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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 37-41

Complete Rockall score in predicting outcomes of elderly patients with acute non-variceal upper gastrointestinal bleeding: A tertiary care study


Department of Medicine, Assam Medical College and Hospital, Assam, India

Date of Submission23-Jul-2021
Date of Acceptance27-Jul-2021
Date of Web Publication05-Oct-2021

Correspondence Address:
Dr. Subha Lakshmi Das
Department of Medicine, Assam Medical College and Hospital, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_13_21

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  Abstract 

Background: Upper gastrointestinal bleeding (UGIB) is a common life-threatening emergency with an overall mortality rate of around 10%. Complete Rockall score is designed to identify patients who are at greater risk of adverse outcome. The aim of this study was to assess the Rockall score as a predictor of adverse outcome in elderly population presenting with non-variceal UGIB. Materials and Methods: This study was an observational study conducted in 116 patients of age >60 years. After stabilizing the patient, endoscopy was performed using a Pentax endoscope. Severity of bleeding was assessed with complete Rockall scoring. The statistical significance was fixed at 5% level (P-value <0.05). Results: The mean age of the study population was 70.16 ± 6.01 years with male-to-female ratio of 2.63:1. Majority of patients (55.17%) presented with both hematemesis and melena. The most common lesion was duodenal ulcer (33.62%). The mean blood transfusion was 1.56 ± 1.14 U. The mean Rockall score was 4.37 ± 2.12. The mean hospitalization was 3.26 ± 1.69 days. Rebleeding occurred in 12.93% of the patients and 8.62% of the patients expired during hospitalization. Out of the 10 patients expired, 20.0% belonged to the moderate-risk and 80.0% belonged to the high-risk Rockall groups, which were found to be statistically significant (P-value <0.001). Conclusion: Acute UGIB is a medical emergency and Rockall score is ideal to stratify elderly patients to anticipate outcome and prognosis.

Keywords: Non-variceal, Rockall, upper gastrointestinal bleed


How to cite this article:
Bhattacharyya A, Das SL. Complete Rockall score in predicting outcomes of elderly patients with acute non-variceal upper gastrointestinal bleeding: A tertiary care study. Assam J Intern Med 2021;11:37-41

How to cite this URL:
Bhattacharyya A, Das SL. Complete Rockall score in predicting outcomes of elderly patients with acute non-variceal upper gastrointestinal bleeding: A tertiary care study. Assam J Intern Med [serial online] 2021 [cited 2021 Dec 3];11:37-41. Available from: http://www.ajimedicine.com/text.asp?2021/11/2/37/327514


  Introduction Top


Upper gastrointestinal bleeding (UGIB) is a common life-threatening emergency that accounts for over 507,000 annual hospital admissions accounting for over 4.85 billion annual health expenditure.[1] In spite of the development of newer interventions, the overall mortality rate remains around 10% in most studies.[2] Advanced age is a risk factor for adverse outcome among patients presenting with non-variceal UGIB. Mortality rate is found to be much higher (12%–35%) in elderly males aged more than 60 years.[3],[4],[5] Endoscopic study done within the first 24 h of bleeding has been shown to be the most reliable investigation which can identify the source which helps in stratifying the patients into different risk groups.[6] UGIB is defined as hemorrhage that originates proximal to the ligament of Treitz. Clinically, it can present as hematemesis (vomiting of blood) or melena (passage of black, tarry, and semi-solid stools) or both.[7] The most common cause of UGIB is peptic ulcer disease that includes duodenal ulcer (DU) and gastric ulcer (GU). Several scoring tools have been developed to stratify the severity of bleeding to identify patients who are at great risk for mortality and rebleeding.[7] The most commonly used post-endoscopy scoring system is the complete Rockall score designed to combine information such as patients’ age, occurrence of shock assessed from systolic blood pressure records and pulse rate, presence and severity of comorbid conditions, and stigmata of hemorrhage.[8],[9] The aim of this study was to assess the Rockall score as a predictor of adverse outcome in elderly population presenting with non-variceal UGIB.


