ABSTRACT

BACKGROUND:

Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce.

OBJECTIVE:

This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome.

METHODS:

In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared.

RESULTS:

The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725).

CONCLUSION:

Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.

Keywords:
Upper gastrointestinal bleed; rebleed; mortality; Glasgow Blatchford score; pre- endoscopy Rockall score; AIMS65; Modified Early Warning Score.

RESUMO

CONTEXTO:

Tradicionalmente, a doença úlcera péptica era a causa mais comum de sangramento digestivo alto, mas com a mudança da epidemiologia, outras etiologias do sangramento do trato digestivo alto estão emergindo. Muitas pontuações têm sido descritas para prever resultados e a necessidade de intervenção na hemorragia gastrointestinal superior, mas a comparação prospectiva entre elas é escassa.

OBJETIVO:

Este estudo foi planeado para determinar o padrão etiológico de pacientes com hemorragia digestiva alta e comparar os escores de Glasgow Blatchford, o Rockall pré-endoscopia, o AIMS65 e o Early Warning modificado (MEWS) como preditores do resultado.

MÉTODOS:

Neste estudo prospetivo de coorte, 268 pacientes com sangramento digestivo alto foram acompanhados durante 8 semanas. Os escores Glasgow Blatchford, Rockall pré-endoscopia, AIMS65 e MEWS foram calculados para cada paciente, e a área sob a curva (AUC-ROC) para cada pontuação foi comparada.

RESULTADOS:

A etiologia mais comum para a hemorragia gastrointestinal alta foi varizes gastroesofágicas 150 (63,55%), seguida de úlcera péptica 29 (12,28%) e de doença erosiva de mucosa 27 (11,44%). No total, 38 (15,26%) doentes voltaram a sangrar e 71 (28,5%) doentes morreram. No total, 126 (47%) doentes necessitaram de transfusão de componentes sanguíneos, 25 (9,3%) necessitaram de ventilação mecânica e 2 (0,74%) destes doentes necessitaram de intervenção cirúrgica. O escore de Glasgow Blatchford foi o melhor na previsão da necessidade de transfusão (corte - 10, AUC-ROC =0,678). Enquanto o AIMS65 com uma pontuação de ≥2 foi o melhor na previsão de ressangramento (AUC-ROC =0,626) e mortalidade (AUC-ROC =0,725).

CONCLUSÃO:

O sangramento gastrointestinal alto mais comum é de origem varicosa em centro de referência terciária. O AIMS65 é o melhor escore simples, com uma pontuação de ≥2 para prever o ressangramento e a mortalidade.

Palavras-chave:
Sangramento digestivo alto; ressangramento; mortalidade; escore de Glasgow Blatchford, escore Rockall pré-endoscopia; AIMS65; Modified Early Warning Score

INTRODUCTION

Upper gastrointestinal (UGI) bleed is a common presentation in a medical emergency. UGI bleed is anatomically defined as any gastrointestinal (GI) bleed originating proximal to the ligament of Treitz¹1. Khamaysi I, Gralnek IM. Acute upper gastrointestinal bleeding (UGIB) - Initial evaluation and management. Best Pract Res Clin Gastroenterol. 2013;27:633-8..

