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

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Abstract

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.

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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