Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding.

BACKGROUND: Acute upper gastrointestinal hemorrhage (UGIH) is a common reason for hospitalization with substantial associated morbidity, mortality, and cost. Differentiation of high- and low-risk patients using established risk scoring systems has been advocated. The aim of this study was to determine whether these scoring systems are more accurate than an emergency physician's clinical decision making in predicting the need for endoscopic intervention in acute UGIH.
METHODS: Patients presenting to a tertiary care medical center with acute UGIH from 2003 to 2006 were identified from the hospital database, and their clinical data were abstracted. One hundred ninety-five patients met the inclusion criteria and were included in the analysis. The clinical Rockall score and Blatchford score (BS) were calculated and compared with the clinical triage decision (intensive care unit vs non-intensive care unit admission) in predicting the need for endoscopic therapy.
RESULTS: Clinical Rockall score greater than 0 and BS greater than 0 were sensitive predictors of the need for endoscopic therapy (95% and 100%) but were poorly specific (9% and 4%), with overall accuracies of 41% and 39%. At higher score cutoffs, clinical Rockall score greater than 2 and BS greater than 5 remained sensitive (84% and 87%) and were more specific (29% and 33%), with overall accuracies of 48% and 52%. Clinical triage decision, as a surrogate for predicting the need for endoscopic therapy, was moderately sensitive (67%) and specific (75%), with an overall accuracy (73%) that exceeded both risk scores.
CONCLUSIONS: The clinical use of risk scoring systems in acute UGIH may not be as good as clinical decision making by emergency physicians.