Patients generally present with hematemesis or melena. Incidence and etiology vary from region to region and the level of the health care center, ranging from 48-160 cases per 100,000 adults per year²2. Rotondano G. Epidemiology and Diagnosis of Acute Nonvariceal Upper Gastrointestinal Bleeding. Gastroenterol Clin North Am. 2014;43:643-63.. India has a huge burden of UGI bleed with nearly 4.6% of hospital admissions due to UGI bleed³3. Singh SP, Panigrahi MK. Spectrum of upper gastrointestinal hemorrhage in coastal Odisha. Trop Gastroenterol. 2013;34:14-7.. The etiology of UGI bleed is generally divided into variceal and non-variceal in origin⁴4. Jairath V, Desborough MJR. Modern-day management of upper gastrointestinal haemorrhage. Transfus Med. 2015;25:351-7.. Non-variceal bleed includes peptic ulcer disease (PUD), erosive disease, esophagitis, Mallory Weiss tears, vascular malformation, and malignancies. Variceal bleed is generally due to esophageal varices but rarely can be due to gastric and even ectopic varices in the duodenum⁵5. Parikh K, Ali MA, Wong RCK. Unusual Causes of Upper Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am. 2015;25:583-605.. Most available data suggests PUD as the most common cause of UGI bleed in western countries and variceal bleed constitutes only a minor fraction⁴4. Jairath V, Desborough MJR. Modern-day management of upper gastrointestinal haemorrhage. Transfus Med. 2015;25:351-7.. Few studies have shown an increasing incidence of variceal bleed in recent times⁶6. Dursun M, Yilmaz S, Yükselen V, Canoruç F, Tuzcu A. Analysis of 1242 cases with upper gastrointestinal system bleeding in Southeastern Turkey: a different etiologic spectrum. Hepatogastroenterology. 2005;52:1456-8.^,77. Shrestha UK, Sapkota S. Etiology and Adverse Outcome Predictors of Upper Gastrointestinal Bleeding in 589 Patients in Nepal. Dig Dis Sci. 2014;59:814-22.. This rising trend may be due to increased alcohol consumption, the rise of chronic viral hepatitis B and C and non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) cases around the globe. The clinical severity of UGI bleed may vary from being insignificant to fatal. Mortality from UGI bleed varies from 2 to 26 % whereas 10-30% have re-bleed²2. Rotondano G. Epidemiology and Diagnosis of Acute Nonvariceal Upper Gastrointestinal Bleeding. Gastroenterol Clin North Am. 2014;43:643-63.^,88. 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.^,99. Stanley AJ, Dalton HR, Blatchford O, Ashley D, Mowat C, Cahill A, 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;34:470-5.. Many scoring systems have been used to identify high-risk and low-risk patients to predict outcomes and the need for intervention. The scoring systems which are widely used are Glasgow Blatchford Score (GBS), Pre-Endoscopy Rockall score (PRS), AIMS65, and Modified Early Warning Score (MEWS), formulated by using basic clinical data, blood investigations, and endoscopic parameters¹⁰10. Bozkurt S, Köse A, Arslan ED, Erdoğan S, Üçbilek E, Çevik İ, et al. Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding. Scand J Trauma Resusc Emerg Med. 2015;23:109.

11. Rockall TA, Logan RF, Devlin HB NT. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet (London, England). 1996;347:1138-40.^-1212. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet (London, England). 2000;356:1318-21.. The higher score predicts the need for intensive care and intervention. But the utility of these scoring systems as a predictor of outcome is still controversial.

METHODS

Study design and study site: this prospective cohort study was conducted at the Postgraduate Institute of medical education and research (PGIMER), a tertiary care center in Chandigarh, Northern India. The study was conducted from December 2017 to December 2018 with the collaboration of the Department of Internal medicine, gastroenterology, and hepatology, after prior approval from the institutional Ethics Committee.

Screening and enrollment: the patients presenting with a history of UGI bleed at the emergency medical outpatients department were screened for enrollment in the study as per inclusion and exclusion criteria after getting informed consent.

Inclusion and exclusion criteria

Irrespective of gender and with age of ≥18 years, all patients with UGI bleed were included in the study.

Patients with a lower GI bleed and not willing to give consent were excluded from the study.

Management protocol

Patient presenting with hematemesis, melena or hematochezia were considered as having UGI bleed. A detailed history and clinical characteristics were noted down to rule out other causes such as hemoptysis or lower GI bleed. The study was community-based however the study population consisted more of referral patients than primary presentation as ours is a referral center. Once recruited, a blood sample was drawn for assessing baseline hemogram, coagulation profile, electrolytes, renal function, and liver functions. Ultrasonogram (USG) of the abdomen or Fibroscan was performed when required. Data was collected for each patient in a predesigned proforma. All patients were risk stratified by using the GBS, PRS, AIMS65 and MEWS. All patients were managed using standard emergency protocols. For the management-airway, brea­thing and circulation were given initial priority. A crystalloid infusion was given as and when required. Blood transfusion was given to maintain the target Hb of 7-9 g/dL or with signs of hemodynamic instability despite fluid resuscitation. All patients were subjected to UGI endoscopy within 12-24 hrs of presentation. All patients with non-variceal UGI bleed received endoscopic therapy according to the European Society of Gastrointestinal Endoscopy (ESGE) guideline 2015, which included the use of dual modalities (injection and mechanical) when feasible. Re-bleed was defined as significant UGI bleed anytime post endoscopy leading to repeat endoscopy, hemodynamic instability, a significant drop in hemoglobin (Hb), or requiring blood transfusions during the follow-up period. In case of a re-bleed, another attempt on endoscopic hemostasis was taken and in cases of failure, surgical intervention was advised. The patients were observed during the hospital course and were followed up to 8 weeks via phone call or OPD basis.

