VALIDATION OF THE ROCKALL SCORE IN UPPER GASTROINTESTINAL TRACT BLEEDING IN A COLOMBIAN TERTIARY HOSPITAL

Validação da pontuação Rockall no sangramento do trato gastrointestinal superior em um hospital terciário colombiano

ABSTRACT

Background

Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose upper gastrointestinal bleeding (UGIB). Several studies have been conducted in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. Also, there is controversy regarding the best cut-off point for the score. Moreover, no studies validating this score in Colombia have been carried out.

Objective

To assess the diagnostic performance of the Rockall score in predicting rebleeding and mortality in patients with non-varicose UGIB.

Methods

A prospective cohort study was conducted in patients requiring upper gastrointestinal endoscopy (UGIE) for non-varicose bleeding. The pre-and post-endoscopy Rockall scores were calculated and outcomes, including mortality, UGIB-associated mortality and in hospital rebleeding were determined at the 1 and 3-month time points. The association between the scores and these outcomes was assessed using the chi² or the Fisher test, whereas the discrimination ability of the score was determined using the areas under the ROC curve (AUC). High discrimination ability was considered to exist in cases in which an AUC ≤0.7 with α=0.05 could be rejected.

Results

Overall, 177 patients were analyzed. In-hospital outcomes at 1 and 3 months were 12%, 17% and 23% for general mortality, 6%, 12% and 15% for UGIB mortality, and 19%, 30% and 37% for rebleeding. The post-endoscopy Rockall score was associated with the three outcomes at the three time points assessed, while the pre-endoscopy score was only associated with general mortality at the three time points, and rebleeding at 1 and 3 months. Regarding discrimination ability, although the AUC was greater than expected by randomness (0.5) in all cases, only one AUC ≤0.7 was rejected in the post-endoscopy score for in-hospital UGIB mortality (AUC=0.901; 95%CI: 0.845—0.958), at 1 month (AUC=0.836; 95%CI: 0.717—0.954) and at 3 months (AUC=0.869; 95%CI: 0.771—0.967), and for rebleeding at 1 month (AUC=0.793; 95%CI: 0.725—0.861) and at 3 months (AUC=0.806; 95%CI: 0.741—0.871).

Conclusion

An association was found between the Rockall score and rebleeding and mortality in patients with non-varicose UGIB. Only the post-endoscopy score had a high predictive ability for rebleeding and UGIB mortality.

Keywords:
Upper gastrointestinal tract; gastrointestinal hemorrhage; sensitivity and specificity; prognosis; endoscopy; mortality

RESUMO

Contexto

O escore de Rockall é a escala de prognóstico mais amplamente usada para avaliar o risco de complicações de sangramento gastrointestinal superior não varicoso. Vários estudos foram conduzidos em populações adultas com sangramento gastrointestinal superior não varicoso em diferentes partes do mundo, com achados conflitantes quanto à extensão da associação entre o escore e alguns desfechos de morbimortalidade. Há também controvérsias em relação ao melhor ponto de corte para a pontuação. Além disso, não foram realizados estudos que validem essa pontuação na Colômbia.

Objetivo

Avaliar o desempenho diagnóstico do escore de Rockall na previsão de ressangramento e mortalidade em pacientes com sangramento gastrointestinal superior não varicoso.

Métodos

Um estudo de coorte prospectivo foi conduzido em pacientes que necessitaram de endoscopia digestiva alta (EDA) para sangramento não varicoso. Os escores de Rockall pré e pós-endoscopia foram calculados e os resultados, incluindo mortalidade, mortalidade associada ao sangramento gastrointestinal superior não varicoso e ressangramento intra-hospitalar foram determinados nos pontos de tempo de 1 e 3 meses. A associação entre os escores e esses desfechos foram avaliados pelo teste de chi² ou Fisher, enquanto a habilidade de discriminação do escore foi determinada pelas áreas sob a curva ROC (AUC). Alta capacidade de discriminação foi considerada existente nos casos em que uma AUC ≤0,7 com α=0,05 poderia ser rejeitada.

