The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study

ABSTRACT BACKGROUND: Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients. OBJECTIVE: To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding. DESIGN AND SETTING: Prospective cohort study in an emergency department in Bursa, Turkey. METHODS: Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated. RESULTS: A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001). CONCLUSION: The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study

ABSTRACT BACKGROUND: Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes. OBJECTIVE: To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage. DESIGN AND SETTING: Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019. METHODS: Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded. RESULTS: A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001). CONCLUSION: PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.

Comparação dos escores não endoscópicos para a previsão de resultados em doentes com sangramento gastrointestinal alto na emergência de um hospital de referência em cuidados terciários: um estudo de coorte prospectivo / Comparison of non-endoscopic scores for the prediction of outcomes in patients of upper gastrointestinal bleed in an emergency of a tertiary care referral hospital: a prospective cohort study

ABSTRACT BACKGROUND: Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. OBJECTIVE: This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. METHODS: In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. RESULTS: The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). CONCLUSION: Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.

RESUMO CONTEXTO: Tradicionalmente, a doença úlcera péptica era a causa mais comum de sangramento digestivo alto, mas com a mudança da epidemiologia, outras etiologias do sangramento do trato digestivo alto estão emergindo. Muitas pontuações têm sido descritas para prever resultados e a necessidade de intervenção na hemorragia gastrointestinal superior, mas a comparação prospectiva entre elas é escassa. OBJETIVO: Este estudo foi planeado para determinar o padrão etiológico de pacientes com hemorragia digestiva alta e comparar os escores de Glasgow Blatchford, o Rockall pré-endoscopia, o AIMS65 e o Early Warning modificado (MEWS) como preditores do resultado. MÉTODOS: Neste estudo prospetivo de coorte, 268 pacientes com sangramento digestivo alto foram acompanhados durante 8 semanas. Os escores Glasgow Blatchford, Rockall pré-endoscopia, AIMS65 e MEWS foram calculados para cada paciente, e a área sob a curva (AUC-ROC) para cada pontuação foi comparada. RESULTADOS: A etiologia mais comum para a hemorragia gastrointestinal alta foi varizes gastroesofágicas 150 (63,55%), seguida de úlcera péptica 29 (12,28%) e de doença erosiva de mucosa 27 (11,44%). No total, 38 (15,26%) doentes voltaram a sangrar e 71 (28,5%) doentes morreram. No total, 126 (47%) doentes necessitaram de transfusão de componentes sanguíneos, 25 (9,3%) necessitaram de ventilação mecânica e 2 (0,74%) destes doentes necessitaram de intervenção cirúrgica. O escore de Glasgow Blatchford foi o melhor na previsão da necessidade de transfusão (corte - 10, AUC-ROC =0,678). Enquanto o AIMS65 com uma pontuação de ≥2 foi o melhor na previsão de ressangramento (AUC-ROC =0,626) e mortalidade (AUC-ROC =0,725). CONCLUSÃO: O sangramento gastrointestinal alto mais comum é de origem varicosa em centro de referência terciária. O AIMS65 é o melhor escore simples, com uma pontuação de ≥2 para prever o ressangramento e a mortalidade.

Valor de la Escala de Rockall en la predicción de la mortalidad de la Hemorragia digestiva alta / Value of the Rockall score in predicting mortality from Upper gastrointestinal bleeding

Introducción: La hemorragia digestiva alta (HDA) presenta una incidencia mundial entre 50 y 140 pacientes por cada 100 000 habitantes al año; la mortalidad varía de un país a otro, pero en Cuba en las últimas décadas oscila entre 4 y 10 por ciento en los de origen no varicoso y alcanza 30 por ciento en los casos asociados a hipertensión portal. Objetivo: Evaluar la utilidad de la Escala de Rockall en la estratificación del riesgo de mortalidad en pacientes con sangrado digestivo alto. Material y Métodos: Se realizó un estudio longitudinal y prospectivo en los pacientes que ingresaron en el Hospital Militar Central Dr. Carlos J. Finlay con diagnóstico de sangrado digestivo alto durante el período comprendido entre noviembre de 2012 y marzo de 2016, a quienes se les aplicó la Escala de Rockall para determinar la capacidad predictiva de la misma con la mortalidad. Resultados: Se estudiaron 394 enfermos de los cuales fallecieron 48 (12,19 por ciento), al estratificar los pacientes en grupos de riesgo según la Escala de Rockall se encontró que la mayor cantidad pertenecía al grupo de alto riesgo donde se encontraban todos los fallecidos del estudio. Al aplicar la curva de COR (Característica Operativa del Receptor) se obtuvo un área bajo la curva de 0,888 lo cual constituye una buena habilidad predictiva para mortalidad. Conclusiones: la Escala de Rockall es útil para predecir la mortalidad en la evolución de enfermos con SDA(AU)

