Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers

Acute endoscopic intervention in non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding is one of the commonest emergencies encountered by general physicians. Once haemodynamic stability has been achieved, therapeutic endoscopy is vital in control and arrest of bleeding. Various methods are available and the evidence is reviewed as to the most optimal approach. Clinical parameters including timing of endoscopy, risk stratification, and predictors of failure will also be discussed together with a summary of recommendations based on current available evidence.

Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation

OBJECTIVES

To assess the effectiveness of a centralised upper-gastrointestinal haemorrhage (UGIH) unit.

METHODS

The UK Audit of acute UGIH resulted in the formulation of a simple numerical scoring system. The Rockall score categorises patients by risk factors for death and allows case-mix comparisons. A total of 900 consecutive patients admitted to a UGIH unit between October 1995 and July 1998 were analysed prospectively. Patients were given an initial Rockall score and, if endoscopy was performed, a complete score. This method of risk stratification allowed the proportion of deaths (in our study) to be compared with the National Audit using risk standardised mortality ratios.

RESULTS

The distribution of both initial and final Rockall scores was significantly higher in our study than in the National Audit. A total of 73 (8.1%) patients died, compared with the National Audit mortality of 14%. Risk-standardised mortality ratios using both initial and complete Rockall scores were significantly lower in our study when compared with those in the National Audit.

CONCLUSION

A specialised UGIH unit is associated with a lower proportion of deaths from UGIH, despite comprising a greater number of high-risk patients than the National Audit. This lower mortality therefore cannot be attributed to a more favourable case mix and demonstrates that further improvements in mortality for UGIH can be made.

Comparison of three different risk scoring systems in non-variceal upper gastrointestinal bleeding

BACKGROUND AND AIMS

To prospectively validate in patients with non-variceal upper gastrointestinal bleeding three risk scoring systems (the Baylor College scoring system, the Rockall's risk scoring system and the Cedars-Sinai Medical Centre predictive index) previously proposed to be predictive of rebleeding/death after upper gastrointestinal bleeding.

PATIENTS AND METHODS

We calculated values of the scores for 343 patients, who underwent endoscopy after non-variceal upper gastrointestinal haemorrhage during the years 1997-1999. We compared the observed outcomes with the ones expected upon the original series contributed by the authors. Discriminative ability was evaluated by calculating the area under the receiver operating characteristic curve.

RESULTS AND CONCLUSIONS

Rockall's score accurately predicted rebleeding in low- and intermediate-risk categories (< 6), but not in high-risk patients. The rates of rebleeding were significantly higher than the ones predicted by the low-risk categories of either Cedars-Sinai index (< or = 2) or Baylor score (< or = 6). The predicted and the observed mortality was not significantly different throughout all the categories of Rockall's score, except for patients with a score of 4. All the scores had better discriminative ability for mortality than for rebleeding. The Rockall's score identifies a low-risk group of patients (Rockall's score < or = 2) for rebleeding and mortality.

Diagnostic and therapeutic options in the management of nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding from peptic ulcers is common. Advances in prognostication, therapeutic endoscopy, and medical management have evolved rapidly. Patients most likely to rebleed after therapy can now be identified and monitored more closely, and patients with ulcers of low risk for rebleeding can be managed on an outpatient basis. High-risk patients include those with ulcers containing a visible vessel or who are actively bleeding. Endoscopic therapy is mandatory in high-risk patients and involves at least two hemostatic techniques. Second-look endoscopy and repeated hemostasis should be performed promptly in patients who rebleed. Adjunctive treatment includes intravenous proton pump inhibitor administered in high doses for the first 72 hours after endoscopic therapy. Further studies are needed to determine the optimal combination of hemostatic techniques to better target patients who are at risk for ulcer rebleeding.

Recurrent duodenal ulcer haemorrhage: a pharmacoeconomic comparison of various management strategies

BACKGROUND

Duodenal ulcer (DU) bleeding has a 7 - 13% mortality rate and bleeding often recurs. Prevention of recurrence is, therefore, an important goal. Eradication of Helicobacter pylori or maintenance treatment with a proton pump inhibitor (PPI) may reduce recurrent DU bleeding. Economic comparison of these options is sparse.

METHODS

After the control of index bleeding with endotherapy and drugs, three strategies were evaluated: empirical treatment for possible H. pylori infection followed by a PPI for 2 months; test for H. pylori, eradication if positive, maintenance PPI if negative; maintenance PPI alone. Probability and direct cost data were obtained from a Medline search and Indian hospitals, respectively. Cost-minimisation, cost-utility, one- and two-way sensitivity analyses and threshold values were evaluated.

RESULTS

Treatment of H. pylori, particularly empirical, was the preferred strategy and dominated maintenance treatment with PPI. The test-and-treat strategy was better than the empirical treatment strategy only when the probabilities of H. pylori eradication, ulcer healing following eradication and of frequency of H. pylori infection in bleeding DU were less than 58, 73 and 58%, respectively.

CONCLUSIONS

Eradication of H. pylori is preferred in preventing recurrent bleeding from DU.