Post on 28-May-2015
description
The use of Rockall Score in predicting mortality, recurrent bleeding and need for
surgery in non-variceal upper gastrointestinal bleeding at a University Hospital in the East
Coast of Peninsular Malaysia
The use of Rockall Score in predicting mortality, recurrent bleeding and need for
surgery in non-variceal upper gastrointestinal bleeding at a University Hospital in the East
Coast of Peninsular Malaysia
Yeong Yeh Lee
MD MRCP(UK) MMedYeong Yeh Lee
MD MRCP(UK) MMed
ORAL PRESENTATION APDW 2008
BackgroundBackground
Many scoring systems have been developed to direct appropriate patient management of upper GI bleeding and enable cost effective use of resources .
The most widely used score was developed by Rockall et al in 1996. The Rockall score was designed to predict mortality, but Rockall et al suggested that it could also be used for the prediction of re-bleeding1.
1 Rockall TA, Logan RF, Devlin HB, Northfield TC (1997). Gut.41:606-11
Many scoring systems have been developed to direct appropriate patient management of upper GI bleeding and enable cost effective use of resources .
The most widely used score was developed by Rockall et al in 1996. The Rockall score was designed to predict mortality, but Rockall et al suggested that it could also be used for the prediction of re-bleeding1.
1 Rockall TA, Logan RF, Devlin HB, Northfield TC (1997). Gut.41:606-11
ME
TH
OD
OL
OG
YSample size calculationn = 1.96² x P(1-P)
0.05²P=anticipated population proportion = 20%1
Significance level 0.05n=245
Data analysis1.Descriptive analysis2.Univariate analysis3.Multivariate analysis4.Specificity and Sensitivity of Rockall Score
1 CB Ferguson, RM Mitchell Ulster Med J 2006; 75 (1) 32-39
DefinitionsDefinitionsMortality
Mortality was defined as in hospital death
Recurrent bleeding Recurrent bleeding was defined as new episode of
bleeding during hospitalization after the initial bleeding has stopped, manifested as recurrence of haematemesis, fresh malaena, haematochezia or fresh blood in the nasogastric aspirate.
Need for surgery Need for surgery was defined as the need to undergo
laparotomy after the first or second endoscopy failed to secure the upper GI bleeding episode.
Mortality Mortality was defined as in hospital death
Recurrent bleeding Recurrent bleeding was defined as new episode of
bleeding during hospitalization after the initial bleeding has stopped, manifested as recurrence of haematemesis, fresh malaena, haematochezia or fresh blood in the nasogastric aspirate.
Need for surgery Need for surgery was defined as the need to undergo
laparotomy after the first or second endoscopy failed to secure the upper GI bleeding episode.