Introduction: Upper gastrointestinal bleeding (UGB) has a worldwide incidence between 50 and 140 patients for every 100 000 inhabitants a year; the mortality varies from a country to another, but during the last decades in Cuba, it fluctuates between 4 and 10 percent in those of non-varicose origin and reaches 30 pèrcent in cases associated with portal hypertension. Objective: To evaluate the utility of the Rockall score in the risk stratification for mortality in patients with upper gastrointestinal bleeding. Material and Methods: A longitudinal prospective study was conducted in patients that came to Dr. Carlos J. Finlay Central Military Hospital with the diagnosis of upper gastrointestinal bleeding from November 2012 to March 2016, to whom the Rockall score was applied to determine its predictive capacity of estimating mortality. Results: 394 patients were studied; 48 of them died (12,19 percent). When stratifying the patients in risk groups according to Rockall score it was found that the greatest quantity belonged to the high risk group, which also included all the deceased during the study period. When applying the Receiver Operating Characteristic Curve (ROC) an area under the curve of 0,888 was obtained, which constitutes a good predictive ability for mortality. Conclusions: The Rockall score can be used to predict mortality in upper gastrointestinal bleeding during the evolution of patients suffering from it(AU)

Comparison of prediction of outcomes in upper GI bleed using non-endoscopic scoring systems

Background: Several scoring systems have been designed for risk stratification and prediction of outcomes in upper GI bleed. Endoscopy plays a major role in the diagnostic and therapeutic management of UGIB patients. However not all patients with UGIB need endoscopy. The objective of the present study was compared the prediction of mortality using different scoring systems in patients with upper GI bleed. A decision tool with a high sensitivity would be able to identify high and low risk patients and for judicious utilization of available resources.Methods: 100 patients were assessed with respect to their clinical parameters, organ dysfunction, pertinent laboratory parameters and five risk assessment scores i.e. clinical Rockall, Glasgow Blatchford, ALBI, PALBI and AIMS65 were calculated.Results: For prediction of outcomes, AIMS65 was superior to the others (AUROC of 0.889), followed by the GBS (AUROC of 0.869), followed by clinical Rockall score (AUROC 0.815), followed by ALBI score (AUROC of 0.765), followed by PALBI score (AUROC of 0.714) all values being statistically significant.Conclusions: The AIMS65 score is best in predicting the mortality in patients with upper GI bleed. The optimum cut off being >2. Though GBS may be better in predicting the need for intervention, it is inferior in predicting the mortality. The newer scores like ALBI and PALBI are inferior to AIMS65 and GBS in predicting mortality.

Comparative study on Glasgow-Blatchford score and full Rockall score system in predicting clinical outcomes of upper gastrointestinal bleeding / 天津医药

Objective To compare Glasgow-Blatchford score (GBS) with full Rockall score system (full RS) in predicting clinical outcomes of upper gastrointestinal bleeding(UGIB).Methods Four hundred hospitalized UGIB patients were enrolled in this study in Baoji Central Hospital from March 2014 to June 2016. Patients were scored by full RS and GBS,respectively.The receiver operating characteristic(ROC)curve analysis was used to compare the predictive values of the two score systems for mortality,re-bleeding,transfusion,ICU admission and endoscopic intervention. Results Thirty-eight cases were lost in follow-up. The one-month mortality rate, re-bleeding rate, blood transfusion rate, ICU admission rate and endoscopic intervention rate of 362 patients were 11.6%, 9.4%, 17.7%, 13.3% and 16.0%, respectively. GBS showed better predictive values in ICU admission (AUC=0.731, P=0.009), re-bleeding (AUC=0.707, P=0.019), blood transfusion (AUC=0.704, P=0.021) and endoscopic intervention (AUC=0.742, P=0.006). Full RS showed better predictive values in one-month mortality (AUC=0.681, P=0.040). There was significant difference in predicting value of clinical outcomes of UGIB by ROC curve between GBS and full-RS systems (P<0.05). Conclusion The GBS system is more suitable for predicting clinical outcomes of ICU admission, re-bleeding, blood transfusion and endoscopic intervention in patients of UGIB.The full-RS system is more suitable for predicting one-month mortality of UGIB patients.

Comportamiento de la hemorragia digestiva alta en el quinquenio 2009 a 2013 / Behavior of the high digestive bleeding in the five-year period 2009-2013

Introducción: la hemorragia digestiva alta constituye un problema frecuente de salud en el mundo; así se comporta en Cuba, en la provincia Matanzas y en el hospital de estudio. Actualmente es considerada como causa mayor de morbimortalidad. Objetivo: determinar el comportamiento de la hemorragia digestiva alta en el Hospital Militar de Matanzas. Materiales y Métodos: se realizó una investigación descriptiva, en un periodo de cinco años que incluyó a todos los pacientes ingresados con ese diagnóstico, y los que durante su ingreso por otra causa presentaron episodios de hemorragia. El índice de Rockall permitió evaluar la necesidad de cirugía, recidiva y mortalidad. Resultados: la mayoría de los pacientes pertenecieron al grupo de riesgo intermedio. Los hombres fueron los más afectados, el grupo de tercera edad presentó mayor incidencia. La gastritis hemorrágica fue la primera causa de sangrado. La hipertensión arterial resultó ser el factor de riesgo relevante y el tabaquismo el hábito tóxico más frecuente. Conclusiones: como beneficio relevante se demostró la importancia de la endoscopia precoz para el diagnóstico de la causa, tratamiento y pronóstico de la hemorragia. Se observó una buena correlación entre el pronóstico del paciente al ingreso y su estado al final del tratamiento (AU).

