Prediction scores in gastrointestinal bleeding: a systematic review and quantitative appraisal

Background and study aims: Several algorithms predicting outcomes in acute gastrointestinal bleeding have been developed over the past three decades. These algorithms differ substantially and therefore the aim of the current study was to conduct a systematic review to compare their predictive performance and methodological quality in gastrointestinal bleeding.

Methods: A PubMed literature search was performed up to 1 July 2011. All studies reporting prediction scores in gastrointestinal bleeding were included. Studies were analyzed for predictive performance, and a quality appraisal of these rules was performed for which a score range of 0 (lowest) to 29 (highest) was used.

Results: A total of 372 studies were identified, of which 16 were eligible for inclusion. The studies evaluated different outcomes: mortality (n = 5), rebleeding (n = 2), intervention required (n = 2), or a combination (n = 7). The predictive performance of the identified prediction scores varied between an area under the curve of 0.71 – 0.92 (if given). The mean overall quality rating was 17 (SD 4.0, range 9 – 25). Major methodological shortcomings were the absence of validation and absence of impact analyses. Eight of 16 scores (50 %) were determined “easy to use,” and five scores (31 %) reported some type of action based on the results.

Conclusion: Substantial heterogeneity in outcomes and results was seen in the 16 identified prediction scores. Moreover, the methodological quality was suboptimal in most studies. However, we suggest that clinicians should use the “best available” scores according to performance and quality, which are the Blatchford score to assess the need for intervention, and the scores of Villanueva et al. for poor outcome, Guglielmi et al. for rebleeding, and Chiu et al. for mortality risk.