Resultados

No geral, 177 pacientes foram analizados. Os desfechos hospitalares em 1 e 3 meses foram de 12%, 17% e 23% para mortalidade geral, 6%, 12% e 15% para mortalidade com hemorragia digestiva alta e 19%, 30% e 37% para ressangramento. O escore de Rockall pós-endoscopia foi associado aos três desfechos nos três momentos avaliados, enquanto o escore pré-endoscopia foi associado apenas à mortalidade geral nos três momentos, e ressangramento em 1 e 3 meses. Em relação à capacidade de discriminação, embora a AUC fosse maior do que o esperado pela aleatoriedade (0,5) em todos os casos, apenas uma AUC ≤0,7 foi rejeitada no escore pós-endoscopia para mortalidade com hemorragia digestiva alta intra-hospitalar (AUC =0,901; 95%IC: 0,845—0,958), em 1 mês (AUC =0,836; 95%IC 0,717—0,954) e em 3 meses (AUC =0,869; 95%IC: 0,771—0,967), e para ressangramento em 1 mês (AUC =0,793; 95%IC: 0,725—0,861) e aos 3 meses (AUC =0,806; 95%IC: 0,741—0,871).

Conclusão

Foi encontrada associação entre o escore de Rockall, ressangramento e mortalidade em pacientes com hemorragia digestiva alta não varicosa. Apenas o escore pós-endoscopia teve alta capacidade preditiva para ressangramento e mortalidade por sangramento gastrointestinal superior não varicoso.

Palavras-chave:
Trato gastrointestinal superior; hemorragia gastrointestinal; sensibilidade e especificidade; prognóstico; endoscopia; mortalidade

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) tract is defined as any gastrointestinal (GI) bleeding occurring above the ligament of Treitz, including the esophagus, the stomach and the proximal duodenum¹. It is the most frequent medical emergency in gastroenterology². It has been associated with preventable risk factors, primarily alcohol consumption, H. pylori infection and the use of non-steroidal anti-inflammatory agents (NSAIDs)^3,4.

Despite breakthroughs in management, advances in endoscopic techniques and the introduction of proton pump inhibitors (PPIs), UGIB is still associated with significant morbidity and mortality and represents a substantial cost for the health system⁵. Mortality rate between 5% and 10% has been described^6-7, with higher rates found in patients hospitalized for other causes who develop bleeding during their hospital stay⁷. Moreover, close to 20% of patients will develop rebleeding after the first hemostatic endoscopy, which is also an important predictor of mortality, with a 10-fold increase in risk⁸. Medium-term outcomes in these patients are also worse because both the bleeding episode as well as potential adjustments to chronic medications (including platelet aggregation inhibitors) act as decompensation factors. This impacts prognosis and increases the risk of mortality even months after the acute episode⁹. Mortality has been described to increase 27 times during the first month after hospital admission, and although this increased risk remains over time, it is considerably less significant after four months¹⁰. Consequently, UGIB is a public health problem, creating the imperative need to develop strategies designed to identify patients who require urgent upper GI endoscopy as well as closer surveillance.

Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose UGIB. This score can be applied before or after upper gastrointestinal endoscopy (UGIE), the latter being the preferred timing because it allows to include endoscopic findings in the calculation as the best predictors for decision-making in these patients¹¹. According to Rockall’s initial study with 4,000 patients, there is a correlation between rebleeding and the score¹². The score has been reviewed in various settings around the world. The first independent validation was a cohort study in New Zealand which established a cut-off point of four to distinguish between high and low mortality risk patients¹³. However, several studies have been conducted over the past few years in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. There is also a controversy regarding the best cut-off point for the score^14-16. Moreover, no studies validating this score in Colombia have been carried out.