Outcome assessment

The outcomes were assessed as etiology of UGI bleed, the incidence of re-bleed, need for surgical intervention, blood transfusion, mechanical ventilation, duration of hospital stays (>3 days was taken as a prolonged hospital stay), and mortality within 8 weeks. GBS, PRS, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. [Risk factors of each score given in supplementary TABLE 1-4].

Statistical analysis

The data was analyzed using SPSS (22.0) after compilation of data in a spreadsheet. Descriptive data distribution was presented with the mean and standard deviation. Categorical data were presented as proportions. Nominal variables were evaluated using either Pearson’s x²-test or Fisher’s exact test. All the correlations between continuous variables were assessed using Pearson’s correlation coefficient and chi-square test to look for significant differences. The difference in the distribution of variables between variceal and nonvariceal bleed subgroups was done using multivariate regression analysis. The P-value of less than 0.05 was taken as statistically significant (95%CI). The area under the receiver operating characteristic (AUC-ROC) curve was calculated for the GBS, PRS, AIMS65, and MEWS and the predictive accuracy of each scoring system was measured. Pair-wise AUC-ROC comparisons were performed between combinations of two different scoring systems using the nonparametric approach developed by DeLong et al.¹³13. DeLong ER , DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44:837-45.. The AUC-ROC curve of >0.6 was taken as acceptable and the higher the AUC-ROC curve the better is the predictor of outcome.

RESULTS

The clinical and demographic data was recorded of total 268 patients (Table 1). The mean age of the patients enrolled in the study was 48.49±13.23 years. The maximum number of patients was in the age group 45-60 years and males constituted 82.83% of the patients. The most common comorbid condition was chronic liver disease (CLD) seen in 64.17% of patients followed by diabetes mellitus (14.2%) and hypertension (11.9%). Alcohol (79.06%) was the most common etiology for CLD. The most common presentation was hematemesis (47.38%) followed by melena (29.85%), while 22.76% presented with both (hematemesis and melena). The most common clinical finding was pallor (75.4%) followed by tachycardia (54.85%) (Table 1).

Etiology and endoscopic findings

Out of 268 patients, only 236 could undergo endoscopy for definitive therapy and etiology of UGI bleed due to poor clinical condition or not giving consent for endoscopy. (Figure 1) The most common cause of UGI bleed was due to variceal pathology seen in 150 (63.55%) patients followed by PUD (12.28%) and mucosal erosive disease (11.44%). Endoscopic interventions were required in 146 (61.86%) of 236 patients who underwent endoscopy. Endoscopic variceal ligation (EVL) was the most common intervention (48.72%) done followed by Glue injection (5.50%) in patients having fundal varices. Multimodal therapy (adrenaline instillation followed by hemostatic clips) was needed in 2.96% of patients (Table 2).

Outcomes

Out of 268 patients, 249 patients completed follow-up. Re-bleed occurred in 38 (15.26%) cases out of which 28 cases were of variceal etiology. Out of 249 patients, 126 (50.60%) patients required blood component transfusion and 25 (10.04%) patients required mechanical ventilation and 2 (0.80%) patients required surgical intervention for control of bleed. The mean duration of hospital stay was 3.0±1 day with 35 (14.05%) patients having a hospital stay of >3 days. Out of 249 patients, overall mortality was 71 (28.51%) patients, out of which, 33 (46.5%) patients had variceal bleed, 15 (21.1%) patients had non-variceal bleed and 23 (32.4%) could not undergo endoscopy to establish the etiology of UGI bleed.

Pre endoscopy scores as a predictor of outcome

Pre-endoscopy Scores (GBS, AIMS65, MEWS & PRS) were calculated for 249 patients who completed follow up. These scores were calculated at initial presentation (Table 3). AIMS65 was the best in predicting re-bleed with cut-off value of ≥2 which achieved sensitivity and specificity of 79% and 48% respectively. None of the scores were predictive for duration of hospital stay. GBS and AIMS65 were predictive for the need for blood component transfusion while PRS and MEWS had insignificant AUC-ROC curves. For the need for mechanical ventilation; MEWS, AIMS65 and GBS had good predictive ability. The AUC-ROC for AIMS65, MEWS, and GBS were significant for the need for surgical intervention and was found to be 0.914, 0.753 and 0.681 respectively. For predicting mortality AUC-ROC for AIMS65, GBS, and PRS was significant. Further, we separately compared the AUC-ROC curves for each outcome in variceal and non-variceal patients. AIMS65 was better in both groups in predicting re-bleed and mortality as compared to PRS (Table 4).