  Materials and Methods Top


This study was an observational study conducted for 1 year, from June 2018 to May 2019 which was carried out after obtaining approval from Institutional Ethics Committee. A total of 116 cases with age more than 60 years admitted in the Department of Medicine, Assam Medical College and Hospital, Dibrugarh presenting with hematemesis, melena, or both were selected. Patients with portal hypertension with or without liver diseases were excluded. Melena was considered when patients presented with passage of black tarry foul-smelling semi-solid stool and hematemesis when there was vomiting of fresh or altered blood or both. Immediately following admission, vital signs of all patients were assessed, and necessary resuscitation was done by maintaining airways, posture, replacing the initial blood loss by isotonic saline, or synthetic colloid till blood was available for transfusion. After stabilizing the patient hemodynamically, they were subjected to thorough history-taking and complete physical examination to find out the risk factors, etiology, and clinical presentation and to assess the severity of bleeding. Upper gastrointestinal endoscopy was performed in the Department of Medicine at the endoscopy unit using a Pentax UGI Endoscope. The Rockall score was calculated. Patients were categorized on the basis of this score and assigned to three groups: low-risk group: a score of ≤2, moderate-risk group: a score of 3–7, and high-risk group: a score of ≥8. For all analyses, the statistical significance was fixed at the 5% level (P-value <0.05).




  Results Top


The mean age of the study population was 70.16 ± 6.01 years [Figure 1] with male-to-female ratio being 2.63:1. Majority of patients (55.17%) presented with both hematemesis and melena at the time of admission, whereas 36.21% of the patients presented with melena and 8.62% presented with hematemesis alone. Out of the 116 patients, 38.79% patients presented with shock, whereas 61.21% of the patients were stable at the time of admission. In 52.59% of the patients, upper gastrointestinal endoscopy was done within 24 h. The most common lesion was DU found in 39 patients (33.62%), followed by GU in 32 patients (27.59%), gastric erosion in 27 patients (23.28%), duodenal erosion in 7.76%,  Mallory-Weiss tear More Details in 4.31%, growth in stomach in 7.76%, and growth in esophagus in 1.72%. Normal endoscopic study was seen in 3.45% [Figure 2]. The stigmata of ulcer bleeding were assessed with Forrest grading, and grade II ulcers were found in 54.93%, grade III in 32.39%, and grade I in 12.68%. Alcohol intake was the most common risk factor found in 49.14% of the patients followed by NSAIDs in 41.38% and smoking in 18.97%. Comorbidities including hypertension constituted 37.07% of the patients, whereas 16.38% had diabetes, 12.07% had chronic kidney disease, and other comorbidities constituted 22.41%. Helicobacter pylori positivity was found to be 65.33%. The mean hemoglobin was found to be 7.17 ± 2.24 g/dL. Low risk (Rockall score 1–2) was seen in 25.0% of the patients, moderate (score 3–7) in 62.93%, and high risk (score ≥8) in 12.07% [Figure 3]. The mean Rockall score was 4.37 ± 2.12. The mean hospital stay was found to be 3.26 ± 1.69. In 78.45% of the patients, there was no bleeding after initiation of treatment, 12.93% presented with rebleeding, and 8.62% of the patients expired during the course of hospitalization. The mean hospitalization was 2.45 ± 0.63 in the Rockall low-risk group, 3.65 ± 1.81 in the moderate-risk group, and 5.33 ± 0.82 in the high-risk group. Blood transfusion was done in 81.9% of the patients with the mean number of transfusion being 1.56 ± 1.14. The mean requirement of blood transfusion was found to be 2.43 ± 1.34 in the high-risk group, 1.68 ± 1.07 in the moderate-risk group, and 0.83 ± 0.80 in the low-risk group. Mortality was seen in 80.0% of the patients in the high-risk group with a mean Rockall score of 8.30 ± 1.06. Eighty percent of the patients presenting with rebleeding belonged to the moderate-risk group and 20% belonged to the high-risk group [Table 1]. The mean Rockall score was found to be 5.93 ± 1.39 among patients with rebleeding. Strong correlations of Rockall scoring with a period of hospitalization, requirement of blood transfusion, and patient outcome were observed (P-value = 0.001) in our study.
Table 1: Percentage of outcome in each risk category