The objective of this study is to assess the performance of the Rockall score in predicting in-hospital mortality and rebleeding in patients with non-varicose UGIB at 1 and 3 months. Secondary objectives include determining the association between the score and the need for transfusion, and its correlation with how fast the endoscopic assessment is performed.

METHODS

This study was approved by the Ethics and Research Committee of La Samaritana Hospital, Bogotá DC, Colombia. La Samaritana Hospital is a tertiary teaching hospital, and local referral center. A prospective cohort study was conducted using convenience sampling in a population consisting of patients undergoing UGIE due to suspected UGIB at La Samaritana Hospital between September 1, 2019, and January 31, 2021. The primary sources of information included clinical records, official UGIE reports and phone calls made 1 and 3 months after the endoscopic procedure. The study population consisted of patients ≥18 years of age hospitalized in the emergency service or the general ward undergoing UGIE during their stay because of UGIB, with completed follow-up by telephone call. Patients with varicose UGIB and patients with GI bleeding during their stay in intensive or step-down units were excluded. All the patients were informed and signed the informed consent form.

Admission sociodemographic and clinical variables were collected, including the variables comprising the pre-endoscopy Rockall score. Endoscopic variables were also collected, including need for, and type of, hemostatic therapy provided, as well as the variables comprising the post-endoscopy Rockall score. Moreover, outcome variables for in-hospital rebleeding and mortality, both general as well as UGIB-specific, were also collected.

With α=0.05 error and assuming an area under the ROC curve (AUC) =0.85 and a positive outcome in 20% of patients, it was estimated that a sample of 155 patients would have 80% power to detect an AUC >0.7, considered as a cut-off point with high discrimination ability.

A univariate analysis was performed using absolute and relative frequencies for qualitative variables and medians and inter-quartile ranges (IQR) for quantitative variables, given the non-normal distribution of the latter according to the Shapiro-Wilk test. A bivariate analysis was then performed between exposure and outcome variables. Chi² tests were used for qualitative exposure variables if the expected values in less than 20% of the cells were <5 and <1 in none, and Fisher’s test was used in the opposite case; and given their non-normal distribution, the U-Mann-Whitney test was used for quantitative variables.

To validate pre- and post-endoscopy Rockall scores, an association test was initially performed in 2 x n tables between the results of each of the scores and the outcome variables, also using chi² or Fisher’s tests, as appropriate. The AUC was then estimated in order to evaluate discrimination ability. For those outcomes in which H₀ was rejected (AUC ≤0.7), sensitivity, specificity, LR+ and LR- of the different cut-off points of the score were described, ROC curves were plotted and the proportion of positive outcomes for each score was tabulated. The Spearman coefficient was used to assess the correlation between the two scores and the time from the onset of symptoms until UGIE and length of stay.

Data sources were reviewed again for completion of missing data, and only complete data were finally analyzed. All statistical analyses were performed using the Stata 13.0 (Stata Corporation, College Station, TX, USA) software package and two-tailed calculations were used for all P values, which were considered significant if lower than 0.05.

RESULTS

Data from 177 patients were collected. Table 1 summarizes the sociodemographic, clinical and outcomes characterization for these patients, as well as their results in the Rockall score.

TABLE 1
General population characterization.

