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Risk scoring in acute upper gastrointestinal haemorrhage
Digestive and Liver Disease 38 (2006) 10–11
Commentary
Risk scoring in acute upper gastrointestinal haemorrhage T.A. Rockall ∗ Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UK Available online 10 October 2005 See related article on pages 12–17
Despite many advances in medical and surgical management, acute upper gastrointestinal haemorrhage (AUGIH) remains a very common medical emergency with a significant mortality [1]. Assessing risk following presentation with AUGIH has been the subject of research over several decades. The purpose generally has been to stratify people early on in their presentation into groups at low or high risk of either rebleeding or death with a view to instigate different management protocols and to manage resources effectively. This includes selecting patients at low risk of rebleeding and death in whom resource utilisation can be safely reduced (e.g. managing these cases without hospital admission) [2,3] as well as selecting patients at high risk who might benefit from admission to a higher dependency unit or early recourse to endoscopic therapy or surgery [4]. Risk scores have also been developed to allow risk-adjusted comparative audit [5]. Categorisation of patients has usually been done on the basis of clinical factors, endoscopic findings, pathology, clinical progress or a combination of all of these. With the advent of routine flexible endoscopy much attention was focused on the pathological findings and in particular the diagnosis and the presence of stigmata of recent haemorrhage. The categorisation of stigmata of recent haemorrhage specifically related to peptic ulcer disease resulted in the Forrest criteria [6] which gave a clear relationship between the category and the risk of rebleeding, which is itself an independent predictor of mortality. Patients who rebleed have a mortality up to five times that of patients who present with an initial bleed and subsequently stop bleeding. With the advent of endoscopically applied therapy these stigmata of recent haemorrhage with their associated rebleeding rates formed the basis of decision making as to whether ∗
Tel.: +44 208 348 0569. E-mail address: [email protected].
to administer therapy. Patients with actively bleeding peptic ulcers (Forrest Ia and Ib) or those with a non-bleeding visible vessel (Forrest IIa) are at greatest risk of rebleeding and endoscopic therapy significantly reduces that risk. It is intuitive to suggest that the likelihood of rebleeding is mostly related to the nature of the bleeding lesion compounded by any haematological abnormality (iatrogenic or pathological). However, it is not only patients who rebleed that are at risk of dying but also equally the majority of patients who do rebleed will in fact survive. Mortality following AUGIH is much more multifactorial. Large unselected studies show a mortality of at least 10% [7] but close scrutiny would suggest that relatively few of these patients die of exsanguination. Mortality is clearly related to many more general factors including the age and co-morbidity of the patient. Indeed, those under 60 years of age with no co-morbidity are at negligible risk of death regardless of the severity of the bleed. Large-scale multivariate analysis [5] has shown that factors related to the patient (e.g. age and co-morbidity), factors related to the volume and rapidity of blood loss (e.g. pulse and blood pressure) and factors related to the disease (e.g. diagnosis and stigmata of recent haemorrhage) all have a significant influence on a patient’s likelihood of survival. The event of further haemorrhage (including ‘continued bleeding’ or ‘rebleeding’) further influences the outcome. A simple scoring system based upon these factors has been both internally and externally validated [8] as a predictor of mortality and has been used for comparative audit and case selection [7]. Another study showed the ‘Rockall’ scoring system to be predictive of mortality and rebleeding in both peptic ulcer and oesophageal varices sub-groups [9]. Some investigators have concluded that the ‘Rockall’ score does not predict rebleeding as well as it predicts death. This is not necessarily surprising. Whilst the scoring system includes elements that are integral to the prediction of risk
1590-8658/$30 © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2005.09.001
T.A. Rockall / Digestive and Liver Disease 38 (2006) 10–11
of rebleeding, it may not do this very well for a number of reasons. Firstly, it was not developed with rebleeding as an outcome. Secondly, we already know that most people who rebleed do not die and many people who die have not rebled. If you want to analyse a risk of rebleeding alone then a scoring system designed specifically for this purpose may be appropriate. However, a score of 2 or less in the ‘Rockall’ score is reliably associated with a minimal risk of rebleeding and a negligible risk of death. In predicting mortality, the risk score is robust and has been validated in selected subgroups of patients as well as unselected studies, including those with peptic ulcers undergoing endoscopic therapy. Understanding a patient’s risk of death at the time of admission is important and can be used as a method of determining treatment protocols. Success in haemostasis is not everything in the management of these patients and a reduction in mortality depends also on optimising their medical care to prevent death from organ failure or infection in particular. Crude mortality associated with patients presenting with AUGIH will remain high and may even increase as the patient population ages. Undoubtedly, a number of patients present with an AUGIH as their peri-terminal event with established organ failure or disseminated malignancy. Improving outcome in this group is both difficult and often not appropriate. It is worth bearing in mind however that the ‘Rockall’ scoring system works well for the subgroups of patients most likely to benefit from treatment and is a good method of undertaking ongoing clinical audit. From the clinical standpoint, the risk of rebleeding is probably more dependent on the pathological factors and endoscopic findings and as far as a protocol for endoscopic therapy and surgery are concerned these are the risk factors that should determine early endoscopic or surgical intervention.
