An assessment of five readily available measures in emergency settings could improve patient triage and outcomes.
Scoring systems based on clinical characteristics of patients with upper gastrointestinal bleeding (UGIB) pre- and postendoscopy can predict mortality and rebleeding, allowing for more-efficient use of resources through risk stratification. Now, researchers have developed a simple scoring system for clinicians to use when patients present with acute UGIB in emergency departments (EDs).
Using a large clinical database, investigators retrospectively identified risk factors associated with mortality among 29,222 patients admitted with UGIB through the EDs of 187 hospitals. They then retrospectively validated the results through a different cohort of 32,504 patients. Using recursive partitioning, investigators identified clinical characteristics that were associated with mortality, resulting in a treelike algorithm. To simplify the scoring calculation, they used the number of risk factors present rather than data generated from the algorithm.
This process identified five factors associated with increased risk for mortality: serum albumin <3.0 g/dL, an international normalized ratio >1.5, altered mental status, hypotension (systolic blood pressure 90 mm Hg), and age >65. Mortality increased with the number of risk factors present, as did length of hospital stay and cost. In the validation cohort, mortality increased from 0.3% with no risk factors (score, 0) to 24.5% with all five risk factors (score, 5). The predictive accuracy of the scoring system was high, with area under the receiver operating curve of 0.80 for the derivation cohort and 0.77 for the validation cohort.
The authors conclude that this risk stratification system is a simple way for ED clinicians to identify patients who require aggressive therapy.
Comment: Prior studies of scoring systems have demonstrated that endoscopic stigmata, bleeding volume, patient age, and comorbidities increase the risk for death in patients with acute UGIB. This new system came to the same conclusion but without the need for endoscopic data. The absence of a prospective validation cohort and data on rebleeding prevents meaningful comparisons with other scoring systems. However, the take-home message from all scoring systems is that older patients with high-volume bleeds and comorbidities are at much higher risk for poor outcomes than young, otherwise healthy patients with small-volume bleeds.
Source: Journal Watch Gastroenterology
ARYAN'S BLOG 