Characteristics	Median (IQR) or frequency (%)	95%CI
Sociodemographic
Age	66 years (49—78)	62—70 years
Male sex	110 (62%)	55—69%
Place of origin
Bogotá	51 (29%)	23—36%
Cundinamarca	31 (18%)	13—24%
Other departments	95 (54%)	46—61%
Clinical
Any comorbidity	150 (85%)	79—89%
Heart ratea	85 BPM (74—95)	82—86 BPM
SBPa	117 mmHg (106—133)	115—122 mmHg
DPBa	72 mmHg (66—78)	70—74 mmHg
Shock statusb
No	120 (68%)	60—74%
Tachycardia	35 (20%)	15—26%
Hypotension	22 (12%)	8—18%
NSAID use	44 (25%)	19—32%
ASA use	47 (27%)	21—34%
Hba	10.7 g/dL (7.2—13.6)	9.6—11.2 g/dL
Leukocytesa	9560 x µL (6980—13540)	8630—10054 x µL
Pre-UGIB transfusionc	61 (35%)	28—42%
Length of hospital stay	7 days (3.2—15.2)	5.7—8.6 days
Time from onset of symptoms to UGIE	15 hours (4—27)	13—18 hours
Endoscopic
Major stigmata of recent bleedingd	55 (31%)	25—38%
Endoscopic diagnosisb
Mallory-Weiss	3 (2%)	1—5%
No lesions or bleeding stigmata	57 (32%)	26—40%
Other diagnoses	104 (59%)	51—66%
Upper GI malignancy	13 (7%)	4—12%
Hemostatic therapy provided
None	139 (79%)	72—84%
Argon plasma	1 (1%)	0—4%
Only adrenaline	17 (10%)	6—15%
Only hemoclip	3 (2%)	1—5%
Adrenaline + hemoclip	17 (10%)	6—15%
Outcomes during hispitalization
Deaths	22 (12%)	8—18%
Death from UGIBe	10 (6%)	3—10%
Rebleeding	33 (19%)	14—25%
Outcomes at 1 month
Deaths	30 (17%)	12—23%
Deaths from UGIBe	12 (7%)	4—12%
Rebleeding	53 (30%)	24—37%
Characteristics	Median (IQR) or frequency (%)	95%CI
Outcomes at 3 months
Deaths	41 (23%)	17—30%
Deaths from UGIBe	15 (9%)	5—14%
Rebleeding	66 (37%)	30—45%
Rockall
Pre-endoscopy
0	12 (7%)	4—12%
1	10 (6%)	3—10%
2	31 (18%)	13—24%
3	47 (27%)	21—34%
4	43 (24%)	18—31%
5	21 (12%)	8—18%
6	12 (7%)	4—12%
7	1 (1%)	0—4%
Post-endoscopy
0	8 (5%)	2—9%
1	4 (2%)	1—6%
2	10 (6%)	3—10%
3	38 (21%)	16—28%
4	30 (17%)	12—23%
5	27 (15%)	11—21%
6	28 (16%)	11—22%
7	17 (10%)	6—15%
8	7 (4%)	2—8%
9	6 (3%)	2—7%
10	2 (1%)	0—4%

• SBP: systolic blood pressure; DBP: diastolic blood pressure; NSAID: non-steroidal anti-inflammatory agents; ASA: admission shock status, aspirin; UGIE: upper gastrointestinal endoscopy; UGIB: upper gastrointestinal bleeding; GI: gastrointestinal. ^aOn admission. ^bAccording to Rockall score. ^c≥2 red blood cell unit. ^dAccording to Rockall score: blood, clot or visible or bleeding vessel. ^eDeath from bleeding that could not be controlled endoscopically and/or patients with refractory hypovolemic shock or with no other diagnosis as the main cause of death recorded in the death certificate.

The bivariate analysis found that place of origin (other departments), heart rate (HR) and mean arterial pressure (MAP) on admission, shock status, aspirin (ASA) use, and Hb on admission were associated with the need for transfusion before UGIE, and with rebleeding (TABLES S1 and S2 of the supplementary material). Moreover, some UGIE findings were associated with rebleeding (TABLE S2): the presence of major recent bleeding stigmata, endoscopic diagnosis (GI malignancy or other diagnoses, in their order, compared with Mallory-Weiss tear or no findings) and the need for endoscopic hemostasis. Mortality was found to be associated with age, the presence and number of comorbodities, HR and MAP on admission, shock status, ASA use, Hb and leukocytes on admission, the need for transfusion before UGIE, major recent bleeding stigmata on UGIE and GI malignancy on UGIE (TABLE S3).

