UGIB Risk Scores: Blatchford vs. Rockall for Clinical Intervention

American Journal of Emergency Medicine (2007) 25, 774 – 779
www.elsevier.com/locate/ajem
Original Contribution
Risk scoring systems to predict need for
clinical intervention for patients with nonvariceal
upper gastrointestinal tract bleeding
I-Chuan Chen MDa, Ming-Szu Hung MDb, Te-Fa Chiu MDc,
Jih-Chang Chen MDc, Cheng-Ting Hsiao MDa,*
a
Department of Emergency Medicine, Chang Gung Memorial Hospital, Puzih City, Chiayi County 613, Taiwan, ROC
Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Puzih City, Chiayi County 613,
Taiwan, ROC
c
Department of Emergency Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine,
Taoyuan County 333, Taiwan, ROC
b
Received 16 December 2006; revised 24 December 2006; accepted 29 December 2006
Abstract
Background: Several risk score systems are designed for triage patients with acute nonvariceal upper
gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is
used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical
Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who
have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on
clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have
recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion,
endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to
compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in
identifying high-risk cases in patients with acute nonvariceal UGIB.
Methods: International Classification of Diseases, Ninth Revision, Clinical Modification codes for
admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to
a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant
blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient.
High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0,
and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if
they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such
patients were defined as high-risk patients.
Results: The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for
clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control).
The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete
Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk
* Corresponding author. Tel.: +886 5 3621000 2639; fax: +886 5 3623002.
E-mail address: [email protected] (C-T Hsiao).
0735-6757/$ – see front matter D 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2006.12.024
Predictors for non-variceal UGI bleeding
775
cases with the Blatchford score was significantly greater than with the clinical Rockall score ( P b .0001)
or with the complete Rockall score ( P b .0001).
In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical
intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as
aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk.
Only 1 patient who met the study definition of needing clinical intervention was not identified via
Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood
transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four
patients who met the study definition of needing clinical intervention were not recognized via clinical
Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion.
The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients
who met the study definition of needing clinical intervention were not recognized via complete Rockall
score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion.
Conclusions: The Blatchford score, which is based on clinical and laboratory variables, may be a useful
risk stratification tool in detecting which patients need clinical intervention in patients with acute
nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the
clinical Rockall score and the complete Rockall score in identifying high-risk patients.
D 2007 Elsevier Inc. All rights reserved.
1. Introduction
2. Methods
Upper gastrointestinal bleeding (UGIB) has an estimated
incidence of about 102 in 100 000 people per year [1].
Upper gastrointestinal bleeding is a common medical
emergency in clinical practice. There is no doubt that
hospitalization is mandatory for variceal hemorrhage in
cirrhotic patients. However, nonvariceal UGIB is highly
inconstant in severity and outcome. Patients with UGIB
may present with a wide range of clinical severity, ranging
from insignificant bleeding to fatal outcomes [2]. Several
systems have been designed to identify patients with high
risks of adverse outcomes (commonly defined as a risk of
recurrent bleeding of N5% and N1% mortality) and
differentiate them from patients with lower risks [3-8].
However, because clinical treatment aims to prevent
patients from dying and complication, we believe that
identifying which patients will require clinical intervention
is more practical than identifying who may die or have
recurrent bleeding.
The Blatchford score suggests that it be used to identify
patients with acute UGIB who need clinical intervention
before endoscopy. Patients with a Blatchford score of
greater than 0 are considered to require clinical intervention
[9]. The clinical Rockall score is calculated from routine
clinical variables. Patients with a clinical Rockall score of
greater than 0 are considered to be at high risk for adverse
outcomes. Besides the clinical Rockall score, the complete
Rockall score is calculated from clinical and endoscopic
variables. Patients with a complete Rockall score of greater
than 2 are considered to be at high risk for recurrent
bleeding and death [2,3,10,11].
Our study aims to compare the Blatchford score with the
clinical Rockall score and the complete Rockall score in
their utilities in assessing the need for clinical intervention
in patients with acute nonvariceal UGIB.
