actively taking nonsteroidal anti-inflammatory drugs, including aspirin, before UGIB developed. All 354 patients were treated with proton pump inhibitors; 22 were treated with omeprazole (6.2%) and 332 (93.8%) were treated with pantoprazole. Of the
Discussion
In patients with GI tract bleeding, the severity of an upper GI source influences the urgency of upper endoscopy, the need for blood transfusion, and the need to consult specialists to control GI tract bleeding [13], [14], [15], [16]. In recent years, several practice guidelines and risk scores, combining clinical and endoscopic parameters, have been developed [3], [5], [17], [18] with the aim of assisting physicians in the early stages of decision making [3], [15], [19], [20], [21], [22], [23]
Conclusion
In summary, 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.
Further prospective studies are indicated to evaluate such risk stratification system in the
Acknowledgment
We thank Mrs Estella Liu for her thoughtful comment on this article.
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