Regarding validation of the Rockall score, it was found that the post-endoscopy score was associated with all outcome variables, whereas the pre-endoscopy score reached significance only for predicting the need for pre-endoscopy transfusion, in-hospital death, and rebleeding and death at 1 and 3 months (Table 2). However, although in all cases the AUC was higher than randomly expected (0.5), only one AUC ≤0.7 was rejected in the post UGIE score for outcomes: in-hospital death due to UGIB at 1 month, and at 3 months, and rebleeding at 1 month and at 3 months (Table 2). Sensitivity, specificity, LR+ and LR- for these outcomes are shown in Table 3, the ROC curve graphs are shown in Figure 1, and the tabulation of the proportion of positive outcomes for each score is shown in Table 4. Finally, there was poor correlation with both the time from the onset of symptoms to UGIE as well as with the length of stay: P=-0.001 and P=0.217 for the pre-endoscopy score, and P=-0.131 and P=0.170 for the post-endoscopy score, respectively.

TABLE 2
Associations between the Rockall score and outcome variables and discrimination ability.

Outcome	Pre-endoscopy Rockall			Post-endoscopy Rockall
	P a	AUC	95%CI	P a	AUC	95%CI
In-hospital
Pre-endoscopy transfusionb	0.041	0.621	0.536—0.706	—	—	—
Rebleeding	0.069	0.653	0.551—0.755	0.001	0.748	0.665—0.832
Death	<0.001	0.784	0.694—0.874	0.017	0.775	0.685—0.864
Death from UGIB	0.124	0.769	0.640—0.898	<0.001	0.901	0.845—0.958
At 1 month
Rebleeding	0.018	0.653	0.566—0.738	<0.001	0.793	0.725—0.861
Death	<0.001	0.756	0.657—0.855	0.004	0.746	0.654—0.838
Death from UGIB	0.273	0.665	0.492—0.839	0.003	0.836	0.717—0.954
At 3 months
Rebleeding	0.007	0.631	0.548—0.714	<0.001	0.806	0.741—0.871
Death	<0.001	0.762	0.679—0.845	0.001	0.744	0.661—0.827
Death from UGIB	0.077	0.708	0.562—0.855	<0.001	0.869	0.771—0.967

• UGIB: upper gastrointestinal bleeding; AUC: rea under the curve; 95%CI: 95% confidence interval. ^achi² or Fisher test ^b≥2 red blood cell unit.

TABLE 3
Sensitivity, specificity, LR+ and LR- of the post-endoscopy Rockall score.

