Comparison of Risk Scores for Predicting In-hospital Mortality among Patients Presenting with Acute Upper Gastrointestinal Bleed: A Retrospective Study from a Tertiary Care Centre, Chennai, India

Abstract

Introduction: Acute Gastrointestinal (GI) bleeding results in 5% of admissions to an Emergency Department/Room (ER), with mortality rates ranging from 2 to 15%. To predict the outcomes of these patients, multiple scoring systems have been developed. Early detection of individuals at high risk of mortality could allow for more targeted care including specialised care and early therapies, which could improve outcomes. Glasgow Blatchford Score (GBS), Pre-endoscopy and Rockall score, AIMS-65 (Albumin, International Normalised Ratio, Altered Mental status, Systolic blood pressure, Age >65 years), and the recently proposed ABC (Age, Blood parameters, Co-morbidities) score are some of the risk scores that have been devised for risk stratification. According to recent studies, the discriminative performance of these current scores for predicting patient mortality is relatively weak. Aim: To compare the risk scores for predicting in-hospital mortality among patients presenting with acute upper gastrointestinal bleed. Materials and Methods: A retrospective observational study was conducted on patients referred to the ER of a tertiary care hospital, Chennai, Tamil Nadu, India, with an acute upper GI bleed (characterised as haematemesis, coffee coloured vomitus, or melena) from July 2018 to June 2020. Data collected from medical records included detailed clinical history, vitals, relevant blood investigations, patient requirement for blood transfusion, endoscopic therapy, surgical procedures, radiological intervention along with mortality. The data was analysed using appropriate biostatistics Statistical Package for Social Sciences (SPSS) version 26.0, paired t-tests were performed to calculate the p-values and a p-value <0.05 was considered significant. Results: The study comprised a total of 112 patients. The study population’s median age was 53 years, with a male predominance (83.92%). The presenting complaint was haematemesis in 76.8% of the patients and melena in 23.2%. Ischaemic heart disease (10.71%), cirrhosis (25%), and malignancy (2.68%) were the most common co-morbidities. American Society of Anesthesiologists (ASA) grade III accounted for 45.3%, ASA grade II for 25.6%, and ASA grade I for 28.6%. Following endoscopy, the source of upper GI bleed was noted to be variceal in 39.3% of cases, gastric/duodenal ulcers in 25.9%, erosive changes in 16.1%, and tumour bleed in 2.7% of cases. Endoscopic mode of treatment was performed in 44.6% and 0.9% required surgical intervention. Mortality occurred in 11 patients (9.82%). Based on Area Under the Receiver Operating Characteristics (AUROC), AIMS-65 excelled over other scores in predicting mortality {AIIMS-65 (AUROC; 95% CI) 0.908 (0.85 to 0.97); p-value <0.001, Glasgow-Blatchford score (GBS) 0.818 (0.71-0.93) p-value <0.001, Pre-Rockall 0.756 (0.63-0.89) p-value <0.001, Rockall 0.894 (0.82-0.97) p-value <0.001, ABC 0.778 (0.65-0.90) p-value=0.003}. Conclusion: Systolic blood pressure, heart rate, blood urea, International Normalised Ratio (INR), and albumin showed significant association with mortality. Risk scores encompassing albumin have better mortality prediction. AIMS-65 outperformed other risk scores in predicting mortality, even outperforming the postendoscopy rockall score. Hence, AIMS-65 can be used to stratify patients in the emergency room early to reduce mortality.

Keywords

• age
• blood parameters
• co-morbidities score
• glasgow-blatchford score
• mortality
• rockall
• risk stratification