• References

• 1 van Leerdam ME, Vreeburg EM, Rauws EA et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000.. Am J Gastroenterol 2003; 98: 1494-1499
• 2 Longstreth GF. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1995; 90: 206-210
• 3 Gilbert DA. Epidemiology of upper gastrointestinal bleeding. Gastrointest Endosc 1990; 36 (05) 8-13
• 4 Lanas A, Garcia-Rodriguez LA, Polo-Tomas M et al. The changing face of hospitalisation due to gastrointestinal bleeding and perforation. Aliment Pharmacol Ther 2011; 33: 585-591
• 5 Ahsberg K, Ye W, Lu Y et al. Hospitalisation of and mortality from bleeding peptic ulcer in Sweden: a nationwide time-trend analysis. Aliment Pharmacol Ther 2011; 33: 578-584
• 6 Cryer BL, Wilcox CM, Henk HJ et al. The economics of upper gastrointestinal bleeding in a US managed-care setting: a retrospective, claims-based analysis. J Med Econ 2010; 13: 70-77
• 7 McGinn TG, Guyatt GH, Wyer PC et al. Users’ guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA 2000; 284: 79-84
• 8 Laupacis A, Sekar N, Stiell IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997; 277: 488-494
• 9 Toll DB, Janssen KJ, Vergouwe Y et al. Validation, updating and impact of clinical prediction rules: a review. J Clin Epidemiol 2008; 61: 1085-1094
• 10 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-113
• 11 Rockall TA, Logan RF, Devlin HB et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321
• 12 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
• 13 Vreeburg EM, Terwee CB, Snel P et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999; 44: 331-335
• 14 Marmo R, Koch M, Cipolletta L et al. Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED Score and prospective comparison with the Rockall Score. Am J Gastroenterol 2010; 105: 1284-1291
• 15 Pang SH, Ching JY, Lau JY et al. Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010; 71: 1134-1140
• 16 Masaoka T, Suzuki H, Hori S et al. Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention. J Gastroenterol Hepatol 2007; 22: 1404-1408
• 17 Venerito M, Malfertheiner P. Interaction of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs in gastric and duodenal ulcers. Helicobacter 2010; 15: 239-250
• 18 Malfertheiner P, Megraud F, O’Morain C et al. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut 2007; 56: 772-781
• 19 Ramsoekh D, van Leerdam ME, Rauws EA et al. Outcome of peptic ulcer bleeding, nonsteroidal anti-inflammatory drug use, and Helicobacter pylori infection. Clin Gastroenterol Hepatol 2005; 3: 859-864
• 20 Sung JJ, Tsoi KK, Lai LH et al. Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007; 56: 1364-1373
• 21 Barkun A, Sabbah S, Enns R et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy [RUGBE]: endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am J Gastroenterol 2004; 99: 1238-1246
• 22 Barkun AN, Martel M, Toubouti Y et al. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc 2009; 69: 786-799
• 23 Moher D, Liberati A, Tetzlaff J et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6 e1000097
• 24 McGinn T, Jervis R, Wisnivesky J et al. Tips for teachers of evidence-based medicine: clinical prediction rules [CPRs] and estimating pretest probability. J Gen Intern Med 2008; 23: 1261-1268
• 25 Wasson JH, Sox HC, Neff RK et al. Clinical prediction rules. Applications and methodological standards. N Engl J Med 1985; 313: 793-799
• 26 Travis AC, Wasan SK, Saltzman JR. Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage. J Gastroenterol Hepatol 2008; 23: 1505-1510
• 27 Kollef MH, O’Brien JD, Zuckerman GR et al. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Crit Care Med 1997; 25: 1125-1132
• 28 Villanueva C, Balanzo J, Espinos JC et al. Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection. Dig Dis Sci 1993; 38: 2062-2070
• 29 Strate LL, Orav EJ, Syngal S. Early predictors of severity in acute lower intestinal tract bleeding. Arch Intern Med 2003; 163: 838-843
• 30 Bordley DR, Mushlin AI, Dolan JG et al. Early clinical signs identify low-risk patients with acute upper gastrointestinal hemorrhage. JAMA 1985; 253: 3282-3285
• 31 Corley DA, Stefan AM, Wolf M et al. Early indicators of prognosis in upper gastrointestinal hemorrhage. Am J Gastroenterol 1998; 93: 336-340
• 32 Park KG, Steele RJ, Mollison J et al. Prediction of recurrent bleeding after endoscopic haemostasis in non-variceal upper gastrointestinal haemorrhage. Br J Surg 1994; 81: 1465-1468
• 33 Almela P, Benages A, Peiro S et al. A risk score system for identification of patients with upper-GI bleeding suitable for outpatient management. Gastrointest Endosc 2004; 59: 772-781
• 34 Imperiale TF, Dominitz JA, Provenzale DT et al. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Arch Intern Med 2007; 167: 1291-1296
• 35 Guglielmi A, Ruzzenente A, Sandri M et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 2002; 34: 778-786
• 36 Pimpl W, Boeckl O, Waclawiczek HW et al. Estimation of the mortality rate of patients with severe gastroduodenal hemorrhage with the aid of a new scoring system. Endoscopy 1987; 19: 101-106
• 37 Provenzale D, Sandler RS, Wood DR et al. Development of a scoring system to predict mortality from upper gastrointestinal bleeding. Am J Med Sci 1987; 294: 26-32
• 38 Chiu PW, Ng EK, Cheung FK et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol 2009; 7: 311-316
• 39 Chen IC, Hung MS, Chiu TF et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med 2007; 25: 774-779
• 40 Srirajaskanthan R, Conn R, Bulwer C et al. The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage. Int J Clin Pract 2010; 64: 868-874
• 41 Stanley AJ, Dalton HR, Blatchford O et al. Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2011; 34: 470-475
• 42 Cipolletta L, Bianco MA, Rotondano G et al. Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 2002; 55: 1-5
• 43 Soncini M, Triossi O, Leo P et al. Management of patients with nonvariceal upper gastrointestinal hemorrhage before and after the adoption of the Rockall score, in the Italian Gastroenterology Units. Eur J Gastroenterol Hepatol 2007; 19: 543-547
• 44 Stanley AJ, Ashley D, Dalton HR et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009; 373: 42-47
• 45 Nakajima S, Nishiyama Y, Yamaoka M et al. Changes in the prevalence of Helicobacter pylori infection and gastrointestinal diseases in the past 17 years. J Gastroenterol Hepatol 2010; 25 Suppl 1: 99-S110
• 46 Saeed ZA, Winchester CB, Michaletz PA et al. A scoring system to predict rebleeding after endoscopic therapy of nonvariceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection. Am J Gastroenterol 1993; 88: 1842-1849
• 47 Hay JA, Lyubashevsky E, Elashoff J et al. Upper gastrointestinal hemorrhage clinical-guideline determining the optimal hospital length of stay. Am J Med 1996; 100: 313-322
• 48 Loewen P, Dahri K. Risk of bleeding with oral anticoagulants: an updated systematic review and performance analysis of clinical prediction rules. Ann Hematol 2011; 90: 1191-1200