DISCUSSION

With the changing epidemiology, the most common etiology for UGI bleed was variceal bleed replacing the PUD in our study. This was consistent with the recent studies done across Northern India where variceal etiology appeared as the predominant etiology⁸8. 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.^,1414. Parvez MN, Goenka M, Tiwari I, Goenka U. Spectrum of upper gastrointestinal bleed: An experience from Eastern India. J Dig Endosc. 2016;7:55.^,1515. Anand D, Gupta R, Dhar MAV. Clinical and endoscopic profile of patients with upper gastrointestinal bleeding at tertiary care center of North India. J Dig Endosc. 2014;139-43.. Studies in Nepal also suggested variceal bleeding to be the predominant cause of UGI bleed followed by peptic ulcer disease⁷7. Shrestha UK, Sapkota S. Etiology and Adverse Outcome Predictors of Upper Gastrointestinal Bleeding in 589 Patients in Nepal. Dig Dis Sci. 2014;59:814-22.^,1616. Sharma V, Jeyaraman P, Rana SS, Gupta R, Malhotra S, Bhalla A, et al. Utility of clinical and complete Rockall score in Indian patients with upper gastrointestinal bleeding. Trop Gastroenterol . 2016;37:276-82.. Etiological spectrum and clinical data were compared with regional studies across India and results were similar to the studies done in tertiary care centers in Northern, Southern and Western India, whereas peptic ulcer disease was more commonly seen in Eastern India³3. Singh SP, Panigrahi MK. Spectrum of upper gastrointestinal hemorrhage in coastal Odisha. Trop Gastroenterol. 2013;34:14-7.^,88. 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.^,1414. Parvez MN, Goenka M, Tiwari I, Goenka U. Spectrum of upper gastrointestinal bleed: An experience from Eastern India. J Dig Endosc. 2016;7:55.^,1515. Anand D, Gupta R, Dhar MAV. Clinical and endoscopic profile of patients with upper gastrointestinal bleeding at tertiary care center of North India. J Dig Endosc. 2014;139-43.^,1717. Shyamsundar CM, Sharma GD, Rana BS. Profile of acute upper gastro intestinal bleed: a referral hospital-based study in sub Himalayan region. Int J Adv Med. 2018;5:849-53. doi.org/10.18203/2349-3933.ijam20182994.
https://doi.org/10.18203/2349-3933.ijam2... ^,1818. Kashyap R, Mahajan S, Sharma B, Jaret P, Patial RK, Rana SP, LS. A Clinical Profile of Acute Upper Gastrointestinal Bleeding at Moderate Altitude. JIACM. 2005;224-8..

Various studies in the South Asian regions have shown a higher incidence of variceal bleed in males as compared to females which were consistent with our study where 66.83% of males had variceal bleed whereas non-variceal etiologies were predominant (52.5%) in the female population⁷7. Shrestha UK, Sapkota S. Etiology and Adverse Outcome Predictors of Upper Gastrointestinal Bleeding in 589 Patients in Nepal. Dig Dis Sci. 2014;59:814-22.^,88. 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.^,1919. Gado AS, Ebeid BA, Abdelmohsen AM, Axon AT. Clinical outcome of acute upper gastrointestinal hemorrhage among patients admitted to a government hospital in Egypt. Saudi J Gastroenterol. 2012;18:34-9.. This could be due to higher alcohol consumption in males and increased incidence of CLD. As expected, variceal bleed was the commonest etiology of UGI bleed in CLD patients, however, it was also important to look for nonvariceal causes. We found that 10.96% of our CLD patients had a nonvariceal bleed. It is important because mortality is higher in patients having CLD with non-variceal bleed than patients without CLD²⁰20. Leontiadis GI, Molloy-Bland M, Moayyedi P, Howden CW. Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis. Am J Gastroenterol. 2013;108:331-45. Endoscopic band ligation was the most common therapeutic procedure done due to esophageal varices being the commonest cause of UGI bleed.