An electronic search was made of all adult (N18 years of
age) patients with acute UGIB admitted to the emergency
department (ED) of Chang Gung Memorial Hospital
(Taoyuan County, Taiwan)—a tertiary care, universityaffiliated hospital—with an admission diagnosis of gastrointestinal (GI) bleeding (International Classification of
Diseases, Ninth Revision codes 5780, 5781, and 5789). This
search was made from our hospital’s medical record database
and began from January 2006 to July 2006. These patients
were then further selected for the absence of bleeding
esophageal varices (International Classification of Diseases,
Ninth Revision, Clinical Modification code 4650). Patients
thus chosen for study had the diagnosis of UGIB without
bleeding esophageal varices confirmed on endoscopy.
Before endoscopy, all patients were treated with intravenous
proton pump inhibitors (ie, omeprazole, pantoprazole).
Patients were excluded if they did not undergo endoscopy,
were not treated with proton pump inhibitors, were 18 years
old or younger, or bled from lower-GI source. A patient was
considered to have developed recurrent bleeding if one of the
following events occurred: repeated endoscopy before
hospital discharge, surgery for control of UGIB, or readmission to the hospital within 30 days of discharge due to UGIB.
Patients thus identified had their case records reviewed for
their initial vital signs and their laboratory test results taken
at the time of presentation to the ED with UGIB.
Demographic information, clinical presentation, presence
of comorbid medical conditions (as defined by the Charlson
comorbidity index [12]), findings of endoscopy, number of
unit of blood transfusion, types of treatment of UGIB, and
medication being taken at the time of admission were also
reviewed. Data collections were made by 1 research assistant
who was blinded to the purpose of the study and to the
Rockall and Blatchford score calculations.
776
Table 1
I.-C. Chen et al.
Blatchford score
Admission risk marker
Score component value
Blood urea nitrogen level (mg/dL)
z18.2 to b22.4
z22.4 to b28
z28 to b70
z70
Hemoglobin level for men (g/dL)
z12 to b13
z10 to b12
b10
Hemoglobin level for women (g/dL)
z10 to b12
b10
Systolic blood pressure (mm Hg)
z100 to b109
z90 to b99
b90
Other markers
Pulse rate z100 beats/min
Presentation with melena
Presentation with syncope
Hepatic disease
Heart failure
2
3
4
6
1
3
6
1
6
1
2
3
1
1
2
2
2
2.1. Specification of variables and
statistical analysis
Range of scores is from 0 to 23; maximum score is 23, high risk, greater
than 0.
Patients were defined as needing clinical intervention if
they had a blood transfusion or any operative or endoscopic
intervention to control their bleeding. Such patients were
defined as high-risk patients.
A Blatchford score was calculated for each patient
based on points assigned for 8 clinical or laboratory
variables at the time of patient presentation, including blood
urea nitrogen level, hemoglobin level, systolic blood
pressure, heart rate, presentation with melena, presentation
with syncope, evidence of hepatic disease, and evidence
of heart failure (Table 1). A Blatchford score of greater than
Table 2
0 was considered as high risk, and clinical intervention
was required.
The clinical Rockall score, which was calculated without
endoscopic finding, for each patient was based on points
assigned for 3 clinical variables: patient age at presentation,
shock status based on initial heart rate and systolic blood
pressure, and presence of comorbid disease (Table 2). A
clinical Rockall score of greater than 0 was considered as
high risk for substantial adverse outcomes, such as recurrent
bleeding and death associated with UGIB.
The complete Rockall score (after endoscopy) was
calculated for each patient based on points assigned for
each of the 3 aforementioned clinical variables plus 2
endoscopic variables: endoscopic diagnosis and stigmata of
recent hemorrhage based on the initial endoscopic examination. The complete Rockall score was equal to the sum of
the points assigned. Patients with complete Rockall score of
greater than 2 points were considered to be at high risk for
substantial adverse outcomes.
We compared the proportions of patients identified as
high-risk using v 2 tests, and SPSS statistical software
version 12 (SPSS Inc, Chicago, Ill) was used for data
analysis and management. A 2-sided P value of less than
.05 was thought to be statistically significant. Sensitivity
and specificity in detecting patients who needed clinical
intervention, had recurrent bleeding, or died were calculated
for Blatchford score, clinical Rockall score, and complete
Rockall score with confidence interval.
