Comparison of risk scoring systems for the prediction of clinical outcomes in nonvariceal upper gastrointestinal bleeding: a prospective randomized study

Yıl 2023, Cilt: 6 Sayı: 3, 643 - 649, 31.05.2023

Muhammed Bahaddin Durak , Batuhan Başpınar , İbrahim Ethem Güven , İlhami Yüksel

https://doi.org/10.32322/jhsm.1270718

Öz

Aim: Non-variceal upper gastrointestinal bleeding (UGIB) is a typical gastrointestinal emergency. Detection of high-risk patients is crucial to organize medical care accordingly. This study aims to compare risk assessment scores for their ability to predict prognosis in nonvariceal-UGIB.
Material and Method: Adult patients with nonvariceal-UGIB applied to the emergency department were recruited prospectively. Clinical and Complete Rockall score (RS), Glascow-Blatchford score (GBS), AIMS65, and T-Score were compared for endpoints: (1) need for endoscopic treatment, (2) hospitalization, (3) rebleeding, and (4) 30-day mortality.
Results: A total of 469 patients were included. While 133 (28.0%) patients were discharged within 24 hours, 336 (72.0%) were hospitalized. The median length of hospital stay was 6.6 (0.0-8.0) days. Endoscopic treatment and transfusion were required in 109 (23.0%) and 255 (54.0%) patients, respectively. Rebleeding was observed in 36 (8.0%) patients. The 30-day mortality rate was 11.0 %. Complete Rockall score was superior among all risk scores regarding the prediction of the need for endoscopic treatment (AUC: 0.707, p<0.001) and hospitalization (AUC: 0.678, p<0.001). AUC values of AIMS65, Clinical RS, Complete RS, GBS, and T-score were 0.688, 0.601, 0.634, 0.631, and 0.651, respectively (p>0.05). AIMS65 score (AUC: 0.810, p<0.05) was superior to the clinical RS and GBS at predicting 30-day mortality. However, there was no difference between the AIMS65 score and the other scores of areas under the curve (p> 0.05).
Conclusion: Complete RS and AIMS65 scores are valuable tools to determine UGIB-related endpoints (need for intervention, hospitalization, rebleeding, and mortality). Identifying high-risk patients using the risk scoring systems and performing endoscopy in this group may improve clinical outcomes, while their sensitivity is inadequate in the low-risk patients.

Anahtar Kelimeler

Gastrointestinal hemorrhage, endoscopy, risk assessment, prognosis

Varis dışı üst gastrointestinal kanamada klinik sonuçların tahmininde risk puanlama sistemlerinin karşılaştırılması: prospektif randomize çalışma

Öz

Giriş/Amaç: Varis dışı üst gastrointestinal kanama (UGIB) tipik bir gastrointestinal acil durumdur. Yüksek riskli hastaların tespiti ve medikal yaklaşımı buna göre belirlemek çok önemlidir. Bu çalışma, varis dışı-UGIB'de prognozu predikte etme açısından risk değerlendirme puanlarını karşılaştırmayı amaçlamaktadır.
Gereç ve Yöntemler: Acil servise varis dışı UGIB ile başvuran erişkin hastalar prospektif olarak çalışmaya alındı. Klinik ve Full Rockall skoru (RS), Glascow-Blatcford skoru (GBS), AIMS65 ve T-Skoru, (1) endoskopik tedavi ihtiyacı, (2) hospitalizasyon ihtiyacı, (3) tekrar kanama ve (4) 30 günlük mortalite açısından karşılaştırıldı.
Bulgular: Toplam 469 hasta dahil edildi. 133 (%28,0) hasta 24 saat içinde taburcu edilirken, 336 (%72,0) hasta hastaneye yatırıldı. Hastanede kalış süresi medyan 6,6 (0,0-8,0) gündü. Endoskopik tedavi ihtiyacı 109 (%23,0), transfüzyon ihtiyacı 255 (%54,0) hastada gerekti. 36 (%8,0) hastada tekrar kanama görüldü. 30 günlük mortalite oranı %11.0 idi. Endoskopik tedavi (AUC: 0.707, p<0.001) ve hastaneye yatış (EAA: 0.678, p<0.001) gereksinimini predikte etmede Total Rockall skoru tüm risk skorları arasında üstündü. AIMS65 skoru (EAA: 0.810, p<0.05), 30 günlük mortaliteyi öngörmede klinik RS ve GBS'den üstündü.
Sonuç: GBS ve AIMS65 skorları, UGIB ile ilişkili sonlanım noktalarını (endoskopik tedavi ihtiyacı, hastaneye yatış, tekrar kanama ve mortalite) belirlemek için değerli skorlama sistemleridir. Risk skorlama sistemlerini kullanarak yüksek riskli hastaların belirlenmesi ve bu grupta endoskopi yapılması klinik sonuçları iyileştirebilirken, düşük riskli hastalarda duyarlılıkları yetersizdir.