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Figure 1: Age distribution

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Figure 2: Endoscopic findings

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Figure 3: Rockall score

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  Discussion Top


Acute non-variceal UGIB is a common medical emergency. A major portion of patients with non-variceal GI bleed are elderly and with multiple comorbidities accounting for high mortality. Hence, prediction and early risk stratification for adverse outcomes are very important. The Rockall score is the most widely used scoring system developed originally to predict mortality in patients with GI bleed. Our study was aimed to assess the Rockall score as a predictor of adverse outcome in elderly population presenting with non-variceal UGIB. Out of the 116 patients, 72.41% were male and 27.59% were female with male-to-female ratio of 2.63:1. The mean age of patients was found to be 70.16 ± 6.01 years. Concomitant melena and hematemesis (55.17%) were the most common presentations. Peptic ulcer disease was the most common cause of UGIB which was seen in 61.21% of the patients. Forrest II ulcers were the most common observation. In a study done by García Encinas et al.,[10] 190 patients were included, and 64.2% were males, with an average age of 74 years. In another study by Thongbai et al.,[11] the mean age was 71.63 ± 7.65 years. In a study done by González-González et al.,[12] peptic ulcers, gastroduodenal erosions, and esophagitis accounted for 71.7% of the causes of UGIB. GUs were more frequently found. In another study by Thongbai et al.,[11] the most common cause of acute UGIB was peptic ulcer bleeding. In our study, peptic ulcer disease accounted for 61.21% which is comparable with other studies. In another study done by Mahajan and Chandail,[13] 68.11% presented with both hematemesis and melena, 20.95% presented with hematemesis only, and 10.94% had melena only. Another study done by Bambha et al.[14] found that majority of patients presented with both hematemesis and melena. These findings are comparable with our results.

The mean Rockall score was observed to be 4.37 ± 2.12. Out of the 116 patients, 25.0% belonged to the low-risk group, 62.93% belonged to the moderate-risk group, and 12.07% belonged to the high-risk group. After initiation of treatment, there was no bleeding in 78.45% of the patients. Rebleeding occurred in 12.93% of the patients whereas 8.62% of the patients expired during the course of hospitalization. No mortality was observed in the Rockall low-risk group. Blood was transfused in 81.9% of the patients with the mean number of transfusion being 1.56 ± 1.14. The mean hospitalization was 3.26 ± 1.69. In a study done by Wang et al.,[15] they found that 33.43% of the patients belonged to the Rockall low-risk group, 32.26% of the patients belonged to the moderate-risk group, and 34.31% of the patients belonged to the high-risk group. In another study by González-González et al.,[12] the mean Rockall score was found to be 5.6 ± 1.9. Blood transfusion was required in 66.3% of the patients. In another study done by García Encinas et al.,[10] blood transfusion of more than 2 U was needed in 24.7% of the patients. In our study, blood was transfused in 81.9% of the patients which was higher than that in other studies. In the study done by Wang et al.,[15] 18.47% of the patients developed recurrent bleeding, whereas 8.79% of the patients died during hospitalization. In another study done by García Encinas et al.,[10] overall mortality was found to be 16.8%, whereas 5.52% of the patients had rebleeding. González-González et al.[12] found that rebleeding occurred in 4%, whereas death occurred in 13%.[10]

