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

The value of multidetector-row computed tomography for localization of obscure acute gastrointestinal bleeding

PURPOSE

There are no simple guidelines on when to perform multidetector-row computed tomography (MDCT) for diagnosis of obscure acute gastrointestinal bleeding (AGIB). We used a risk scoring system to evaluate the diagnostic power of MDCT for patients with obscure AGIB.

MATERIALS AND METHODS

Ninety-two patients with obscure AGIB who were referred for an MDCT scan after unsuccessful endoscopic treatment at presentation were studied. We recorded clinical data and calculated Blatchford score for each patient. Patients who required transfusion more than 500mL of blood to maintain the vital signs were classified as high-risk patients. Two radiologists independently reviewed and categorized MDCT signs of obscure AGIB. Discordant findings were resolved by consensus. One-way ANOVA was used to compare clinical data between two groups; kappa statistics were used to estimate agreement on MDCT findings between radiologists.

RESULTS

Of the 92 patients, 62 (67.4%) were classified as high-risk patients. Blatchford scores of high-risk patients were significantly greater than those of low-risk patients. Sensitivity for MDCT diagnosing obscure AGIB was 81% in high-risk patients, as compared with 50% in the low-risk. When used in conjunction with selection of the cut-off value of 13 in Blatchford scoring system, the sensitivity and specificity of MDCT were 70.9% and 73.7%, respectively. Contrast extravasation was the most specific sign of AGIB (k=.87), recognition of which would have improved diagnostic accuracy.

CONCLUSIONS

With the aid of Blatchford scoring system for evaluating the disease severity, MDCT can localize the bleeders of obscure AGIB more efficiently.

Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage

BACKGROUND

The need for therapeutic endoscopy in patients with upper GI hemorrhage is important in determining the risk and disposition of these patients. Pre-endoscopic risk scores may be helpful in predicting this need.

OBJECTIVE

To test the Blatchford and pre-endoscopic Rockall scores with the need for therapeutic endoscopy as the primary outcome.

DESIGN

Prospective validation study.

SETTING

Tertiary-care university-affiliated hospital.

PATIENTS AND INTERVENTIONS

Between January 1, 2006 and February 28, 2007, 1087 patients with upper GI hemorrhage who had undergone an inpatient EGD within 24 hours were entered in the study.

MAIN OUTCOME MEASUREMENTS

Blatchford and pre-endoscopic Rockall scores were prospectively calculated for all patients, and the need for therapeutic endoscopy was determined during the EGD.

RESULTS

Of the 1087 patients, 297 (27.3%) needed therapeutic endoscopy. The mean Blatchford score for those who needed therapeutic endoscopy was significantly higher (mean [standard deviation]: 10.3 [3.5] vs 7.0 [4.4], P < .001). The area under a receiver-operating characteristic curve was 0.72 (95% CI, 0.68-0.75). A threshold of 0 (low risk) predicted the need for therapeutic endoscopy with 100% sensitivity and 6.3% specificity. Fifty (4.6%) patients were identified as low risk. The pre-endoscopic Rockall score was unable to predict this need.

LIMITATIONS

The decision to perform therapeutic endoscopy is a subjective one, although endoscopists are trained to follow international consensus guidelines.

CONCLUSIONS

The Blatchford score is more useful for predicting low-risk patients who do not need therapeutic endoscopy and who may be suitable for outpatient management. A threshold of 0 for low risk should be used. The Rockall score is not helpful in predicting the presence of low-risk lesions.

The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage

BACKGROUND

Upper gastrointestinal (UGI) haemorrhage is a frequent cause of hospital admission. Scoring systems have been devised to identify those at risk of adverse outcomes. We evaluated the Glasgow Blatchford score's (GBS) ability to identify the need for clinical and endoscopic intervention in patients with UGI haemorrhage.