The need for mechanical ventilation occurred in 9.3% of patients which was lower than the previous study²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.. Our study showed mortality (28.51%) on the higher side when compared with other similar studies (2.6-33.5%) done across the world⁷7. Shrestha UK, Sapkota S. Etiology and Adverse Outcome Predictors of Upper Gastrointestinal Bleeding in 589 Patients in Nepal. Dig Dis Sci. 2014;59:814-22.^,1717. Shyamsundar CM, Sharma GD, Rana BS. Profile of acute upper gastro intestinal bleed: a referral hospital-based study in sub Himalayan region. Int J Adv Med. 2018;5:849-53. doi.org/10.18203/2349-3933.ijam20182994.
https://doi.org/10.18203/2349-3933.ijam2... ^,1919. Gado AS, Ebeid BA, Abdelmohsen AM, Axon AT. Clinical outcome of acute upper gastrointestinal hemorrhage among patients admitted to a government hospital in Egypt. Saudi J Gastroenterol. 2012;18:34-9.^,2222. Rathi P, Abraham P, Rajeev Jakareddy PN. Spectrum of upper gastrointestinal bleeding in Western India. Indian J Gastroenterol. 2001;20 (Suppl 2) (A37).^,2323. Venkatesh PGK, Parasa S, Njei B, Sanaka MR, Navaneethan U. Increased mortality with peptic ulcer bleeding in patients with both compensated and decompensated cirrhosis. Gastrointest Endosc. 2014;79:605-14.e3.. This could be attributed to a higher number of variceal bleeds in our study population as compared to the Western population and because of CLD related complications. Re-bleed was seen in 15.26% of patients which was comparable to the Western as well as the Indian studies⁸8. 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.^,2222. Rathi P, Abraham P, Rajeev Jakareddy PN. Spectrum of upper gastrointestinal bleeding in Western India. Indian J Gastroenterol. 2001;20 (Suppl 2) (A37).^,2323. Venkatesh PGK, Parasa S, Njei B, Sanaka MR, Navaneethan U. Increased mortality with peptic ulcer bleeding in patients with both compensated and decompensated cirrhosis. Gastrointest Endosc. 2014;79:605-14.e3..

Risk stratification is an important strategy for the management of patients with UGI bleed regarding in-patient or out-patient care, the need for intervention and early discharge²⁴24. Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, Bini EJ, et al. Improved patient survival after acute variceal bleeding: a multicenter, cohort study. Am J Gastroenterol . 2003;98:653-9.^,2525. Vreeburg EM, Snel P, de Bruijne JW, Bartelsman JF, Rauws EA, Tytgat GN. Acute upper gastrointestinal bleeding in the Amsterdam area: incidence, diagnosis, and clinical outcome. Am J Gastroenterol . 1997;92:236-43.. As the epidemiology of UGI bleed varies from region to region, a well-validated scoring system needs to be in place for a regional set up. Commonly used validated scoring systems for predicting patient outcomes are GBS, AIMS65, PRS and MEWS¹⁰10. Bozkurt S, Köse A, Arslan ED, Erdoğan S, Üçbilek E, Çevik İ, et al. Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding. Scand J Trauma Resusc Emerg Med. 2015;23:109.^,2121. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.^,2626. Stanley AJ, Laine L, Dalton HR, Ngu JH, Schultz M, Abazi R, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432.^,2727. Cúrdia Gonçalves T, Barbosa M, Xavier S, Boal Carvalho P, Firmino Machado J, Magalhães J, et al. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE Port J Gastroenterol. 2018;25:299-307..