Calculation of Rockall ScoreHigh risk score > 5 Low risk score ≤ 51
Calculation of Rockall ScoreHigh risk score > 5 Low risk score ≤ 51
VariableScore
0 1 2 3
Age
Shock
Co Morbidity
Diagnosis
Major SRH
<60
No shockSBP≥100PR<100
No major Co-morbidity
Mallory-Weiss tear, no lesion identified, no SRH or blood
None or dark spot
60-79
TachycardiaSBP≥100PR≥100
All other diagnosis
>80
HypotensionSBP≤100
Cardiac Failure,IHD, any major co-morbidity
Malignancy of upper GI tract
Blood in upper GI tract, adherent clot, visible or spurting vessel
Renal failure, liver failure disseminated malignancy
1. Church NI, Palmer KR (2001). Eur J Gastroenterol Hepatol 13:1149–52.
SBP = systolic blood in mmHg PR = pulse rate IHD=Ischaemic heart DiseaseGI= gatrointestinal SRH= Stigmata recent Haemorrhage
Rockall Score and outcome
Rockall scoreMortality
n(%)p
Recurrent bleeding
n(%)p
Need for surgery
n(%)p
Score > 5Score≤5
7(2.8)2(0.8)
<0.00110(4)
14(5.6)<0.01
6(2.4)5(2.0)
0.43
Score >5SensitivitySpecificity
0.780.86
0.420.87
0.450.85
Demographic
Frequency
Mean ±SDTotaln(%)
Mortalityn (%)
Recurrent Bleeding
n (%)
Need for Surgeryn (%)
TotalAge(years)Gender Male FemaleRace Malay Non-malay Smoking Current Ex
62.1 ±16 250(100)
144(57.6)106(42.4)
209(83.6)41(16.4)
33(13.2)38(15.2)
9(3.6)
5(55.6)4(44.4)
7(77.8)2(22.2)
1(11.1)0
24(9.6)
17(70.8)7(29.2)
22(91.7)2(8.3)
5(20.8)2(8.3)
11(4.4)
8(72.7)3(27.3)
11(100)0
2(18.2)1(9.1)
Comorbidity and association with outcome
Co-morbidity
Frequency /association (p value)
Total (n) Death (n) pRecurrent
bleeding (n)p
Need for op (n)
pHigh risk group (n)
p
Total (n) 9 24 11 37
IHDPrior PUDCRFCLDSepsis
5341411112
21224
NSNSNS
0.008<0.001
16734
NSNSNS
0.0420.004
02311
NSNSNSNSNS
14111246
0.0070.0180.0040.039
<0.001
IHD = Ischaemic Heart DiseasePUD = Peptic Ulcer DiseaseCRF = Chronic Renal FailureCLD = Chronic Liver DiseaseOp = operation / surgical interventtionNS= Not significant
Risk factors , symptoms, clinical parameters - association with outcome
Risk factors
Frequency / association (p value)
nMortality
(n)p
Recurrent bleeding (n)
pNeed for
op(n)p
High risk group (n)
p
Total 9 24 11 37AspirinWarfarinHerbs
57144
220
NS0.019
NS
100
0.022NSNS
002
NSNSNS
942
NSNS
0.046
Symptoms
Epigastric painSymptomatic
anaemia
103
168
2
8
NS
NS
11
23
NS
0.002
9
11
0.005
0.018
16
30
NS
0.05
Clinical parameter
mean±SD mean±SD mean±SD mean±SD mean±SD
DBP 71±15 67±26 NS 71±19 NS 64±10 0.031 67±14 NS
BP = Diastolic Blood Pressure in mmHg Op = operation/ surgical intervention
Examination, laboratory parameters and association with outcome
Examinations
Frequency/ association (p value)
nMortality
(n)p
Recurrent bleeding
(n)p
Need for op (n)
pHigh
risk(n)p
Total 9 24 11 37UnconsciousRT coffee groundPR malaenaTender epigastrium
1358
17
45
55
9
1
<0.0010.019
0.038
NS
40
2
5
0.008NS
NS
NS
15
7
5
NSNS
NS
0.015
511
28
9
0.014NS
NS
NSLaboratory parameters
mean±SD mean±SD mean±SD mean±SDmean±
SD
Hb (g/dl)APTT(secs)Urea(mmol/L)Creatinine(mmol/L)
15.5±8.233.9±1114.1±12170±187
6.4±2.039.9±1222.5±13317±255
0.030NS
0.040NS
6.8±1.638.8±1521.0±15290±230
0.006NS
0.0280.029
6.4±1.335.6±6620.7±13213±153
0.001NSNSNS
7.3±2.437.9±9.418.3±14196±192
0.0220.026
NSNS
RT= Ryles tubeHb=Haemoglobin in grams/deciliterPR = Per rectalAPTT=Activated partial thromboplastin time in seconds
Multiple Logistic Regression Analysis of factors with outcome variable
P Value Odd Ratio 95% Confidence Interval
Mortality
Sepsis 0.021 9.910 1.413-69.513
Recurrent Bleeding
Creatinine 0.012 1.002 1.000-1.004
High risk Group
SRHSepsisWarfarin
<0.0010.0130.028
0.0630.1490.182
0.26-0.1520.034-0.6640.040-0.832
SRH=Stigmata of Recent Haemorrhage
ConclusionConclusion Rockall score has a good predictive value in high risk
patients for mortality but not so in recurrent bleeding and no for the need of surgery.
Sepsis was a significant risk factor for mortality in this study. A prospective study on the use of Rockall score in upper GI bleed patients with sepsis is recommended.
A higher creatinine level was significantly associated with recurrent bleeding in non-variceal upper GI bleeding.
Rockall score has a good predictive value in high risk patients for mortality but not so in recurrent bleeding and no for the need of surgery.
Sepsis was a significant risk factor for mortality in this study. A prospective study on the use of Rockall score in upper GI bleed patients with sepsis is recommended.
A higher creatinine level was significantly associated with recurrent bleeding in non-variceal upper GI bleeding.