METHODS

A retrospective observational study was performed in all patients who attended the A&E department with UGI haemorrhage during a 12-month period. Patients were separated into low and high risk categories. High risk encompassed patients who required blood transfusions, operative or endoscopic interventions, management on high dependency or intensive care units, and those who re-bled, represented with further bleeding, or who died.

RESULTS

A total of 174 patients were seen with UGI bleeding. Eight of them self-discharged and were excluded. Of the remaining 166, 94 had a 'low risk' bleed, and 72 'high risk'. The GBS was significantly higher in the high risk (median = 10) than in the low risk group (median 1, p < 0.001). To assess the validity of the GBS at separating low and high risk groups, receiver-operator characteristic (ROC) curves were plotted. The GBS had an area under ROC curve of 0.96 (95% CI 0.95-1.00). When a cut-off value of > or = 3 was used, sensitivity and specificity of GBS for identifying high risk bleeds was 100% and 68%. Thus at a cut-off value of < or = 2 the GBS is useful for distinguishing those patients with a low risk UGI bleed.

CONCLUSIONS

The GBS accurately identifies low risk patients who could be managed safely as outpatients.

Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score

BACKGROUND

The Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death.

AIMS

To identify the GBS that predicts lack of intervention or death and to apply this to clinical practice by managing low-risk patients in the community.

METHODS

GBSs prospectively calculated on 232 patients with upper gastrointestinal haemorrhage to identify low-risk score. Patients with low-risk of requiring intervention (GBS <or=2, age <70 years) from a further 304 patients were considered for management in the community.

RESULTS

Fifty-two of 232 patients in the first cohort had a GBS <or=2 and were aged less than 70 years: none of these required intervention or died. In the second cohort 104 of 304 (34.2%) patients had a GBS <or=2 and were aged less than 70 years, none of whom died or required endoscopic therapy, blood transfusion, surgery or died. Thrity-two of 104 (10.5% of total cohort) were safely managed in the community.

CONCLUSION

Using the criteria of a GBS <or=2, aged less than 70 years to define patients at 'low risk' allows 10.5% of patients with primary upper gastrointestinal haemorrhage to be safely managed in the community.

Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study

The authors aimed to compare the clinical utility of five scoring systems for the prediction of rebleeding and death in patients with nonvariceal upper gastrointestinal bleeding (UGIB). A total of 239 consecutive patients who had undergone endoscopy due to nonvariceal UGIB were prospectively investigated on the basis of five scoring systems (Forrest classification, Rockall scoring system, Cedars-Sinai Medical Centre Predict Index, Blatchford scoring system, and Baylor college scoring system). Thirty-five patients (14.6%) experienced rebleeding and 20 patients (8.4%) died. Comparison of the high-risk categories of the four predictive systems showed that the Forrest classification was superior to the others in predicting rebleeding and death. The Cedars-Sinai Medical Centre Predict Index and the Rockall scoring system showed high positive predictive values for predicting rebleeding and death, respectively. We concluded that the Forrest classification was the most useful scoring system for the prediction of rebleeding and death in patients with nonvariceal UGIB.

Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation

BACKGROUND

Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.

METHODS

Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.

FINDINGS

Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).

INTERPRETATION

The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

Usefulness of prognostic indices in upper gastrointestinal bleeding

Upper gastrointestinal haemorrhage remains a significant cause of hospital admission, with mortality rates up to 14%. In order to standardise and improve care, various scoring systems (e.g. Rockall, Blatchford and Baylor) have been developed to identify those individuals at high risk of requiring treatment (transfusion, endoscopic or surgical intervention) or of re-bleeding or death. There is also increasing interest in the utilisation of scoring systems to identify individuals at low risk of complications, as these may be discharged early, possibly with outpatient endoscopy. Most scoring systems are developed to predict outcomes in non-variceal bleeding. However, several indices are used to predict the outcome of advanced liver disease, including Child-Pugh and the Model of End-Stage Liver Disease (MELD). This chapter reviews all these aspects of the various scoring systems.