Outcome	AUC	Cut-off	Sensitivity	Specificity	LR+	LR-
In-hospital mortality from UGIB	0.901	≥0	100.0%	0.0%	1.00
		≥1	100.0%	4.8%	1.05	0.00
		≥2	100.0%	7.2%	1.08	0.00
		≥3	100.0%	13.2%	1.15	0.00
		≥4	100.0%	35.9%	1.56	0.00
		≥5	100.0%	53.9%	2.17	0.00
		≥6	100.0%	70.1%	3.34	0.00
		≥7	80.0%	85.6%	5.57	0.23
		≥8	40.0%	93.4%	6.07	0.64
		≥9	20.0%	96.4%	5.57	0.83
		≥10	10.0%	99.4%	16.70	0.91
Mortality from UGIB at 1 month	0.836	≥0	100.00%	0.00%	1.00
		≥1	100.00%	4.85%	1.05	0.00
		≥2	100.00%	7.27%	1.08	0.00
		≥3	100.00%	13.33%	1.15	0.00
		≥4	91.67%	35.76%	1.43	0.23
		≥5	91.67%	53.94%	1.99	0.15
		≥6	91.67%	70.30%	3.09	0.12
		≥7	66.67%	85.45%	4.58	0.39
		≥8	33.33%	93.33%	5.00	0.71
		≥9	16.67%	96.36%	4.58	0.86
		≥10	8.33%	99.39%	13.75	0.92
Mortality from UGIB at 3 months	0.869	≥0	100.00%	0.00%	1.00
		≥1	100.00%	4.94%	1.05	0.00
		≥2	100.00%	7.41%	1.08	0.00
		≥3	100.00%	13.58%	1.16	0.00
		≥4	93.33%	36.42%	1.47	0.18
		≥5	93.33%	54.94%	2.07	0.12
		≥6	93.33%	71.60%	3.29	0.09
		≥7	73.33%	87.04%	5.66	0.31
		≥8	40.00%	94.44%	7.20	0.64
		≥9	26.67%	97.53%	10.80	0.75
		≥10	6.67%	99.38%	10.80	0.94
Rebleeding at 1 month	0.793	≥0	100.00%	0.00%	1.00
		≥1	100.00%	6.45%	1.07	0.00
		≥2	100.00%	9.68%	1.11	0.00
		≥3	100.00%	17.74%	1.22	0.00
		≥4	92.45%	45.16%	1.69	0.17
		≥5	77.36%	62.90%	2.09	0.36
		≥6	66.04%	79.84%	3.28	0.43
		≥7	39.62%	91.13%	4.47	0.66
		≥8	20.75%	96.77%	6.43	0.82
		≥9	9.43%	97.58%	3.90	0.93
		≥10	3.77%	100.00%		0.96
Rebleeding at 3 months	0.806	≥0	100.00%	0.00%	1.00
		≥1	100.00%	7.21%	1.08	0.00
		≥2	100.00%	10.81%	1.12	0.00
		≥3	98.48%	18.92%	1.21	0.08
		≥4	90.91%	48.65%	1.77	0.19
		≥5	75.76%	66.67%	2.27	0.36
		≥6	65.15%	84.68%	4.25	0.41
		≥7	37.88%	93.69%	6.01	0.66
		≥8	18.18%	97.30%	6.73	0.84
		≥9	9.09%	98.20%	5.05	0.93
		≥10	3.03%	100.00%		0.97

• UGIB: upper gastrointestinal bleeding; LR +: positive likelihood ratio; LR-: negative likelihood ratio.

FIGURE 1
Post-endoscopy Rockall score ROC. A) In-hospital mortality from UGIB; B) Mortality from UGIB at 1 month; C) Mortality from UGIB at 3 months; D) Rebleeding at 1 month; E) Rebleeding at 3 months. AUC: area under the ROC curve; UGIB: upper gastrointestinal bleeding.

TABLE 4
Proportion of positive outcomes based on post-endoscopy Rockall score.

Score	In-hospital mortality from UGIB	Mortality from UGIB at 1 month	Mortality from UGIB at 3 months	Rebleeding at 1 month	Rebleeding at 3 months
0	0.0%	0.0%	0.0%	0.0%	0.0%
1	0.0%	0.0%	0.0%	0.0%	0.0%
2	0.0%	0.0%	0.0%	0.0%	10.0%
3	0.0%	2.6%	2.6%	10.5%	13.2%
4	0.0%	0.0%	0.0%	26.7%	33.3%
5	0.0%	0.0%	0.0%	22.2%	25.9%
6	7.1%	10.7%	10.7%	50.0%	64.3%
7	23.5%	23.5%	29.4%	58.8%	76.5%
8	28.6%	28.6%	28.6%	85.7%	85.7%
9	16.7%	16.7%	50.0%	50.0%	66.7%
10	50.0%	50.0%	50.0%	100.0%	100.0%

• UGIB: upper gastrointestinal bleeding.

DISCUSSION

This is the first study to validate the Rockall score in Colombia. This was achieved using a prospective design to evaluate its association with outcomes and its discrimination ability.