11
Conflict of interest statement None declared. References [1] Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage [see comments]. Br Med J 1995;311:222–6. [2] Longstreth GF, Feitelberg SP. Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage. Lancet 1995;345:108–11. [3] Rockall TA, Logan RF, Devlin HB, Northfield TC. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage [see comments]. Lancet 1996;347: 1138–40. [4] Church NI, Palmer KR. Relevance of the Rockall score in patients undergoing endoscopic therapy for peptic ulcer haemorrhage. Eur J Gastroenterol Hepatol 2001;13:1149–52. [5] Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage [see comments]. Gut 1996;38:316–21. [6] Forrest JAH, Finlayson NHC, Shearman DJC. Endoscopy in gastrointestinal bleeding. Lancet 1974;2:394–7. [7] Rockall TA, Logan RF, Devlin HB, Northfield TC. Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Steering Committee of the National Audit of Acute Upper Gastrointestinal Haemorrhage. Gut 1997;41:606–11. [8] Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, Meulen JH, et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999;44:331–5. [9] Sanders DS, Carter MJ, Goodchap RJ, Cross SS, Gleeson DC, Lobo AJ. Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am J Gastroenterol 2002;97:630–5.
Commentary
Risk scoring in acute upper gastrointestinal haemorrhage T.A. Rockall ∗ Minimal Access Therapy Training Unit, Post Graduate Medical School, University of Surrey, Manor Park, Guildford, Surrey GU2 7WG, UK Available online 10 October 2005 See related article on pages 12–17
Despite many advances in medical and surgical management, acute upper gastrointestinal haemorrhage (AUGIH) remains a very common medical emergency with a significant mortality [1]. Assessing risk following presentation with AUGIH has been the subject of research over several decades. The purpose generally has been to stratify people early on in their presentation into groups at low or high risk of either rebleeding or death with a view to instigate different management protocols and to manage resources effectively. This includes selecting patients at low risk of rebleeding and death in whom resource utilisation can be safely reduced (e.g. managing these cases without hospital admission) [2,3] as well as selecting patients at high risk who might benefit from admission to a higher dependency unit or early recourse to endoscopic therapy or surgery [4]. Risk scores have also been developed to allow risk-adjusted comparative audit [5]. Categorisation of patients has usually been done on the basis of clinical factors, endoscopic findings, pathology, clinical progress or a combination of all of these. With the advent of routine flexible endoscopy much attention was focused on the pathological findings and in particular the diagnosis and the presence of stigmata of recent haemorrhage. The categorisation of stigmata of recent haemorrhage specifically related to peptic ulcer disease resulted in the Forrest criteria [6] which gave a clear relationship between the category and the risk of rebleeding, which is itself an independent predictor of mortality. Patients who rebleed have a mortality up to five times that of patients who present with an initial bleed and subsequently stop bleeding. With the advent of endoscopically applied therapy these stigmata of recent haemorrhage with their associated rebleeding rates formed the basis of decision making as to whether ∗
Tel.: +44 208 348 0569. E-mail address: [email protected].