In our study, mortality was seen in 80.0% of the patients in the high-risk group with a mean Rockall score of 8.30 ± 1.06. Eighty percent of the patients presenting with rebleed belonged to the moderate-risk group and 20% belonged to the high-risk group. Mean Rockall score was found to be 5.93 ± 1.39 among patients with rebleeding. The mean hospitalization was 2.45 ± 0.63 in the Rockall low-risk group, 3.65 ± 1.81 in the moderate-risk group, and 5.33 ± 0.82 in the high-risk group. The mean requirement of blood transfusion was found to be 2.43 ± 1.34 in the high-risk group, 1.68 ±1.07 in the moderate-risk group, and 0.83 ± 0.80 in the low-risk group. It was observed that high Rockall score was associated with increased risk of rebleeding and death. Higher the score higher was the requirement of blood transfusion and duration of hospitalization. Significant statistical correlations of Rockall scoring with period of hospitalization, requirement of blood transfusion, and hospital outcome were observed (P-value = 0.001) in our study, which were comparable with different studies done by Mahajan et al., Wang et al., García Encinas et al., and Enns et al.[5],[10],[11]


  Conclusion Top


Acute UGIB is a medical emergency and stratification of patients is of critical importance. The Rockall score helps in stratifying patients into different risk groups at the initial stage. Low-risk group patients can be discharged early, whereas direct specialized care including intensive care unit transfer with closed monitoring is advisable in high-risk group patients. Patients with Rockall score ≥8 are the most vulnerable group for fatal outcome. Prolongation of hospitalization, increased risk of rebleeding, increased requirement of blood transfusion, or supportive care can be anticipated with the help of Rockall scoring early at the time of admission. In a tertiary care center, the Rockall scoring system should ideally be used at the time of hospitalization for appropriate cost-effective management which will definitely help to reduce morbidity and mortality among elderly patients during hospitalization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Laine L. Gastrointestinal bleeding. In: Jameson JL, Kasper DL, editors. Harrison’s Principles of Internal Medicine. 20th ed. New York: Mc Graw Hill; 2018. p. 272-6.  Back to cited text no. 1
    
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Savides TJ, Jensen DM. Gastrointestinal bleeding. In: Feldman M, Friedman LS, Brandt LJ, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 10th ed. Philadelphia: Elsevier Inc.; 2016. p. 297-335.  Back to cited text no. 7
    
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Bozkurt MA, Peker KD, Unsal MG, Yırgın H, Kahraman İ, Alış H. The importance of Rockall scoring system for upper gastrointestinal bleeding in long-term follow-up. Indian J Surg 2017;79:188-91.  Back to cited text no. 9
    
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Encinas CG, Paredes EB, Rojas PG, López RG, Maldonado MC, Sánchez VA. Validation of the Rockall score in elderly patients with non variceal upper gastrointestinal bleeding in a third level general hospital. Rev Gastroenterol Peru2015;35:25-31.  Back to cited text no. 10
    
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Thongbai T, Thanapirom K, Ridtitid W, Rerknimitr R, Thungsuk R, Noophun P, et al. Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding. Asian Biomed 2016;10:115-22.  Back to cited text no. 11
    
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González-González JA, Monreal-Robles R, García-Compean D, Paz-Delgadillo J, Wah-Suárez M, Maldonado-Garza HJ. Nonvariceal upper gastrointestinal bleeding in elderly people: Clinical outcomes and prognostic factors. J Dig Dis 2017;18:212-21.  Back to cited text no. 12
    
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Mahajan P, Chandail VS. Etiological and endoscopic profile of middle aged and elderly patients with upper gastrointestinal bleeding in a tertiary care hospital in North India: A retrospective analysis. J Midlife Health 2017;8:137-41.  Back to cited text no. 13
    
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Bambha K, Kim WR, Pedersen R, Bida JP, Kremers WK, Kamath PS. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut 2008;57:814-20.  Back to cited text no. 14
    
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Wang CY, Qin J, Wang J, Sun CY, Cao T, Zhu DD. Rockall score in predicting outcomes of elderly patients with acute upper gastrointestinal bleeding. World J Gastroenterol 2013;19:3466-72.  Back to cited text no. 15
    


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