Both the pre-endoscopy and post-endoscopy scores showed an association with general mortality, mortality from UGIB and rebleeding at the three time points of the study. However, the superiority of the latter was evident as shown not only by higher AUCs for each of these outcomes, but also because it was the only one to reach high discrimination ability for some of those outcomes (in-hospital UGIB-related death at 1 month and 3 months, and rebleeding at 1 month and 3 months). Best performance is expected with the combined use of clinical and endoscopic information given that endoscopic findings are the best predictors for decision-making in these patients and have been associated with rebleeding, mortality and need for therapeutic endoscopic intervention in observational studies^11,17,18. Moreover, it is consistent with the associations found in our study between endoscopic findings that comprise the post-endoscopy score and the assessed outcomes (TABLES S2 and S3).

Based on ROC curve analyses of the post-endoscopy Rockall score for those outcomes in which discrimination ability was high, the cut-off points with a better balance between sensitivity and specificity for predicting UGIB-related mortality appear to be ≥6 or ≥7, while ≥5 or ≥6 would be the prediction cut-off points for rebleeding. However, the definition of the ideal cut-off point for any score must consider the implications of false negative and false positive results. In this setting, false negatives (patients with low risk based on the score but who develop the outcome) would have worse implications as they would result in early discharges or less stringent surveillance in patients who would eventually re-bleed or die from UGIB¹⁹. Bearing this in mind, the ≥6 cut-off could be proposed so that the score can be used as a tool in deciding discharge of a patient with lower values, considering that it was shown to have 100% sensitivity, equal to an LR- of 0, for in-hospital mortality from UGIB, indicating that this outcome did not occur in any of the patients with a score <6 in our study. On the other hand, the ≥3 could be more useful for less intense follow-up in patients with lower values, given its 100% sensitivity for predicting UGIB-related mortality at 1 month and 3 months and for rebleeding at 1 month. For 3-month rebleeding, the sensitivity of this cutoff point dropped to a still high 98.5%, with an LR of 0.08. Although it does not rule out the outcome, it does reflect a strong reduction in the likelihood of occurrence. The findings by Morales et al. in 464 Colombian patients affected by UGIB would also support these cut-off points²⁰, given that patients with scores <3 had 0% mortality, although the objective of the study was not to validate de post-endoscopy Rockall score.

Our findings and conclusions are similar to those reported in other studies in different geographical areas, which have shown an association between the Rockall score and the risk of death and rebleeding and have identified scores between three and four as the best predictors overall. For example, the study by Dicu et al.²¹ found that close to 10% of the patients died, all of them with a Rockall score ≥5. Gleeson et al.²², in a study conducted in Dublin, Ireland, defined patients with a score ≤3 as mild, given that no deaths or new bleeds occurred in these patients who were considered as low risk and candidates for early discharge. Likewise, Dulai et al.²³, in Los Angeles, USA, found that patients with a Rockall score ≤2 had a lower probability of adverse outcomes, with rebleeding and mortality rates of 4% and 0% versus 19% and 2%, respectively. Regarding the Rockall score’s ability to predict rebleeding, our results are similar to those of other studies, in that the general conclusion is that this score was originally developed for predicting mortality and not rebleeding, hence the loss of some diagnostic performance^15,24,25. In our study, reported mortality was 7%, similar to that found in the studies mentioned above, which ranged between 2% and 18.7%, and to the world figure, which is close to 10%^3,12,21.

Our study found a statistically significant association between the pre-endoscopy Rockall score and the need for transfusion, albeit with no high discrimination ability to predict it. Consequently, it is unlikely that this score can be relevant when it comes to determining the benefit of transfusion in these patients, at least beyond the clinical and paraclinical elements that usually guide this decision. In fact, prior studies have reached similar conclusions: Mokhtare et al., for example, found 71.8% sensitivity, 51.8% specificity and 0.528 AUC for this outcome²⁶, while in the study by Robertson et al., the same estimators were 71%, 55%, and 0.66, respectively²⁷.

