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.