Rockall score for the evaluation of upper gastrointestinal bleeding

Age:

Shock:

comorbidity:

Diagnosis at endoscopy:

Stigmata of recent hemorrhage:

Background Info

The Rockall risk scoring system is based on clinical criteria including age, shock and presence of other comorbidities. The scoring system helps evaluate patients at risk of re-bleeding or death following acute upper gastrointestinal bleeding. The 1996 study recognized key independent risk factors which were later shown to predict mortality accurately. A commonly used mnemonic is ABCDE - (Age, Blood pressure fall (shock), Co-morbidity, Diagnosis and Evidence of bleeding). It is important to assess patients at admission to determine bleeding severity and the potential risk of death.

Key independent risk factors:

Age. There is a close relationship between increasing age and mortality. Patients 80 years of age or greater are at the highest risk of death.
Shock. Defined as a pulse rate of more than 100 beats/min and systolic blood pressure less than 100 mm Hg.
Comorbidity. Mortality rates vary greatly depending on the number and type of comorbidities. Heart failure, ischemic heart disease, or any major comorbidity can have a moderate to high impact on mortality rates. Renal failure, liver failure, or disseminated malignancy carry the highest risk of death from gastrointestinal bleeding.
Endoscopic findings.
- Low risk patients:
  -Normal upper gastrointestinal endoscopy
  -Mallory-Weiss tear
  -Finding of an ulcer with a clean base
- High risk:
  -Active bleeding from a peptic ulcer in a shocked patient carried an 80% risk of continuing bleeding or of death (grade A).
  -A non-bleeding visible vessel is associated with a 50% risk of rebleeding in hospital.

Initial Rockall Score Pre-endoscopy (maximum score: 7)
Parameter	Finding	Points
Age	< 60 years	0
	60 79 years	1
	> 80 years	2

Shock	"No shock"; systolic blood pressure >= 100 mm Hg and pulse < 100 beats per minute	0
	"Tachycardia"; systolic blood pressure >= 100 mm Hg and pulse >= 100 beats per minute	1
	"Hypotension"; systolic blood pressure < 100 mm Hg	2

Comorbidity	no major comorbidity	0
	hear failure, ischemic heart disease, or any major comorbidity	2
	renal failure, liver failure, disseminated malignancy	3
Full score post endoscopy (all parameters - maximum score 11)
Diagnosis at endoscopy	No lesion identified and no sign of recent hemorrhage	0
	Mallory-Weiss tear	0
	All other diagnoses	1
	Malignancy of upper GI tract	2

Major stigmata of recent hemorrhage	None	0
	Dark spot only	0
	Blood in upper GI tract, adherent clot, visible or spurting blood	2

Score Prior to Endoscopy	Mortality
0	0.2%
1	2.4%
2	5.6%
3	11.0%
4	24.6%
5	39.6%
6	48.9%
7	50.0%

Post-endoscopy score	Death	Rebleeding
8+	40% (30% to 51%)	37% (27% to 47%)
7	23% (15% to 31%)	37% (28% to 46%)
6	12% (6.3% to 17%)	27% (20% to 34%)
5	11% (6.3% to 15%)	25% (19% to 31%)
4	8.0% (4.0% to 12%)	15% (10% to 21%)
3	1.9% (0.0% to 3.9%)	12% (6.8% to 17%)
0 to 2	0.0% (0.0% to 0.93%)	5.9% (3.3% to 8.5%)

Post Endoscopy	Rebleed	Total Death	Death with No Rebleed	Death with Rebleed
0	4.9%	0%	0%	0%
1	3.4%	0%	0%	0%
2	5.3%	0.2%	0.3%	0%
3	11.2%	2.9%	2.0%	10.0%
4	14.1%	5.3%	3.5%	15.8%
5	24.1%	10.8%	8.1%	22.9%
6	32.9%	17.3%	9.5%	33.3%
7	43.8%	27.0%	14.9%	43.4%
8 - 11	41.8%	41.1%	28.1%	52.5%

References

1. Rockall TA, Logan RF, Devlin HB, Northfield TC. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet 1996;347:1138-40.

2. Rockall TA, Logan RF, Devlin HB, et al: Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321.

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