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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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