In our study population, AIMS65 was the best in predicting mortality as seen in the previous studies²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.^,2626. Stanley AJ, Laine L, Dalton HR, Ngu JH, Schultz M, Abazi R, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432.. The cut-off value was ≥2, whereas it was ≥3 in other studies²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.^,2626. Stanley AJ, Laine L, Dalton HR, Ngu JH, Schultz M, Abazi R, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017;356:i6432.. GBS and PRS had higher cut-off of ≥14 and ≥3 respectively in studies by Nagaraja et al. and Bozkurt et al. respectively as in comparison to our study having a cut-off of 11¹⁰10. Bozkurt S, Köse A, Arslan ED, Erdoğan S, Üçbilek E, Çevik İ, et al. Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding. Scand J Trauma Resusc Emerg Med. 2015;23:109.^,2828. Nagaraja BS, Vinay K, Rao AK, Umesh KJ, Prashant BC. Comparison of prediction of outcomes in upper GI bleed using non-endoscopic scoring systems. Int J Adv Med . 2018;5:838-44.. AIMS65 was the only predictor for rebleed with a score of ≥2 whereas Robertson et al. kept a cut-off of ≥3. For GBS as a predictor of rebleed, there is conflicting data with a cut-off from 1-13²⁹29. Anchu AC, Mohsina S, Sureshkumar S, Mahalakshmy T, Kate V. External validation of scoring systems in risk stratification of upper gastrointestinal bleeding. Indian J Gastroenterol . 2017;36:105-12.^,3030. Wang CH, Chen YW, Young YR, Yang CJ, Chen IC. A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding. Am J Emerg Med. 2013;31:775-8.. Bozkurt et al. demonstrated the utility of PRS at a cut-off value of four. However, PRS was not effective in our study for predicting rebleed and mortality but gained significance when analyzed separately for the non-variceal population for predicting mortality. Another study from our center showed that PRS works better in non-variceal bleed in predicting outcomes and is similar to our findings¹⁶16. Sharma V, Jeyaraman P, Rana SS, Gupta R, Malhotra S, Bhalla A, et al. Utility of clinical and complete Rockall score in Indian patients with upper gastrointestinal bleeding. Trop Gastroenterol . 2016;37:276-82.. In another large retrospective study done only in variceal bleed patients, AIMS65 was shown to have predictive ability (AUROC >0.8) in predicting mortality but not rebleed³¹31. Tantai XX, Liu N, Yang LB, Wei ZC, Xiao CL, Song YH, Wang JH. Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding. World Journal of Gastroenterology. 2019;25:6668.. In our study population, none of the scores were predictive of prolonged hospital stay of >3 days which was similar to another study²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.. GBS was the best in predicting the need for blood transfusion as seen by Robertson et al. and Goncalves et al.²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.^,2727. Cúrdia Gonçalves T, Barbosa M, Xavier S, Boal Carvalho P, Firmino Machado J, Magalhães J, et al. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE Port J Gastroenterol. 2018;25:299-307.. The cut-off score for the need for blood transfusion was found ≥10 which was consistent with Robertson et al.²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.. AIMS65 with a cut-off of two was also predictive of the need for blood transfusion in our study, which was similar to Robertson et al.²¹21. Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83:1151-60.. MEWS was the best in predicting the need for Mechanical Ventilation with a cut-off value of ≥3. To the best of our knowledge, this was the first study comparing MEWS with the need for mechanical ventilation. GBS and AIMS65 were also fairly predictive for need intensive care unit admission with cut off at 12 and 2 respectively. AIMS65 followed by MEWS were predictive for the need for surgical intervention at a cutoff score of ≥3 and ≥4 respectively whereas Goncalves et al. have reported GBS as the only score predictive for surgical intervention²⁷27. Cúrdia Gonçalves T, Barbosa M, Xavier S, Boal Carvalho P, Firmino Machado J, Magalhães J, et al. Optimizing the Risk Assessment in Upper Gastrointestinal Bleeding: Comparison of 5 Scores Predicting 7 Outcomes. GE Port J Gastroenterol. 2018;25:299-307.. However, patients undergoing surgical intervention were very few (only two); hence predictive ability may not be clinically acceptable.

A single score could not predict all outcomes. AIMS65 emerged as a simple score that was able to predict interventions such as the requirement of blood transfusion and surgery along with outcome variables of rebleed and mortality. AIMS65 with a cut-off of 2-3 can be routinely used in emergency for the need of intensive management (Table 5).

This study was conducted in a tertiary care institute in Northern India which caters to a diverse population from Jammu and Kashmir, Punjab, Haryana, Uttarakhand, Uttar Pradesh, Rajasthan, and Bihar. The sample population is small and might not have been representative of the whole Indian population. A multicenter multiregional study with a larger sample should be conducted for a better evaluation of the complete epidemiology of UGI bleed in our nation.

CONCLUSION

With changing epidemiology, variceal etiology for UGI bleed has become the predominant diagnosis replacing peptic ulcer disease in Northern India and many other Southeastern Asian regions. Rebleed and mortality were more commonly seen in variceal bleed patients as compared to non-variceal bleed patients. Pre-endoscopy Rockall score was not effective in predicting outcomes in variceal bleed patients. AIMS65 was the best & simplest score for predicting mortality and re-bleed in UGI bleed patients.

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