Anahtar Kelimeler

Gastrointestinal hemoraji, Endoskopi, Risk değerlendirmesi, Prognoz

Kaynakça

• Barkun, AN, Bardou M, Kuipers EJ, et al. international consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-13.
• Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 1-46.
• Kumar NL, Travis AC, Saltzman JR. Initial management and timing of endoscopy in nonvariceal upper GI bleeding. Gastrointest Endosc 2016; 84: 10-7.
• Lee JG, Turnipseed S, Romano PS, et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999; 50: 755-61.
• Lim LG, Ho KY, Chan YH, et al. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy 2011; 43: 300-6.
• Schacher GM, Lesbros-Pantoflickova D, Ortner MA, Wasserfallen JB, Blum AL, Dorta G. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A "fortuitously controlled" study. Endoscopy 2005; 37: 324-8.
• Spiegel BM, Vakil NB, Ofman JJ. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med 2001; 161: 1393-404.
• Wysocki JD, Srivastav S, Winstead NS. A nationwide analysis of risk factors for mortality and time to endoscopy in upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2012; 36: 30-6.
• Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-7.
• Lau JY, Barkun A, Fan DM, Kuipers EJ, Yang YS, Chan FK. Challenges in the management of acute peptic ulcer bleeding. Lancet 2013; 381: 2033-43.
• Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med 2008; 359: 928-37.
• Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107: 345-60.
• de Groot NL, van Oijen MG, Kessels K, et al. Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified? Endoscopy 2014; 46: 46-52.
• Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-21.
• Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-21.
• Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011; 74: 1215-24.
• Elsebaey MA, Elashry H, Elbedewy TA, et al. Predictors of in-hospital mortality in a cohort of elderly Egyptian patients with acute upper gastrointestinal bleeding. Medicine (Baltimore)2018; 97: e0403.
• Nahon S, Nouel O, Hagege H, et al. Favorable prognosis of upper-gastrointestinal bleeding in 1041 older patients: results of a prospective multicenter study. Clin Gastroenterol Hepatol2008; 6: 886-92.
• Alkhatib AA, Elkhatib FA. Acute upper gastrointestinal bleeding among early and late elderly patients. Dig Dis Sci2010; 55: 3007-9.
• Tammaro L, Di Paolo MC, Zullo A, et al. Endoscopic findings in patients with upper gastrointestinal bleeding clinically classified into three risk groups prior to endoscopy. World J Gastroenterol 2008; 14: 5046-50.
• Hay JA, Lyubashevsky E, Elashoff J, Maldonado L, Weingarten SR, Ellrodt AG. Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay. Am J Med 1996; 100: 313-22.
• Marmo R, Koch M, Cipolletta L, et al. Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and Prospective Comparison with the Rockall Score. Am J Gastroenterol 2010; 105: 1284-91.
• McLaughlin C, Vine L, Chapman L, et al. The management of low-risk primary upper gastrointestinal haemorrhage in the community: a 5-year observational study. Eur J Gastroenterol Hepatol 2012; 24: 288-93.
• Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012; 10: 1130-5.
• Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017; 356: 6432.
• Monteiro S, Goncalves TC, Magalhaes J, Cotter J. Upper gastrointestinal bleeding risk scores: Who, when and why? World J Gastrointest Pathophysiol 2016; 7: 86-96.
• Stanley AJ, Dalton HR, Blatchford O, et al. Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2011; 34: 470-5.
• Srirajaskanthan R, Conn R, Bulwer C, Irving P. The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage. Int J Clin Pract 2010; 64: 868-74.
• Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53: 300-32.
• Camellini L, Merighi A, Pagnini C, et al. Comparison of three different risk scoring systems in non-variceal upper gastrointestinal bleeding. Dig Liver Dis 2004; 36: 271-7.
• Kim BJ, Park MK, Kim SJ, et al. Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study. Dig Dis Sci 2009; 54: 2523-9.
• Hyett BH, Abougergi MS, Charpentier JP, et al. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc 2013; 77: 551-7.
• Ko IG, Kim SE, Chang BS, et al. Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding. BMC Gastroenterol 2017; 17: 159.
• Tammaro L, Buda A, Di Paolo MC, et al. A simplified clinical risk score predicts the need for early endoscopy in non-variceal upper gastrointestinal bleeding. Dig Liver Dis 2014; 46: 783-7.