Introduction: the high digestive hemorrhage is a frequent health problem in the world; it behaves the same in Cuba, in the province of Matanzas and in the hospital where the study was carried out. Currently it is considered a major cause of morbi-mortality. Objective: to determine the behavior of the high digestive bleeding in the Military Hospital of Matanzas. Materials and Methods: a descriptive research was carried out in a five-year period. It included all the patients admitted with that diagnosis and those who presented episodes of hemorrhage even if they were admitted by any other cause. The Rockall index allowed to assess the necessity of surgery, the recidivism and mortality. Results: most of the patients belonged to the intermediate risk group. Male patients were the most affected one; the group of elder people showed higher incidence. Hemorrhagic gastritis was the first cause of bleeding. Arterial hypertension was the relevant risk factor and smoking the most frequent toxic habit. Conclusions: as a relevant benefit it was showed the importance of precocious endoscopy for the diagnosis of the hemorrhage cause, treatment and prognosis. It was observed a good correlation between the patient´s prognosis at the admission and his status at the end of the treatment (AU).

Comparative Study on Rockall and Blatchford Scoring System for Risk Assessment of Acute Nonvariceal Upper Gastrointestinal Bleeding / 胃肠病学

Acute nonvariceal upper gastrointestinal bleeding (ANVUGIB)is a commonly seen gastrointestinal emergency.Rockall and Blatchford scoring system are commonly used for risk stratification in ANVUGIB.Aims:To investigate the predictive values of Rockall and Blatchford scoring system for assessing the risk of blood transfusion,surgical intervention and mortality in patients with ANVUGIB.Methods:Five hundred and ninety hospitalized patients with ANVUGIB were scored by Rockall and Blatchford scoring system,respectively.Predictive values of these two scoring systems for assessing the risk of blood transfusion,surgical intervention and mortality were assessed by area under the receiver operating characteristic (ROC)curve (AUC).Results:Rockall and Blatchford scores in patients with blood transfusion,surgical intervention and died were significantly higher than those in patients without blood transfusion,surgical intervention and survived (P <0.01 ).The AUC of Rockall scoring system for predicting blood transfusion,surgical intervention and mortality were 0.785 (95% CI:0.743-0.828,P=0.000),0.765 (95% CI:0.693-0.837,P=0.000),0.835 (95% CI:0.703-0.966,P=0.005),respectively.The AUC of Blatchford scoring system for predicting blood transfusion,surgical intervention and mortality were 0.812 (95%CI:0.775-0.848,P=0.000),0.870 (95%CI:0.811-0.930,P=0.000),0.784 (95% CI:0.614-0.954,P=0.017),respectively.Conclusions:Rockall and Blatchford scoring system have high predictive value for blood transfusion,surgical intervention and mortality in patients with ANVUGIB.Rockall scoring system is better for predicting mortality,while Blatchford scoring system is better for predicting blood transfusion and surgical intervention.

The values of Rockall, Blatchford and AIMS65 scoring systems in the diagnosis and treatment of patients with acute upper gastrointestinal bleeding / 天津医药

prognosis of patients with acute upper gastrointestinal bleeding (AUGIB). Methods A total of 130 patients with AUGIB in our hospital were enrolled in this study from August 2014 to August 2016 . Three kinds of scoring systems including Rockall, Blatchford and AIMS65 were used to evaluate the risk classification of the patients. Patients were followed up for 2 months. The incidence rates of re-bleeding and death within 2 months after admission were observed. Data of prognosis in patients with AUGIB were compared between the three scoring systems in the prognosis of patients with AUGIB, including the risk classification and the prediction accuracy of re-bleeding and death. Results There were no significant differences in the re-bleeding rate and fatality rate between the groups divided by Rockall and Blatchford scoring systems ( P>0.05). According to the grouping results of AIMS65 scoring system, the re-bleeding rate of low-risk group was lower than that in high risk group (1.45%vs. 13.11%, P=0.01), but there was no significant difference in fatality rate between the two groups (P>0.05). The values of area under the curve (AUC) of predicting re-bleeding rates by using Rockall, Blatchford and AIMS65 scoring systems were 0.6258, 0.6910, and 0.7241, and the values of AUC of predicting fatality rates were 0.7031, 0.7969, and 0.7031 by using receiver operating characteristic curve (ROC) analysis. There were no significant differences between them (P>0.05). The values of AUC of predicting re-bleeding rates by using the risk grading calculation by Rockall, Blatchford and AIMS65 scoring systems were 0.6189, 0.6139 and 0.7254 (P>0.05). But the values of AUC of predicting fatality rates were 0.6211, 0.6641 and 0.7695 (P<0.01). Conclusion The operation method of AIMS65 scoring system is simple and convenient, which is applicable to a wide range of patients with AUGIB. In the prediction of re-bleeding and mortality, AIMS65 scoring system has high accuracy and stability, which is worthy of promoting in clinical application.

