Point-of-Care Guides

Prognosis in Patients with Upper GI Bleeding



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Am Fam Physician. 2004 Dec 15;70(12):2348-2350.

Clinical Question

What is the risk of rebleeding or death in a patient with upper gastrointestinal (GI) bleeding?

Evidence Summary

Upper GI bleeding remains a common problem and reason for hospital admission.1 A more precise estimate of a patient’s prognosis would be helpful to physicians who are deciding on hospital discharge and the intensiveness of monitoring in inpatient and outpatient settings.

A clinical decision rule has been developed that estimates the likelihood of mortality in patients presenting with upper GI bleeding. A study2 by Rockall and colleagues identified all patients presenting to hospitals in four health regions with acute upper GI hemorrhage who subsequently underwent endoscopy. Patients whose bleeding occurred in the hospital and those who did not undergo endoscopy were excluded from the study. Patients were followed prospectively and their risk of rebleeding and death was determined. This clinical decision rule has been validated36 for the prediction of mortality. The largest and best designed of these validations3 was a prospective evaluation in 951 Dutch patients with a median age of 71 years. Although some of these studies2,3,6 did not find that the prediction of rebleeding was as accurate as the prediction of death, the rule does accurately identify a group with a very low risk of rebleeding (Rockall score of 2 or lower). While other rules79 have been developed, they have not been as well validated as the Rockall2 risk score.

Rish Scoring for Upper Gastrointestinal Bleeding

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Figure 1.

The Rockall risk score and its interpretation using combined data from the original study2 and the Dutch validation study3 are shown in Figures 1 through3. To use the clinical decision rule, determine the number of points for your patient using Figure 1, then determine the patient’s risk of rebleeding and death using Figure 2. Data in Figure 2 are shown for individual scores, as well as scores grouping patients into low-, moderate-, and high-risk groups. A clinical score using the three nonendoscopic variables is shown in Figure 3; it may be especially helpful to family physicians, but it has not been validated outside of Rockall’s original validation study.2

Obviously, no clinical decision rule should be applied without the usual application of clinical judgment. However, these rules can help support clinical decision making by identifying patients who can be considered for early discharge and patients who are at an increased risk but might otherwise be considered for discharge from the hospital.

Applying the Evidence

Mr. Sailors, a 43-year-old man who is in otherwise good health, presents to the emergency department with a single episode of coffee-ground emesis and a large melanotic stool that morning. He has a six-month history of taking a nonsteroidal anti-inflammatory drug for tendonitis. His blood pressure is 108/60 mm Hg, his heart rate is 108 beats per minute, and he complains of lightheadedness when he sits up on the gurney. After being stabilized, he undergoes endoscopy that reveals a small duodenal ulcer, an adherent clot, and some old blood in the gastrointestinal tract. What is the likelihood that he will rebleed or die?

Rish Scoring for Upper Gastrointestinal Bleeding

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Figure 2.

Rish Scoring for Upper Gastrointestinal Bleeding

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Figure 3.

Answer: This patient gets zero points for age, one point for shock, zero points for comorbidity, one point for diagnosis based on endoscopy, and two points for stigmata of recent hemorrhage. His total risk score is four points, which puts him in the moderate risk category (a 13 percent risk of rebleeding and a 6.8 percent risk of death). Based on this information, the physician decides to observe him closely in an inpatient setting for an additional day or two rather than send him home right after the endoscopy.

The Author

MARK H. EBELL, M.D., M.S., is in private practice in Athens, Ga., and associate professor in the Department of Family Practice at Michigan State University College of Human Medicine, East Lansing. He is also deputy editor of evidence-based medicine for American Family Physician.

Address correspondence to Mark H. Ebell, M.D., M.S., 330 Snapfinger Dr., Athens, GA 30605 (e-mail: ebell@msu.edu). Reprints are not available from the author.

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. BMJ. 1995;311:222–6.

2. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996;38:316–21.

3. 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.

4. 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.

5. Oei TT, Dulai GS, Gralnek IM, Chang D, Kilbourne AM, Sale GA. Hospital care for low-risk patients with acute, nonvariceal upper GI hemorrhage: a comparison of neighboring community and tertiary care centers. Am J Gastroenterol. 2002;97:2271–8.

6. Camellini L, Merighi A, Pagnini C, Azzolini F, Guazzetti S, Scarcelli A, et al. Comparison of three different risk scoring systems in non-variceal upper gastrointestinal bleeding. Dig Liver Dis. 2004;36:271–7.

7. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet. 2000;356:1318–21.

8. Katschinski B, Logan R, Davies J, Faulkner G, Pearson J, Langman M. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci. 1994;39:706–12.

9. Das A, Wong RC. Prediction of outcome of acute GI hemorrhage: a review of risk scores and predictive models. Gastrointest Endosc. 2004;60:85–93.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision making at the point of care.


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