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Rockall score in non-variceal upper gastrointestinal bleeding
 

Rockall score in non-variceal upper gastrointestinal bleeding

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The use of Rockall score in predicting risk for non-variceal upper gastrointestinal bleeding in a tertiary hospital

The use of Rockall score in predicting risk for non-variceal upper gastrointestinal bleeding in a tertiary hospital

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  • . SRH= stigmata of recent haemorrhage, defined as blood, adherent clot, visible or spurting vessels or dark spots in GI tract.  

Rockall score in non-variceal upper gastrointestinal bleeding Rockall score in non-variceal upper gastrointestinal bleeding Presentation Transcript

  • 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) MMed ORAL PRESENTATION APDW 2008
  • Background
    • 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-bleeding 1 .
    • 1 Rockall TA, Logan RF, Devlin HB, Northfield TC (1997). Gut. 41:606-11
  • METHODOLOGY
    • Sample size calculation
    • n = 1.96² x P(1-P)
    • 0.05²
    • P=anticipated population proportion = 20% 1
    • Significance level 0.05
    • n=245
    • Data analysis
    • Descriptive analysis
    • Univariate analysis
    • Multivariate analysis
    • Specificity and Sensitivity of Rockall Score
    1 CB Ferguson, RM Mitchell Ulster Med J 2006; 75 (1) 32-39
  • Definitions
    • 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 Score High risk score > 5 Low risk score ≤ 5 1 1. Church NI, Palmer KR (2001). Eur J Gastroenterol Hepatol 13:1149–52. SBP = systolic blood in mmHg PR = pulse rate IHD=Ischaemic heart Disease GI= gatrointestinal SRH= Stigmata recent Haemorrhage Variable Score 0 1 2 3 Age Shock Co Morbidity Diagnosis Major SRH <60 No shock SBP≥100 PR<100 No major Co-morbidity Mallory-Weiss tear, no lesion identified, no SRH or blood None or dark spot 60-79 Tachycardia SBP≥100 PR≥100 All other diagnosis >80 Hypotension SBP≤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
  • Rockall Score and outcome Rockall score Mortality n(%) p Recurrent bleeding n(%) p Need for surgery n(%) p Score > 5 Score≤5 7(2.8) 2(0.8) <0.001 10(4) 14(5.6) <0.01 6(2.4) 5(2.0) 0.43 Score >5 Sensitivity Specificity 0.78 0.86 0.42 0.87 0.45 0.85
  • Demographic Frequency Mean ±SD Total n(%) Mortality n (%) Recurrent Bleeding n (%) Need for Surgery n (%) Total Age(years) Gender Male Female Race 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)
  • IHD = Ischaemic Heart Disease PUD = Peptic Ulcer Disease CRF = Chronic Renal Failure CLD = Chronic Liver Disease Op = operation / surgical interventtion NS= Not significant Comorbidity and association with outcome Co-morbidity Frequency /association (p value) Total (n) Death (n) p Recurrent bleeding (n) p Need for op (n) p High risk group (n) p Total (n) 9 24 11 37 IHD Prior PUD CRF CLD Sepsis 53 41 41 11 12 2 1 2 2 4 NS NS NS 0.008 <0.001 1 6 7 3 4 NS NS NS 0.042 0.004 0 2 3 1 1 NS NS NS NS NS 14 11 12 4 6 0.007 0.018 0.004 0.039 <0.001
  • BP = Diastolic Blood Pressure in mmHg Op = operation/ surgical intervention Risk factors , symptoms, clinical parameters - association with outcome Risk factors Frequency / association (p value) n Mortality (n) p Recurrent bleeding (n) p Need for op(n) p High risk group (n) p Total 9 24 11 37 Aspirin Warfarin Herbs 57 14 4 2 2 0 NS 0.019 NS 1 0 0 0.022 NS NS 0 0 2 NS NS NS 9 4 2 NS NS 0.046 Symptoms Epigastric pain S ymptomatic 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
  • RT= Ryles tube Hb=Haemoglobin in grams/deciliter PR = Per rectal APTT=Activated partial thromboplastin time in seconds Examination, laboratory parameters and association with outcome Examinations Frequency/ association (p value) n Mortality (n) p Recurrent bleeding (n) p Need for op (n) p High risk(n) p Total 9 24 11 37 Unconscious RT coffee ground PR malaena Tender epigastrium 13 58 17 45 5 5 9 1 <0.001 0.019 0.038 NS 4 0 2 5 0.008 NS NS NS 1 5 7 5 NS NS NS 0.015 5 11 28 9 0.014 NS NS NS Laboratory parameters mean±SD mean±SD mean±SD mean±SD mean± SD Hb (g/dl) APTT(secs) Urea(mmol/L) Creatinine (mmol/L) 15.5±8.2 33.9±11 14.1±12 170±187 6.4±2.0 39.9±12 22.5±13 317±255 0.030 NS 0.040 NS 6.8±1.6 38.8±15 21.0±15 290±230 0.006 NS 0.028 0.029 6.4±1.3 35.6±66 20.7±13 213±153 0.001 NS NS NS 7.3±2.4 37.9±9.4 18.3±14 196±192 0.022 0.026 NS NS
  • SRH=Stigmata of Recent Haemorrhage 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 SRH Sepsis Warfarin <0.001 0.013 0.028 0.063 0.149 0.182 0.26-0.152 0.034-0.664 0.040-0.832
  • Conclusion
    • 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.
  • for your Attention Thank you