Índice de Rockall y necesidad de hemotransfusión en pacientes con hemorragia digestiva alta no varicosa / Rockall Index and Need of Blood Transfusion in Patients with Non-Variceal Upper Gastrointestinal Bleeding

Introducción: la reducción de la mortalidad en pacientes con hemorragia digestiva alta está dada no solo por la terapéutica endoscópica, sino por el adecuado manejo clínico que incluye reposición de volumen y transfusión sanguínea si es requerida; por lo que es necesaria la evaluación de la utilidad de parámetros pronósticos en la estratificación del riesgo de necesidad de hemotransfusión. Objetivo: evaluar la utilidad del Índice de Rockall en la estratificación del riesgo de necesidad de hemotransfusión en pacientes con hemorragia digestiva alta no varicosa. Métodos: estudio longitudinal, descriptivo y prospectivo desde diciembre de 2011 hasta junio de 2012. Fueron incluidos los pacientes admitidos en el Cuerpo de Guardia del Hospital Militar Central Carlos J. Finlay, con evidencia clínica de hemorragia digestiva alta, a quienes se les realizó una endoscopia dentro de las 24 horas siguientes al ingreso. Se evaluaron parámetros clínicos (edad, comorbilidad y estado hemodinámico), endoscópicos (hallazgos, estigmas de sangrado) y la necesidad de hemotransfusión. Se relacionaron pacientes transfundidos con las diferentes variables incluidas en la Escala de Rockall para determinar factores de riesgo de necesidad de hemotransfusión. Resultados: se estudiaron 89 pacientes, con predominio del sexo masculino (n= 64; 71,91 por ciento), la edad promedio fue de 63,58 años. Se identificaron como factores de riesgo de necesidad transfusional, la comorbilidad, el estado hemodinámico y la presencia de estigmas de sangrado activo o reciente. Del total de pacientes 26 por ciento de los casos (n= 23) tenía un Índice de Rockall alto. Dicho Índice tuvo pobre capacidad predictiva para la necesidad transfusional (área bajo la curva de COR de 0,682; p= 0,00). Conclusión: el índice de Rockall fue útil en la estratificación de riesgo de necesidad de hemotransfusión, lo que puede tenerse en cuenta para una adecuada selección del paciente con hemorragia digestiva alta no varicosa que requiera una terapia transfusional(AU)

Introduction: Reducing mortality in patients with upper gastrointestinal bleeding is due not only to endoscopic therapy but also to clinical care, including volume replacement and blood transfusion if required. So it is necessary to evaluate the utility of prognostic parameters on the stratification of the risk of need for blood transfusion. Objective: Evaluate the utility of Rockall index on the stratification of the risk of need for blood transfusion in patients with upper gastrointestinal bleeding episode of non varicosa origin. Methods: A longitudinal, descriptive and prospective study was carried out from December 2011 to June 2012. Patients admitted to the hospital emergency room, with clinical evidence of upper gastrointestinal bleeding, who underwent an endoscopy within 24 hours after admission. Clinical parameters (age, comorbidity, and hemodynamic status), endoscopic (findings, stigmata of bleeding) and need for blood transfusion were assessed. Transfused patients and different variables included in the Rockall index were listed to determine risk factors when transfusion need. Results: 89 patients were studied with a predominance of males (n= 64, 71.91 percent), mean age 63, 58 years. Comorbidity, hemodynamic state and the presence of stigmata of active or recent bleeding (RR= 8.31 IC: 0.73-1.27; RR= 2.43 IC: 0.22-1.78 y RR= 5.05 IC: 0.62-1.38 respectively. p=0.00) were identified as risk factors for transfusion need. 26 percent of cases (n= 23) had a high index Rockall. This index had predictive poor capacity of transfusion need (area under the ROC curve of 0.682; p= 0.020). Conclusion: Rockall index was useful to identify patients at increased risk of transfusion need, it can be used for the adequate selection of patients with non- varicosa gastrointestinal bleeding that need transfusional therapy(AU)

Rockall risk score in predicting 30 days non-variceal upper gastrointestinal rebleeding in a Malaysian population

Objective: the aim of this study was to determine the usefulness of Rockall score in predicting outcomes of 30 days rebleeding, mortality and need for surgical intervention of bleeding gastric and duodenal ulcers. Methods: this is a retrospective cohort study of all the emergency endoscopies performed in Hospital sultan Ismail from January 2009 to October 2014 for indications of upper gastrointestinal bleeding (UGIb). Data was extracted from hospital's electronic database and only non-variceal bleeds were included. Rockall score was calculated and outcomes of 30 days rebleeding, mortality and need for surgery was recorded. For each outcome, calibration was done using the Goodness-of-fit tests and discriminative ability was reflected by area under the receiver operating characteristic curve (AUROc). Results: A total of 1323 patients were included with a male preponderance of 64%. the overall rates of rebleeding were 11.2%, mortality rate of 8.7% and need for surgery was 2%. Low AUROc values for rebleeding (0.63), mortality (0.58) and surgery (0.67) showed poor discriminative ability of Rockall score. the Goodness-of-fit test also revealed that the scoring system was poorly calibrated in outcomes of rebleeding (p <0.001), mortality (p = 0.001) and surgery (p = 0.038) with p-value <0.05. Patients with high risk (scores ≥8) displayed highest rebleeding and mortality rates of 20% respectively in comparison to the moderate (score 3-7) and low (score ≤2) risk groups. conclusion: Rockall score has a poor discriminative ability and is poorly calibrated for rebleeding, mortality and need for surgery in upper gastrointestinal bleeding. However, it is the best tool we have now to stratify patients into risk groups.

