Analysis of Clinical Rockall Score in patients with Acute Upper Gastrointestinal Bleeding in the Emergency Services of a Tertiary Hospital

Results: The mean age of patients with AUGIB was 47.83years with males (64.7%). The commonest cause of UGIB was esophageal varices 86 (31.6%), followed by ulcers 53 (19.5%). Hematemesis was the commonest mode of presentation in 133 (48.9%) followed by melena in 95 (34.9%) and both in 44 patients(16.2%). The overall mortality rate was 14.3% and was 0%, 0%, 9.3%, 3.2%, 6.5%, 62.1%, 83.3% and 100% for Clinical Rockall Score of 0,1,2,3,4,5,6 and 7 respectively. High clinical Rockall score of >4 was associated with outcomes like transfusion in 81% patients, rebleeding in 61.9% and mortality in 69% of patients. The predictive accuracy of clinical Rockall score for transfusion, the AUROC was 0.737(95% CI: 0.678-0.791, p=0.001); for rebleeding, the AUROC was 0.863 (95% CI: 0.8-0.927, p=0.001) and for mortality, the AUROC was 0.877 (95% CI: 0.81-0.944, p=0.001).


INTRODUCTION
Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency throughout the world and a cause of 1 AUGIB presents either as passage of black tarry stools (melena) or as passage of fresh blood or coffee ground vomitus(hematemesis).
The etiology of AUGIB varies from trivial causes like gastric erosions to potentially severe conditions like variceal bleed and ulcer bleed. 2 Accurate risk assessment for triaging and prognostication is very important to facilitate discharge of low risk patients from the emergency department and enable urgent active intervention and intensive care monitoring in high risk patients. Several risk scores have been used to predict the clinical outcomes in patients with UGIB. 3 An ideal risk score is the one that is easy to calculate, accurate for relevant outcome and can be measured early after presentation with UGIB. The most widely applied scoring systems include the Glasgow-Blatchford Bleeding Score(GBS), AIMS65 score and the Clinical Rockall Score. 4,5 These scores utilize only the pre endoscopic criteria. The most commonly used risk scoring system in UGIB is the Rockall Score which was described in 1996 following the analysis of data from a large English audit. The Clinical Rockall Score relies only on clinical variables and is used to identify patients who have an adverse outcome such as death or recurrent bleeding. 6,7 The Clinical Rockall Score consisted of the following components: The patients age, the hemodynamic status and the occurrence of a comorbid disease. A maximum score of 7 is possible. The aim of this study was to assess the clinical usefulness and prognostic value of the Clinical Rockall Score in rebleeding and mortality of patients presenting to the Emergency Department with UGIB.

METHODS
This was a hospital based descriptive cross sectional study conducted in the Emergency Department of the Institute of medicine, Tribhuwan University Teaching hospital from May 2017 to April 2018. This study was approved by the Institutional Review Board of Institute of Medicine, Tribhuwan University Teaching Hospital. Patients presenting to the Emergency of Teaching hospital with hematemesis or melena or both who gave written consent for the study were included in the study. For each patient at the emergency room, the baseline clinical data along with co morbid conditions like chronic liver disease, cirrhosis of liver, chronic kidney disease, chronic obstructive lung disease, the laboratory reports including a complete hemogram, liver function tests, renal function tests and arterial blood gas analysis, chest x ray, electrocardiogram, ultrasonography of abdomen and pelvis, transfused blood units, length of hospital stay, rebleeding and outcome after 28 days were all recorded. All the patients were resuscitated according to the standard protocol of upper gastrointestinal bleeding management guidelines of the Emergency room. Clinical Rockall Score was calculated for each patient which included the age of the patient, whether the patient presented in shock or not and the comorbidity of the patient. The patients were admitted in the intensive care unit, medical intensive care unit, general wards or observation room of the emergency after full resuscitation in the emergency room. The patients were followed up at 28th day in terms of mortality outcome by using hospital landline phone or mobile of the principal investigator. The association of 28 day outcome with the Clinical Rockall score was examined.
Data was entered into Microsoft Excel and analysed by using SPSS (Statistical Product and Service Solutions).

RESULTS
A total of 272 patients of UGIB were included in the study. The mean age of the patients was 47.83 years with the age range from 18 to 88 years. Majority of patients 176 (64.7%) were males and only 96 (35.3%) were females. Majority of the patients were in the age group of 37-56 years. The clinical presentation of the patients (Table 1) mainly in the form of hematemesis was 133 (n=272, 48.9%). Melena was seen in 95 (34.9 %) of patients whereas 44 patients (16.2%) presented with both the symptoms. Chronic liver disease was the most common co morbidity with 80 patients (29.9%) suffering from it. It was found out 3.11SD, the mean serum creatinine level was higher than the upper limit of the reference laboratory value of the ER.  Table 2 shows the etiology of the UGIB pa-Of the causes that were attributed to UGIB, variceal bleeding was the most common 86 (31.6%) followed by ulcers in 53 patients. The Clinical Rockall Score was calculated based on the collected data. (Table 3) and the relationship between Clinical Rockall score and the patient outcome in terms of transfusion, rebleeding and mortality was observed.
three risk categories (low, moderate and high) as determined by the Clinical Rockall scoring system, and the observed values of transfusion, rebleeding and mortality in each risk category are shown in Table 4.

CONCLUSIONS
In conclusion, our study shows that the Clinical Rockall score has satisfactory predictive accuracy for outcomes like transfusion, rebleeding and mortality and can be used as an important tool in the emergency room in patients with UGIB.
We recommend the use of non endoscopic scores like clinical Rockall score in the emergency room as a decision tool to predict the outcome in patients with UGIB with aview to improve patient management and promote cost effective use of resources.