Upper GI bleeding: patients with malignancy or varices, or who bleed in hospital were more likely to die.

Clinical bottom line (level 4)

  1. A third of patients with GI bleeding due to malignancy or varices died before discharge.
  2. Few patients admitted as an emergency with a GI bleed due to peptic ulcers or Mallory-Weiss tears died before discharge.
  3. Patients who bled in hospital were at increased risk of dying.
Rockall et al: British Medical Journal 1995; 311: 222-226
Expires October 2002

The study

Case series with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: 74 acute hospitals, UK

4185 patients (aged 54 to 80; mean 66, 57% male) with clinical evidence of acute upper GI bleeding (haematemesis or melaena) or a history of bleeding within the last 10 days (84% emergency admissions)

Excluded if
  • aged < 16
  • GI bleed in hospital
  • underwent endoscopy for another reason




    • Logistic regression analysis was used to identify the risk factors that predicted mortality and rebleeding.

    ?100% followed for hospital stay
    Outcomes studied:
  • death if emergency admission with peptic ulcer
  • death if emergency admission with varices
  • death if emergency admission with a Mallory-Weiss tear
  • death if emergency admission with malignancy
  • death if in-patient with peptic ulcer
  • death if in-patient with malignancy
  • death if in-patient with Mallory-Weiss tear
  • death if in-patient with varices

    • Clinical prediction rule: sum the score for each factor. 2 scores can be derived: pre and post-endoscopy.
    • age
      • < 60: (0)
      • 60 to 79: (1)
      • >79: (2)
    • shock
      • 'no shock': systolic bp = 100, pulse <100: (0)
      • 'tachycardia': systolic bp = 100, pulse more than 100 beats/min: (1)
      • 'hypotension': systolic bp < 100: (2)
    • comorbidity
      • no major co-morbidity: (0)
      • cardiac failure, ischaemic heart disease, any major co-morbidity: (2)
      • renal failure, liver failure, disseminated malignancy: (3)
    • diagnosis
      • Mallory-Weiss tear, no lesion identified and no stigmata of recent haemorrhage: (0)
      • all other diagnoses: (1)
      • malignancy of upper GI tract: (2)
    • major stigmata of recent haemorrhage
      • none or dark spot seen: (0)
      • blood in upper GI tract, adherent clot, visible or spurting vessel: (2)
    • The clinical prediction rule was validated in an independent set of 1625 patients.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    death if emergency admission with peptic ulcer hospital stay 65/1235 8.8%
    (7.2% to 10%)    		 11
    (10 to 14)
    death if emergency admission with varices hospital stay 60/154 39%
    (31% to 47%)    		 3
    (2 to 3)
    death if emergency admission with a Mallory-Weiss tear hospital stay 4/203 2.0%
    (0.059% to 3.9%)    		 51
    (26 to 1700)
    death if emergency admission with malignancy hospital stay 50/132 38%
    (30% to 46%)    		 3
    (2 to 3)
    death if in-patient with peptic ulcer hospital stay 55/180 31%
    (24% to 37%)    		 3
    (3 to 4)
    death if in-patient with malignancy hospital stay 7/20 35%
    (14% to 56%)    		 3
    (2 to 7)
    death if in-patient with Mallory-Weiss tear hospital stay 2/10 20%
    (0.0% to 45%)    		 5
    (2 to infinity)
    death if in-patient with varices hospital stay 12/19 64%
    (41% to 75%)    		 2
    (1 to 2)

    Comments

    1. The data reported comes from the validation set.
    2. These require validation in a hospital outside the study centre.

    Citation

    1. Rockall TA, Logan RF, Devlin HB: incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. British Medical Journal 1995; 311: 222-226
    Contributor: Chris Ball and Bob Phillips, October 1999
    Reviewer: Horand Meier

    Clinical Question.
    Patient upper GI bleed
    Intervention or Exposure clinical prediction rule
    Outcome rebleeding, death