Comparison of AIMS65 Score and Other Scoring Systems for Predicting Clinical Outcomes in Koreans with Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND/AIMS: The AIMS65 score has not been sufficiently validated in Korea. The objective of this study was to compare the AIMS65 and other scoring systems for the prediction of various clinical outcomes in Korean patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB). METHODS: The AIMS65 score, clinical and full Rockall scores (cRS and fRS) and Glasgow-Blatchford (GBS) score were calculated in patients with NVUGIB in a single center retrospectively. The performance of these scores for predicting mortality, rebleeding, transfusion requirement, and endoscopic intervention was assessed by calculating the area under the receiver-operating characteristic curve. RESULTS: Of the 523 patients, 3.4% died within 30 days, 2.5% experienced rebleeding, 40.0% required endoscopic intervention, and 75.7% needed transfusion. The AIMS65 score was useful for predicting the 30-day mortality, the need for endoscopic intervention and for transfusion. The fRS was superior to the AIMS65, GBS, and cRS for predicting endoscopic intervention and the GBS was superior to the AIMS65, fRS, and cRS for predicting the transfusion requirement. CONCLUSIONS: The AIMS65 score was useful for predicting the 30-day mortality, transfusion requirement, and endoscopic intervention in Korean patients with acute NVUGIB. However, it was inferior to the GBS and fRS for predicting the transfusion requirement and endoscopic intervention, respectively.

A study of capsule endoscopy and clinical scoring system for risk stratification of acute upper gastrointestinal bleeding / 重庆医学

Objective To evaluate the guidance value of capsule endoscopy and clinical scoring system in risk stratification for acute upper gastrointestinal bleeding (AUGIB) .Methods 24 patients presenting to the emergency room with AUGIB ,were randomly divided into two groups (12 cases in each group) .Pre‐Endoscopic Blatchford and Rockall scores were calculated for all pa‐tients .All patients underwent endoscopy(EGD) within 24 hours .The timing of EGD was based on clinical scores in control group , and on VCE in observation group .Positive VCE was defined as red blood ,clot or coffee grounds .Mean Rockall and Blatchford scores for all 24 patients were compared to differentiate high‐and low‐risk patients .Rockall and Blatchford scores were also com‐pared with VCE findings .Results A total of 13 out of 24 patients had high‐risk stigmata on EGD ,with the mean Rockall and Blatchford scores of 3 and 13 respectively .Meanwhile ,the mean Rockall and Blatchford scores of the other 11 patients were 2 and 11 .There was no statistically significant difference between the Blatchford scores of the two groups(95% CI:5 .2‐1 .4 ;P=0 .23) . Also there was no statistically significant difference between the Rockall scores of the two groups(95% CI:2 .2‐0 .3;P=0 .12) .In the subgroup of 12 patients who underwent VCE ,9/12 had positive findings confirmed at EGD afterward ,compared with the other 3 patients with negative VCE and endoscopy .Conclusion Both the Rockall and the Blatchford scores are not accurate to predict the degree of risk in patients with AUGIB identified at EGD .However ,VCE is sensitive and specific enough to a better risk stratifica‐tion tool .

Utilidad de la escala clínica de Rockall en la hemorragia digestiva alta no varicosa / Usefulness of Rockall clinical score in upper non variceal gastrointestinal bleeding

Introducción: la escala clínica de Rockall se utliza para clasificar la hemorragia digestiva alta en individuos atendiendo al riesgo de presentar sangrado activo, que necesiten de la realización urgente de la endoscopia digestiva. Objetivo: evaluar, la eficacia de la escala clínica de Rockall para identificar a los pacientes que requieren terapéutica endoscópica. Métodos: se realizó un estudio prospectivo. Se calculó el índice clínico de Rockall según escala homónima. Se realizó endoscopia de urgencia y terapéutica hemostática a pacientes con sangrado activo o reciente. La eficacia de este proceder se determinó mediante el análisis por curva de escala clínica de Rockall, índice de Youden y cálculo de sensibilidad y especificidad del mejor punto de corte. Resultados: incluidos 118 pacientes, 22 de los cuales (18,6 por ciento) recibieron terapéutica endoscópica por presentar sangrado activo o reciente. Índice clínico de Rockall con una media de 1,79 puntos. Riesgo alto 83 pacientes (70,3 por ciento) y bajo 35 casos (29,7 por ciento). La capacidad predictiva excelente, con valor del área bajo la curva = 0,960 (IC 95 por ciento: 0,904-1,017); punto de corte igual a 1 ( índice de Youden = 0,971) con una sensibilidad de 97 por ciento y de especificidad de 71 por ciento. Conclusiones: la escala clínica de Rockall puede ser utilizada con seguridad para la toma de decisiones en relación con la realización urgente de la endoscopia en el paciente con hemorragia digestiva alta no varicosa(AU)

