Acute bleeding from the upper gastrointestinal track is a common emergency. Patients may experience a spectrum of events from mild and clinically self-limited bleeding to fatal exsanguination. Several scoring systems have been developed to assist in the urgent assessment of patients presenting with acute upper gastrointestinal bleeding, but these have not been widely adopted in clinical practice. Many scores are based on the risk of death or rebleeding and do not accommodate the impact of modern changes in treatment. Blatchford and colleagues developed and tested a simple scoring system to identify patients at highest risk of requiring hospital admission and aggressive treatment to control gastrointestinal bleeding.
Data were obtained from more than 1,740 admissions to hospitals in Scotland for acute upper gastrointestinal bleeding. The logistic regression model constructed from these data focused on the need for blood transfusion, operative or endoscopic intervention to control bleeding, or death, rebleeding or a substantial fall in hemoglobin to identify and rank the associated risk factors (see accompanying table). Hemoglobin and blood urea nitrogen levels, blood pressure, pulse and readily accessible clinical factors emerged as the most predictive. These factors were used to construct the scoring system. In a second study, the scoring system was used prospectively on 197 consecutive adult patients presenting to three hospitals during a three-month period because of upper gastrointestinal hemorrhage.
The new scoring system was strongly predictive of a need for clinical intervention to control bleeding. It was also highly correlated with length of hospital stay and use of blood transfusion. The authors calculate a sensitivity of 99 percent and a specificity of 32 percent. The new score better predicted patients at high risk than the Rockall score that was normally used in the participating hospitals.
The authors stress that the new score can be easily calculated by first-line staff and provides reliable identification of patients at highest risk. They call for further clinical experience and validation of the scoring system, with emphasis on better identification of patients at lower risk.
|Risk marker||Score component value|
|Blood urea nitrogen—mg per dL (mmol per L)|
|≥18.2 and <22.4 (≥6.5 and <8.0)||2|
|≥22.4 and <28.0 (≥8.0 and <10.0)||3|
|≥28.0 and <70.0 (≥10.0 and <25.0)||4|
|≥70.0 (> 25)||6|
|Hemoglobin in men—g per dL (g per L)|
|≥12.0 and <13.0 (≥120 and <130)||1|
|≥10.0 and <12.0 (≥100 and <120)||3|
|Hemoglobin in women—g per dL (g per L)|
|≥10.0 and <12.0 (≥100 and <120)||1|
|Systolic blood pressure—mm Hg|
|100 to 109||1|
|90 to 99||2|
|Pulse ≥ 100 per minute||1|
|Presentation with melena||1|
|Presentation with syncope||2|