to administer therapy. Patients with actively bleeding peptic ulcers (Forrest Ia and Ib) or those with a non-bleeding visible vessel (Forrest IIa) are at greatest risk of rebleeding and endoscopic therapy significantly reduces that risk. It is intuitive to suggest that the likelihood of rebleeding is mostly related to the nature of the bleeding lesion compounded by any haematological abnormality (iatrogenic or pathological). However, it is not only patients who rebleed that are at risk of dying but also equally the majority of patients who do rebleed will in fact survive. Mortality following AUGIH is much more multifactorial. Large unselected studies show a mortality of at least 10% [7] but close scrutiny would suggest that relatively few of these patients die of exsanguination. Mortality is clearly related to many more general factors including the age and co-morbidity of the patient. Indeed, those under 60 years of age with no co-morbidity are at negligible risk of death regardless of the severity of the bleed. Large-scale multivariate analysis [5] has shown that factors related to the patient (e.g. age and co-morbidity), factors related to the volume and rapidity of blood loss (e.g. pulse and blood pressure) and factors related to the disease (e.g. diagnosis and stigmata of recent haemorrhage) all have a significant influence on a patient’s likelihood of survival. The event of further haemorrhage (including ‘continued bleeding’ or ‘rebleeding’) further influences the outcome. A simple scoring system based upon these factors has been both internally and externally validated [8] as a predictor of mortality and has been used for comparative audit and case selection [7]. Another study showed the ‘Rockall’ scoring system to be predictive of mortality and rebleeding in both peptic ulcer and oesophageal varices sub-groups [9]. Some investigators have concluded that the ‘Rockall’ score does not predict rebleeding as well as it predicts death. This is not necessarily surprising. Whilst the scoring system includes elements that are integral to the prediction of risk
1590-8658/$30 © 2005 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2005.09.001
T.A. Rockall / Digestive and Liver Disease 38 (2006) 10–11
of rebleeding, it may not do this very well for a number of reasons. Firstly, it was not developed with rebleeding as an outcome. Secondly, we already know that most people who rebleed do not die and many people who die have not rebled. If you want to analyse a risk of rebleeding alone then a scoring system designed specifically for this purpose may be appropriate. However, a score of 2 or less in the ‘Rockall’ score is reliably associated with a minimal risk of rebleeding and a negligible risk of death. In predicting mortality, the risk score is robust and has been validated in selected subgroups of patients as well as unselected studies, including those with peptic ulcers undergoing endoscopic therapy. Understanding a patient’s risk of death at the time of admission is important and can be used as a method of determining treatment protocols. Success in haemostasis is not everything in the management of these patients and a reduction in mortality depends also on optimising their medical care to prevent death from organ failure or infection in particular. Crude mortality associated with patients presenting with AUGIH will remain high and may even increase as the patient population ages. Undoubtedly, a number of patients present with an AUGIH as their peri-terminal event with established organ failure or disseminated malignancy. Improving outcome in this group is both difficult and often not appropriate. It is worth bearing in mind however that the ‘Rockall’ scoring system works well for the subgroups of patients most likely to benefit from treatment and is a good method of undertaking ongoing clinical audit. From the clinical standpoint, the risk of rebleeding is probably more dependent on the pathological factors and endoscopic findings and as far as a protocol for endoscopic therapy and surgery are concerned these are the risk factors that should determine early endoscopic or surgical intervention.
11
Conflict of interest statement None declared. References [1] Rockall TA, Logan RF, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage [see comments]. Br Med J 1995;311:222–6. [2] Longstreth GF, Feitelberg SP. Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage. Lancet 1995;345:108–11. [3] Rockall TA, Logan RF, Devlin HB, Northfield TC. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage [see comments]. Lancet 1996;347: 1138–40. [4] Church NI, Palmer KR. Relevance of the Rockall score in patients undergoing endoscopic therapy for peptic ulcer haemorrhage. Eur J Gastroenterol Hepatol 2001;13:1149–52. [5] Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage [see comments]. Gut 1996;38:316–21. [6] Forrest JAH, Finlayson NHC, Shearman DJC. Endoscopy in gastrointestinal bleeding. Lancet 1974;2:394–7. [7] Rockall TA, Logan RF, Devlin HB, Northfield TC. Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Steering Committee of the National Audit of Acute Upper Gastrointestinal Haemorrhage. Gut 1997;41:606–11. [8] Vreeburg EM, Terwee CB, Snel P, Rauws EA, Bartelsman JF, Meulen JH, et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999;44:331–5. [9] Sanders DS, Carter MJ, Goodchap RJ, Cross SS, Gleeson DC, Lobo AJ. Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am J Gastroenterol 2002;97:630–5.