Introduction: the clinical Rockall score serves to stratify the individuals with non variceal upper gastrointestinal hemorrhage depending on the risk of presenting active bleeding and therefore, they urgently need digestive endoscopy. Objective: to evaluate the effectiveness of the Rockwall clinical score in identifying patients who need therapeutic endoscopy. Methods: a prospective study with calculation of the Rockall clinical score according to a homonymous scale. Performance of urgent endoscopy and of therapeutic hemostatic endoscopy in patients with active or recent bleeding. Determination of efficacy through the analysis of ROC curves, Youden´s index and calculation of sensibility and specificity of the best cutoff point. Results: one hundred and eighteen patients were included, 22 of whom (18.6 percent) received therapeutic endoscopy to manage active or recent bleeding. Rocwall clinical score reached a mean of 1.79 points. It was found that 83 (70.3 percent) were high and 35 (29.7 percent) low risk patients. The predictive capacity was excellent, being the ABC= 0.960 (95 percent CI: 0,904-1,017). The cutoff point was 1 (J= 0.971) with 97 percent sensibility and 71 percent specificity. Conclusions: the Rockall clinical score can be safely used to make a decision on the urgent performance of endoscopy in patients with non-variceal upper gastrointestinal bleeding(AU)

Utilidad del índice de Rockall en pacientes con episodios de hemorragia digestiva alta no variceal / Utility of Rockall index in patients with upper non-variceal gastrointestinal bleeding episodes

INTRODUCCIÓN: por la alta mortalidad de pacientes con hemorragia digestiva alta, es necesario la utilización de sistemas pronósticos para el adecuado manejo de aquellos con alto riesgo de resangrar. OBJETIVO: evaluar la capacidad del índice de Rockall para predecir el riesgo de resangrado y mortalidad en el paciente con episodio de hemorragia digestiva alta de origen no variceal. MÉTODOS: estudio longitudinal, descriptivo y prospectivo entre diciembre de 2011 y junio de 2012. Se incluyeron 89 pacientes admitidos en el cuerpo de guardia del Hospital Militar Central "Dr. Carlos J. Finlay", con evidencia clínica de hemorragia digestiva alta, a quienes se les realizó una endoscopia dentro de las 24 h posteriores al ingreso. Se evaluaron parámetros demográficos (edad, género) y endoscópicos (hallazgos, terapéutica). Se aplicó el índice de Rockall y se evolucionó al paciente las 72 h siguientes al ingreso. Se realizó un análisis por curva de COR. RESULTADOS: hubo un predominio del sexo masculino (64/89; 71,9 %); la edad promedio fue de 63,6 años. El 26,0 % de los casos (n= 23) presentó un índice de Rockall alto, con una capacidad predictiva sobre la mortalidad (área bajo la curva de COR de 0,875) y el resangrado (área bajo la curva de COR de 0,757; p= 0,020). CONCLUSIONES: se confirma la utilidad del índice de Rockall para identificar a los pacientes con alto riesgo de fallecer y resangrar, lo que puede ser utilizado para el manejo del paciente con hemorragia digestiva no variceal.

INTRODUCTION: the use of prognostic systems is necessary for the proper management of those at high risk of bleeding again. OBJECTIVE: to evaluate the ability of the Rockall index for predicting the risk of rebleeding and mortality in patients with upper gastrointestinal bleeding episode of non-variceal origin. METHODS: a longitudinal, descriptive, prospective study was conducted in 89 patients who arrived with clinical evidence of upper gastrointestinal bleeding at ER of "Dr. Carlos J. Finlay" Central Military Hospital from December 2011 to June 2012. They underwent an endoscopy within 24 h after admission. Demographic parameters (age, gender) and endoscopic (findings, therapeutic) were evaluated. Rockall index was applied and patients were followed up 72 h after admission. COR curve Analysis was performed. RESULTS: there was a predominance of males (64/89, 71.91 %); the average age was 63.58 years. 26 % of cases (n= 23) had a higher rate of Rockall, with a predictive capacity for mortality (area under the ROC curve = 0.875) and rebleeding (area under the ROC curve = 0.757, p= 0.020). CONCLUSIONS: Rockall index utility is confirmed to identify patients at high risk of death and reindent, which can be used for the management of patients with non-variceal gastrointestinal bleeding.

Hemorragia digestiva alta no varicosa: comportamiento e índice de Rockall / Behavior and Rockall risk scoring in the non-variceal upper gastrointestinal bleeding

Introducción: la hemorragia digestiva alta no varicosa es actualmente una emergencia quirúrgica de difícil manejo, hecho que motivó el conocer su comportamiento y, usando el índice de Rockall, el riesgo de los afectados de sufrir resultados adversos durante su evolución, aquellos de posible alta precoz y las causas que la impiden. Métodos: estudio descriptivo de corte transversal realizado en el Hospital General Docente Ernesto Guevara de la Serna con 182 pacientes atendidos entre 2009 y 2010. Resultados: los hombres fueron los más afectados (54,4 por ciento) y el grupo de 60-80 años tuvo el mayor número de casos. La úlcera gastroduodenal fue la primera causa (52,7 por ciento). La melena se presentó como manifestación inicial en el 60,4 por ciento de los pacientes. La hipertensión arterial fue la comorbilidad más frecuente (60,7 por ciento). El 44,5 por ciento de los pacientes necesitó transfusión sanguínea. La mortalidad fue del 8,2 por ciento. La mayor parte de la muestra se ubicó en el grupo de riesgo intermedio de Rockall (40,1 por ciento). Recibió alta precoz solo el 11,5 por cientode los pacientes, y la inestabilidad hemodinámica (38 por ciento) fue la mayor responsable de este bajo número. El Rockall tuvo sensibilidad del 98,3 por ciento, especificidad del 56,9 por ciento, valor predictivo positivo del 52,3 por ciento, valor predictivo negativo del 98,6 por ciento y una exactitud del 70,9 por ciento. En los pacientes clasificados de bajo riesgo la única complicación fue la recidiva (1,4 por ciento). Conclusiones: el alta precoz puede ser dada a pacientes con Rockall bajo, siempre que se preste especial atención a la estabilidad hemodinámica.