3. Results
Three hundred fifty-four patients with acute nonvariceal
UGIB were enrolled and analyzed. Two hundred thirty-
Rockall risk score
Variable
Score
0
1
2
Age (y)
Shock
Comorbidity
b60
60-79
HR N 100 beats/min
z80
SBP b 100 mm Hg
IHD, CHF, any
major comorbidity
Endoscopic diagnosis
Mallory-Weiss tear or
no lesion observed
Clean-based ulcer,
flat pigmented spot
Stigmata of
recent hemorrhage
Peptic ulcer disease,
erosive esophagitis
3
Renal failure,
liver failure,
metastatic malignancy
Malignancy of upper GI tract
Blood in upper GI tract,
clot, visible vessel, bleeding
The clinical Rockall score, which is calculated without endoscopic finding, for each case was based on points assigned for 3 clinical variables: patient age at
presentation, shock status based on initial heart rate and systolic pressure, and presence of comorbid disease. The complete Rockall score (after endoscopy)
is calculated for each case based on points assigned for each of 3 aforementioned clinical variables plus 2 endoscopic variables: the endoscopic diagnosis
and stigmata of recent hemorrhage based on the initial endoscopic examination. Patients with clinical Rockall scores (before endoscopy) of greater than 0
and patients with complete Rockall scores (after endoscopy) of greater than 2 are considered to be at high risk for developing adverse outcomes (recurrent
bleeding, death). HR indicates heart rate; SBP, systolic blood pressure; IHD, ischemic heart disease; CHF, congestive heart failure.
Predictors for non-variceal UGI bleeding
777
seven were men (66.9%) and 117 were women (33.1%).
The mean age of total number of patients was 61.6 (16.2SD)
years. About 42% (148/354) were actively taking nonsteroidal anti-inflammatory drugs, including aspirin, before
UGIB developed. All 354 patients were treated with proton
pump inhibitors; 22 were treated with omeprazole (6.2%)
and 332 (93.8%) were treated with pantoprazole. Of the
Table 3
Characteristics of patients in our study
No. of patients in our study
No. of patients identified as high-risk
in total no. of patients
Blatchford score
Clinical Rockall score
Complete Rockall score
No. of patients treated with proton
pump inhibitors
No. of patients treated with pantoprazole
No. of patients treated with omeprazole
No. of high-risk patients in our study
No. of patients treated with pantoprazole
in high-risk patients
No. of patients identified as high-risk in
our high-risk group
Blatchford score
Clinical Rockall score
Complete Rockall score
No. of missed patients (who should have
been identified as high-risk but were not)
Blatchford score
Clinical Rockall score
Complete Rockall score
No. of patients treated with pantoprazole
in missed patients
Blatchford score
Clinical Rockall score
Complete Rockall score
Total no. of patients who developed
recurrent bleeding in our study
No. of patients who developed recurrent
bleeding in missed patients
Blatchford score
Clinical Rockall score
Complete Rockall score
Total no. of patients who died in our study
No. of patients who died in missed patients
Blatchford score
Clinical Rockall score
Complete Rockall score
Total no. of patients who received blood
transfusion in our study
No. of patients treated with pantoprazole
in patients with blood transfusion
No. of patients who received blood
transfusion in missed patients
Blatchford score
Clinical Rockall score
Complete Rockall score
354
326
289
248
354
(92.1%)
(81.6%)
(70.1%)
(100%)
332 (93.8%)
22 (6.2%)
246
246
245 (99.6%)
222 (90.2%)
224 (91.1%)
1
24
22
1
24
22
23
0
7
3
3
0
0
2
191
191
0
6
20
total 354 patients, 68 (19.2%) had gastric ulcer bleeding, 64
(18.1%) had duodenal ulcer bleeding, 71 (20.0%) had
gastric ulcer with protruding vessel, 64 (18.1%) had
duodenal ulcer with protruding vessel, and 87 (24.6%)
had UGIB due to other causes (eg, esophageal ulcer,
hemorrhagic gastritis). Twenty-three (6.5%) patients developed recurrent bleeding and 3 (0.85%) patients died.