The poor correlation found between the score obtained and length of stay is to be expected, at least for two reasons: 1) just like higher scores can be associated with the need for longer hospitalization, they can also be associated with higher mortality, lowering the correlation; 2) although one of the main abilities of this score is to define a sufficiently low risk as to prompt discharge, clinicians frequently ignore it when it comes to making this and other decisions¹⁹, actually resorting more frequently to the endoscopic findings than to the Rockall score²⁸. Among other reasons, this is due to the lack of continuing education, the absence of studies that assess outcomes using the score versus clinical judgement, and the paucity of objective evidence regarding the enhanced use of resources derived from the incorporation of the score in decision-making¹⁹.

Our population was similar to that affected by UGIB in other national and international studies in terms of characteristics such as age, proportion of men, the number of comorbidities, and mortality, among others^2,6,20,29,30; therefore, it is valid to assume that our findings would not lack external validity. Likewise, our study found an association between the outcomes and several of the risk factors reported previously: age, the presence of comorbidities, use of NSAIDs or ASA, shock status, endoscopic findings, among other variables, most of which are part of the post-endoscopy Rockall score^2,19,20,31.

A low percentage of patients with low Rockall scores was found in our study when compared to the study by Morales et al.²⁰. A likely explanation is that, in the context of the current health system, access to hospital admission is relatively difficult, and it is not beyond reason that many of these patients had been managed on an outpatient basis, considering this study was conducted mostly during the COVID-19 pandemic. This fact may also have prevented patients from visiting the hospital out of fear of leaving their homes during the pandemic.

The study has some limitations that could undermine the validity of the estimated ROC curves. For example, discrimination ability could have been negatively affected at least in three ways: 1) follow-up bias, derived from the fact that patients who did not complete telephone follow-up, and who may have had both higher scores as well as worse outcomes, were excluded; 2) selection bias due to the inclusion of only in-hospital UGIB, because outpatients could have had better outcomes and lower scores; 3) selection bias due to the exclusion of patients in the intensive care or step-down unit, who could also have had higher scores and worse outcomes. However, our results are a more accurate reflection of the clinical settings in which the Rockall score would be useful, rendering those exclusions necessary. Moreover, in this setting, as in most settings, a type II error is preferable over a type I error. On the other hand, a single-center study could have limited external validity: for example, the population served in this center is usually of middle-to-low socioeconomic status which confers several particular exposures and characteristics. However, most of the variables assessed, at least those with the highest clinical relevance, were similar to those used in previous studies, particularly to those reported in the past by other institutions in this country. Verification of the clinical record data by at least two researches could have resulted in a lower risk of transcription bias. Finally, although a potential classification bias may have existed in relation to patient classification in the Rockall score, given experience variability among the six endoscopists who performed the endoscopic procedure, this would be a non-differential bias, which usually moves associations towards nil value. Therefore, again, a type II error would be favored, not invalidating the positive associations actually found.

CONCLUSION

Both the pre-endoscopy as well as the post-endoscopy Rockall scores were associated with rebleeding and mortality in patients with non-varicose UGIB. Discrimination ability was high only for the post-endoscopy score and specifically for the outcomes of death from in-hospital UGIB at 1 month and 3 months, and rebleeding at 1 month and 3 months. A post-endoscopy Rockall score <6 appears to be useful for making the decision of discharging these patients, while a score <3 appears to be useful for less stringent outpatient follow-up decisions.

ACKNOWLEDGMENTS

The authors are grateful to Dayla Liliana Pérez, nurse coordinator of the Digestive Endoscopy Unit, for her work of recruiting patients at the time of the endoscopy, as well as to the Research Department of La Samaritana University Hospital E.S.E for the advice provided.

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• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  15 Apr 2022
• Date of issue
  Jan-Mar 2022

History

• Received
  16 July 2021
• Accepted
  20 Oct 2021