Introduction: Non-variceal upper gastrointestinal bleeding is a current surgical emergency of difficult management. This fact prompted the authors to find out its behavior and to use Rockall risk scoring system to determine the risk of suffering adverse effects during the recovery period, those patients that may be early discharged and the causes that prevent it. Methods: Cross-sectional descriptive study conducted in 182 patients from Ernesto Guevara de la Serna general teaching hospital, who were seen in the period of 2009 through 2010. Results: Males were the most affected (54.4 per cent) and the 60-80 years age group registered the highest number of cases. Gastroduodenal ulcer was the first cause (52.7 por ciento). The initial manifestation was tarry stools in 64 per cent of cases. Blood hypertension was the most frequent comorbidity (60.7per cent). In the study group, 44.5per cent of patients needed blood transfusion. The mortality rate was 8.2 per cent. Most of patients were classified as intermediate risk cases according to Rockall system (40.1 per cent). Just 11.5 per cent of patients were early discharged since the hemodynamic instability (38 per cent) was the main responsible for this low number. Rockall risk scoring system showed 98.3per cent sensitivity, 56.9per cent specificity, 52.3 per cent positive predictive value, 98.6per cent negative predictive value and 70.9 per cent accuracy. The only complication in low risk patients were relapse (1.4 per cent). Conclusions: Early discharge from hospital occurs in low Rockall risk score patients provided that special attention is paid to hemodynamic stability.

Comparison of the Risk Stratification Tools Including the Blatchford Score and the Clinical Rockall for Nonvariceal Upper Gastrointestinal Bleeding in the Emergency Department

PURPOSE: Upper gastrointestinal bleeding (UGIB) is a common medical emergency condition in the emergency department (ED). Patients with UGIB show a wide range of clinical severity, from mild bleeding to death. The objective of this study was to evaluate methods for risk stratification of active UGIB in the ED. METHODS: We retrospectively reviewed patients with UGIB who were admitted to the ED of a tertiary care, university-affiliated hospital center from January 2011 to December 2011. Our study subjects were patients over 20 years old who complained of symptoms and signs of gastrointestinal tract bleeding and underwent endoscopic gastroduodenoscopy (EGD) evaluation. However, patients diagnosed with variceal gastrointestinal bleeding, disseminated malignancy, coagulopathy, and lower gastrointestinal bleeding and patients who did not undergo EGD within 6 hours were excluded. The Blatchford score and the clinical Rockall score were calculated for the enrolled patients. In cases where the value of each score was greater than 0, the scores were considered high risk. Active UGIB was defined as a symptom of patients who underwent emergency endoscopic intervention such as ligation or sclerotherapy. We compared the proportions of patients identified as high risk using chi tests. The areas under the receiver operating characteristic (AUROC) curve for detection of patients requiring emergency endoscopic intervention were calculated for both the Blatchford score and the clinical Rockall score. RESULTS: The numbers of patients with high risk according to the Blatchford score and the clinical Rockall were 220 (93.6%) and 192 (81.7%) of 235 patients, respectively. The number of patients with active UGIB was 96 (40.9%) of 235 patients. The sensitivity and specificity of risk stratification based on the Blatchford score was 100% (96/96) and 10.8% (15/139) (p=0.001), respectively, while those based on the clinical Rockall score were 80.2% (77/96) and 17.3% (24/139) (p>0.05). The AUROC curves of the Blatchford score and the clinical Rockall score were 0.617 (95% CI; 0.546-0.688) and 0.495 (95% CI; 0.420-0.571), respectively. CONCLUSION: The Blatchford score could be more useful as a risk stratification tool than the clinical Rockall score for active UGIB patients in the ED. The Blatchford score would be preferable as a clinical tool that can discriminate patients who need emergency endoscopic intervention for control of UGIB.

Evaluación de la clasificación de Rockall como predictor de mortalidad en pacientes con hemorragia digestiva alta de origen no variceal / Assessment of Rockall score as a mortality predictor in patients with non-variceal upper gastrointestinal bleeding

Introduction: Upper gastrointestinal bleeding (UGIB), a high morbi-mortality disease, is a medical emergency with high incidence among the population. It also represents a significant health expense and its mortality rate is 4-12 percent. There are different systems to classify the risk for these patients; one of them is the Rockall Score. This system has been previously validated as mortality predictor. Objective: To evaluate the use in our environment of the Rockall Score as a mortality predictor, the need for surgery and hemoderivative requirements. Materials and Methods: Retrospective study in adult patients subjected to emergency upper digestive endoscopy due to potential non-variceal UGIB at Hospital Militar de Santiago. Many clinical and endoscopic variables were analyzed. Validation of Rockall Score was carried out by ROC curve analysis. Results: Ninety-one patients were studied: 2/3 male; 70 percent > 60 years; 68 percent with a related disease. The most frequent endoscopic diagnosis was stomach and duodenal lesions. Mortality rate of 8.8 percent. Rockall Score indicated an acceptable discrimination ratio as a predictor of mortality, need for surgery and red blood cell transfusion. The best sensitivity and specificity correlation score was >_ 5 to determine the high-risk group. Conclusion: Rockall Score proved to be a good mortality predictor in patients with non-variceal UGIB in our environment. The identification of high-risk UGIB patients will allow for an appropiate therapeutic approach.