The Blatchford score identified 326 (92.1%) of the
354 patients as those with high risk for clinical intervention
(ie, blood transfusion, endoscopic or surgical management
for bleeding control). The clinical Rockall score identified
289 (81.6%) of the 354 patients as high-risk, and the
complete Rockall score identified 248 (70.1%) of the 354
patients as high-risk. The yield of identifying high-risk
patients with the Blatchford score was significantly greater
than with the clinical Rockall score ( P b .0001) or with the
complete Rockall score ( P b .0001).
Of our total 354 patients, 191 (54.0%) patients needed
blood transfusion. All of these 191 patients were treated
with pantoprazole. A total of 246 (69.5%) patients were
categorized as those with high risk for clinical intervention
(blood transfusion, endoscopic or surgical management for
bleeding control, as aforementioned) in our study. All of
these 246 patients were treated with pantoprazole. The mean
age of these high-risk patients was 63.9 (14.8SD) years, and
160 (65.0%) were men. The Blatchford score identified 245
(99.6%) of 246 patients as high-risk. Only 1 patient who
met the study definition of needing clinical intervention was
not identified via Blatchford score. This patient did not have
recurrent bleeding nor die and did not receive blood
transfusion, and he was treated with pantoprazole. Therapeutic endoscopy was performed to this patient to control
bleeding caused by Mallory-Weiss tear. The clinical Rockall
score identified 222 (90.2%) of 246 patients as high-risk.
Twenty-four patients who met the study definition of
needing clinical intervention were not recognized via
clinical Rockall score. Of these patients, 0 died, 7 developed
recurrent bleeding, and 6 needed blood transfusion. All of
these 24 patients were treated with pantoprazole. The
complete Rockall score identified 224 (91.1%) of 246
patients as high-risk. Twenty-two patients who met the
study definition of needing clinical intervention were not
recognized via complete Rockall score. Of these patients, 2
died, 3 developed recurrent bleeding, and 20 needed blood
transfusion. All of these 22 patients were treated with
pantoprazole (Table 3).
4. Discussion
In patients with GI tract bleeding, the severity of an upper
GI source influences the urgency of upper endoscopy, the
need for blood transfusion, and the need to consult specialists
to control GI tract bleeding [13-16]. In recent years, several
practice guidelines and risk scores, combining clinical and
endoscopic parameters, have been developed [3,5,17,18]
with the aim of assisting physicians in the early stages of
778
I.-C. Chen et al.
Table 4 Test characters of Blatchford score, clinical Rockall score, and complete Rockall score in detection of high-risk patients,
recurrent bleeding, and death in nonvariceal UGIB
Blatchford score
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Clinical Rockall score
Sensitivity
Specificity
Positive predictive value
Negative predictive value
Complete Rockall score
Sensitivity
Specificity
Positive predictive value
Negative predictive value
High-risk patients
Recurrent bleeding
Death
99.6
25.0
75.2
96.4
(97.7-99.9)
(17.8-33.9)
(70.2-79.5)
(82.3-99.4)
100
8.5
7.1
100
(85.7-100)
(5.9-12.0)
(4.7-10.4)
(87.9-100)
100
8.0
0.9
100
(43.8-100)
(5.6-11.3)
(0.3-2.7)
(87.9-100)
90.2
38.0
76.8
63.1
(85.9-93.4)
(29.4-47.4)
(71.6-81.3)
(50.9-73.8)
69.6
17.5
5.5
89.2
(49.1-84.4)
(13.8-22.0)
(3.4-8.8)
(79.4-94.7)
100
18.5
1.0
100
(43.8-100)
(14.8-22.9)
(0.4-3)
(94.4-100)
91.1
77.8
90.3
79.2
(86.8-94.0)
(69.1-84.6)
(86.0-93.4)
(70.6-85.9)
87.0
31.1
8.1
97.2
(67.9-95.5)
(26.4-36.3)
(5.3-12.1)
(92.0-99.0)
33.3
29.6
0.4
98.1
(6.1-79.2)
(25.1-34.6)
(0.1-2.2)
(93.4-99.5)
Values inside parentheses are 95% confidence intervals.
decision making [3,15,19-23]. Such a prediction may help
physicians decide about hospital admission or discharge, the
level of assistance that admitted patients’ need, and the type
of treatment to be adopted. Of these various scoring systems
for UGIB, the complete Rockall score has been assumed as a
predictive index assessing risk of rebleeding and mortality of
UGIB most frequently [3,22,24]. It is based on clinical and
endoscopic findings. The clinical Rockall score is obtained
by clinical findings alone.
