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Indian Journal of Gastroenterology

, Volume 38, Issue 2, pp 95–97 | Cite as

Scoring systems for upper gastrointestinal bleeding: Which one scores better?

  • Vinay DhirEmail author
  • Rahul Shah
Editorial
  • 542 Downloads

Scoring systems allow us to compartmentalize the myriad presentations, risk factors, and outcomes, into more or less uniform groups, so as to prioritize management and resource allocation. Multiple scoring systems abound in gastroenterology, often several for the same disorder. Their routine utilization in bedside management depends upon many factors, ease and practicality of use being the major one. While some like acute physiology and chronic health evaluation (APACHE), and model for end-stage liver disease (MELD) became rapidly integrated in clinical management, others are not routinely utilized despite strong recommendations from several societies and organizations. Scoring systems for upper gastrointestinal bleed (UGIB) fall into the latter category. A recent survey in the USA revealed that, of the 1402 emergency physicians, internists, and gastroenterologists surveyed, only 53% had ever heard of these, and 30% had ever used any scoring system [1]. While this is not an indictment of the scoring systems, it does convey the problem of cross-specialty awareness, and difficulty in remembering and recalling the parameters during an emergency.

UGIB presents in different age groups and has multiple etiologies, variceal, and non-variceal being the main categorization. Elderly patients often have co-morbidities, which influence the outcome. An ideal scoring system should take these differences into account, should be simple and easy to use, and should answer important prognostic questions like need for admission, need for intensive care and blood transfusion, need and timing of index endoscopy, possible course, and hospitalization; and likely outcome.

Scoring systems for UGIB were developed and validated from 1990s onwards [2, 3, 4, 5, 6, 7, 8, 9]. The primary aim was to segregate the patients into low-risk and high-risk groups. The scoring systems were developed with differing goals like assessing mortality, or interventions, or blood transfusions, and we should remember this while comparing them. Some of these required only clinical data, while others needed additional endoscopic findings (Table 1). The Glasgow Blatchford score (GBS) [2] was developed with the aim of predicting the risk of re-interventions like endoscopy or surgery. It is a pre-endoscopy clinical score ranging from 0 to 23. Patients with a score of 0–1 do not require early endoscopy or hospital admission. The Rockall score [4] has both clinical and endoscopic components, and can also be used solely as a clinical score before endoscopy. However, it remains the most widely used post-endoscopic risk assessment score. Each of the five components of the Rockall score (age, shock, co-morbidity, endoscopic diagnosis, and evidence of bleeding) is an independent prognostic factor. The AIMS65 (albumin, international normalized ratio [INR], mental status, systolic blood pressure, age >65 years) score [3] also has five elements, but it is a pre-endoscopy score, easy to remember and calculate at the bedside. It predicts length of hospital stay and mortality. Several other scores have also been described with differing goals. It has also been proposed that the use of a single criterion, increasing blood urea nitrogen at 24 h, may predict a worse outcome in patients with non-variceal UGIB [10].
Table 1

Scoring systems for upper gastrointestinal bleeding

Primary outcome

Clinical scores

Endoscopy scores

Time to endoscopy

 

T score

Re-bleeding

 

Forrest

  

BBS

Need for re-intervention

GBS

 

Length of stay

AIMS65

CSMCPI

Mortality

Rockall

Rockall

 

AIMS65

PNED

BBS Baylor bleeding score, GBS Glasgow Blatchford score, CSMCPI Cedars-Sinai medical centre predictive index, PNED Progetto Nazionale Emorragia Digestiva, AIMS65  albumin, international normalized ratio (INR), mental status, systolic blood pressure, age>65

Multiple large prospective studies have proved the utility of these scores in predicting the need for interventions, prolonged hospitalization, and mortality [11, 12, 13]. It was also possible to segregate a group of patients who were at low risk and did not need hospital admission. Several gastroenterology and endoscopy societies have recommended and encouraged the utilization of these scoring systems in patient management.

In this issue of the Journal, Chandnani et al. [14] prospectively assessed UGIB scoring systems in 300 patients in western India followed up for 30 days. Variceal bleed was the commonest cause, and the patient population was younger. The mortality rate was 10%, while 16.6% patients had re-bleeding. Their results were in tune with the findings of the other published studies. The Rockall score was superior in predicting mortality, while Progetto Nazionale Emorragia Digestiva (PNED) was better for predicting rebleeding. GBS was better for predicting need for blood transfusions or interventions. Thus, there was no single scoring system which was superior to others in answering all the questions.

In another study published in this issue of the Journal, Rout et al. [15] prospectively studied a large cohort (1011 UGIB patients) with the aim of finding out whether the scoring systems perform equally well for variceal and non-variceal UGIB. They found that the scoring systems predict outcomes better for non-variceal UGIB. These findings are similar to an earlier published study from India [16]. Rout et al. found that AIMS65 was the best predictor of mortality, probably because it does include albumin levels and INR, both measures of liver failure.

The scoring systems for UGIB were primarily developed and tested in cohorts with predominant non-variceal UGIB, and Rout et al. as well as some previous studies show us that these scores may not perform as well for patients with variceal UGIB [17]. Rout et al. also did not find a single scoring system, which gives all the requisite prognostic information.

Both the studies published in this issue validate the utility of UGIB scores in Indian patients, with the caution from Rout et al. that they may not perform as well in the variceal UGIB cohort. There are large prospective studies similar to those of Chandnani et al. and Rout et al. with more or less similar published results [11, 12, 13]. There are several unanswered questions. Are UGIB scoring systems routinely used in India? If not, what is preventing their regular use in emergency departments? Do we need a separate score for variceal UGIB, despite having a plethora of already available scoring systems? It is obvious in today’s personalized medicine environment that there is no one fit for all patients. An elderly patient with low scores might still need admission for observation, and possible endoscopy. But it is imperative upon our societies to exhort the gastroenterologists to utilize these scoring systems, to bring uniformity in care, and better standardization of data.

Notes

Compliance with ethical standards

Conflict of interest

VD, and RS declare that they have no conflict of interest.

Disclaimer

The authors are solely responsible for the data and the content of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, or the printer/publishers are responsible for the results/ findings and content of this article.

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Copyright information

© Indian Society of Gastroenterology 2019

Authors and Affiliations

  1. 1.Institute of Digestive and Liver CareS L Raheja HospitalMumbaiIndia

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