Introducción: Hemorragia digestiva alta (HDA), patología de alta morbimortalidad, es una emergencia médica, presenta alta incidencia poblacional y demanda alto gasto en salud. Presenta una mortalidad entre 4-12 por ciento. Existen diferentes sistemas de clasificación de riesgo para estos pacientes, uno de los cuales es la clasificación de Rockall. Este sistema ha sido previamente validado como predictor de mortalidad. Objetivo: Evaluar en nuestro medio el uso de la clasificación de Rockall, para predecir mortalidad, necesidad de cirugía y requerimientos de hemoderivados. Materiales y Métodos: Estudio restrospectivo en pacientes adultos sometidos a endoscopia digestiva alta de urgencia por sospecha de HDA no variceal en el Hospital Militar de Santiago. Se analizaron diversas variables clínicas y endoscópicas. La validación de la clasificación de Rockall se realizó con el análisis de curva ROC. Resultados: Se estudiaron 91 pacientes: 2/3 de sexo masculino; 70 por ciento > 60 años; 68 por ciento presentaban alguna enfermedad asociada. El diagnóstico endoscópico mas frecuente fue lesiones en estómago y duodeno. Tasa de mortalidad de 8,8 por ciento. La clasificación de Rockall mostró un aceptable nivel de discriminación como predictor de mortalidad, requerimiento de cirugía y tranfusión de glóbulos rojos. El puntaje de mejor correlación de sensibilidad y especificidad fue > 5 para definir el grupo de alto riesgo. Conclusión: La clasificación de Rockall resultó ser un buen predictor de mortalidad en pacientes con HDA no variceal en nuestro medio. Identificar pacientes con HDA de alto riesgo, permitiría un adecuado enfrentamiento terapéutico.

Riesgo de resangrado y muerte en pacientes hospitalizados en el Servicio de Gastroenterología del Hospital Jesús Yerena con el diagnostico de hemorragia digestiva superior no variceal, durante el período comprendido entre enero 2002 y agosto 2008 / Rebleeding and dearth risks in inpatients at Hospital Jesús Yerena Gastoenterology Service diagnosed with non-varicose upper disgestive hemorrahage between january 2002 and august 2008

La hemorragia digestiva superior es una de las causas más frecuentes de consulta y hospitalización en los hospitales generales y en los servicios de gastroenterología a nivel mundial. Existen criterios que permiten orientarnos hacia la evolución que puedan tener estos pacientes. Los criterios de Rockall, aplicados a pacientes con hemorragia digestiva superior no variceal y según las características clínicas-endoscópicos nos permiten predecir el riesgo de resangrado y muerte. Estadificar según criterios de Rockall el riesgo de resangrado y muerte en pacientes hospitalizados con diagnostico de Hemorragia Digestiva superior no variceal a la emergencia del hospital de Lídice, durante el período comprendido entre Enero 2002 y agosto 2008. Se realiza estudio retrospectivo de corte transversal con una muestra de 150 pacientes, recopilando los datos de las historias clínicas de pacientes hospitalizados con diagnóstico de hemorragia digestiva superior no variceal a los cuales se les calculó según Rockall el riesgo de resangrado y muerte. Del total de 150 pacientes, presentaron riesgo bajo de muerte y resangrado 53 pacientes (8 resangraron y sólo 1 falleció por otra causa), riesgo intermedio 57 pacientes (14 resangraron y 2 fallecieron) y riesgo alto 40 pacientes (20 resangraron y 10 fallecieron). Nuestro trabajo confirma el valor de la escala de Rockall para determinar el riesgo de resangrado y muerte en pacientes con sangrado digestivo superior no variceal...

Upper digestive hemorrhage is one of the most frequent causes of worldwide consult and hospitalization in general hospitals and gastroenterology services as well. There are criteria allowing to being guided to the evolution that said patients could experience. Rockall criteria applied to patients with non-varicose upper digestive hemorrhage, and as per the clinical-endoscopic features, let us predict the rebleeding and death risks. According to Rockall criteria, staging the rebleeding and death risks in hospitalized patients diagnosed with non-varicose upper digestive hemorrhage at Hospital de Lidice’s ER between January 2002 and August 2008. A cross-sectioned retrospective study is carried out with a 150-patient sample, collecting clinical records data of hospitalized patients diagnosed with non-varicose upper digestive hemorrhage who were computed, according to Rockall, the rebleeding and death risks. Out of the total of 150 patients, 53 presented death and rebleeding risks (8 rebled and just 1 died due to other cause), 57 patients presented intermediate risk (14 rebled and 2 died), and patients showed high risk (20 rebled and 10 died). This research confirms the Rockall score’s value for determining the risk of rebleeding and death in patients diagnosed with non-varicose upper digestive bleeding...