However, because clinical treatment aims to prevent
patients from dying, facilitate patients to heal, and prevent
patients from complications, we believe that identifying
which patients will require clinical intervention (ie, blood
transfusion, endoscopy or surgery for bleeding control) is
more logical than identifying who may die or have recurrent
bleeding. Also, some patients identified to be at low risk for
recurrent bleeding and death may need blood transfusion
after UGIB. Admission to the hospital is indicated to such
patients, and they are therefore no longer low-risk patients.
The Blatchford score is a validated risk assessment device
for the need for clinical intervention of patients with acute
UGIB. The Blatchford score is based on only clinical and
laboratory data, so it can be applied soon without the need
for urgent endoscopy. Thus, we hypothesize that the
Blatchford score has higher sensitivity for identifying
patients with acute nonvariceal UGIB who need clinical
intervention than other risk scoring systems.
The findings of our study are consistent with our
hypothesis. In our retrospective study of 354 patients, 246
patients were categorized as high-risk in whom clinical
intervention was needed. Of 246 patients, the Blatchford
score identified 245 (99.6%) patients, and only 1 was not
identified. This patient did not have recurrent bleeding nor die
and did not receive blood transfusion. In contrast, the clinical
Rockall score missed 24 patients who needed clinical
intervention; none of them died, and 7 of them developed
recurrent bleeding, although there were only 23 patients who
had recurrent bleeding in our total of 354 patients.
The complete Rockall score missed 22 patients who
needed clinical intervention; 2 of them died, 3 of them
developed recurrent bleeding, and 20 of them needed blood
transfusion. Only 3 people died in our total of 354 patients,
and the complete Rockall score failed to recognize 2 of
them. Table 4 reveals the sensitivity, specificity, positive
predictive value, and negative predictive value of the
Blatchford score, the clinical Rockall score, and the
complete Rockall score in identifying patients with acute
nonvariceal UGIB who needed clinical intervention, who
developed recurrent bleeding, and who died. The Blatchford
score had higher sensitivity in all 3 categories.
The first limitation of our study is that it is a
retrospective study. Medical records that are not designed
for research purposes may not include all variables of
research interest or may contain inaccurate descriptions. To
resolve these problems, we collected all data needed by a
joint review of medical records by 2 principal investigators. In addition, undefined chart review procedures result
in unreliable abstraction or, worse, biased abstraction if the
abstractor knows the specific hypothesis. To maximize the
validity and reliability of the review process, we used
several techniques recommended for chart reviews—
formal inclusion criteria, abstractor blinding to specific
hypotheses, abstractor blinding between predictor and
outcome variables, maintenance and regular revision of a
study manual, specific variable definitions, standardized
abstraction forms, and periodic abstractor monitoring. A
second limitation of our study is that because only medical
record data from our institution were available for
reviewing, the data on postdischarge outcomes may be
incomplete. However, we believe that most patients
discharged from our hospital would return to the same
institution if UGIB recurred. A third limitation is the
Predictors for non-variceal UGI bleeding
impact of treatment. Although we have limited the drug
options for acute UGIB to proton pump inhibitors in our
study, different drugs (such as omeprazole and pantoprazole) were chosen according to the clinical physicians’
favorite. However, we believe these drug options would
not have much influence to the results of our study
[25,26].
5. Conclusion
In summary, the Blatchford score, which is based on
clinical and laboratory variables, may be a useful risk
stratification tool in detecting which patients need clinical
intervention in patients with acute nonvariceal UGIB. It
does not need urgent endoscopy for scoring and has higher
sensitivity than the clinical Rockall score and the complete
Rockall score in identifying high-risk patients.
Further prospective studies are indicated to evaluate such
risk stratification system in the identification of high-risk
patients with acute UGIB.
Acknowledgment
We thank Mrs Estella Liu for her thoughtful comment on
this article.
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