Division of Gastroenterology, New York Hospital Queens Weill Cornell Medical College, 56-45 Main Street, Flushing, NY 11355, USA.
Therap Adv Gastroenterol. 2013 May;6(3):193-8. doi: 10.1177/1756283X13481020.
Upper gastrointestinal bleeding (UGIB) accounts for 400,000 hospital admissions in the US each year. Despite advances, mortality rates remain high and are estimated to be 5-10%. Early therapeutic endoscopy is widely recommended as a means of reducing morbidity and mortality. The Rockall and Blatchford scores are clinical scoring systems devised to assist in risk stratifying patients with UGIB. In a prior study we found that rapid live bedside video capsule endoscopy (VCE) utilizing Pillcam ESO(®) correctly identified patients with high-risk stigmata of bleeding seen on upper endoscopy. In this study, we compare the accuracy of the Rockall and Blatchford scores with Pillcam ESO(®) in predicting high-risk endoscopic stigmata.
Pre-endoscopy Blatchford and Rockall scores were calculated for 25 patients (14 males, 11 females) presenting to the emergency room with acute UGIB. The average patient was 66 years of age. A total of 24 out of 25 patients underwent upper endoscopy within 24 hours. One patient did not undergo endoscopy due to clinical instability. The timing of endoscopy was based on clinical parameters in 12 patients, and on live view VCE with Pillcam ESO(®) in the other 13 patients. Positive VCE was defined as red blood, clot or coffee grounds. Mean Rockall and Blatchford scores for all 24 patients were compared to determine potential differences between high- and low-risk patients. Rockall and Blatchford scores were also compared with VCE findings.
Of 24 patients, 13 had high-risk stigmata on upper endoscopy. The mean Rockall and Blatchford scores were 3 and 13, respectively. In the 11 patients without stigmata, the mean Rockall and Blatchford scores were 2 and 11, respectively. There was no statistically significant difference between the Blatchford scores of the two groups (95% confidence interval [CI] -5.1 to 1.3; p = 0.22). There was no statistically significant difference between the Rockall scores of the two groups (95% CI -2.3 to 0.3; p = 0.11). In the subgroup of 12 patients who underwent VCE prior to endoscopy, 8/12 had positive findings, which were all confirmed at endoscopy. All 4 patients with negative VCE had no high-risk stigmata at endoscopy.
In emergency room patients with acute UGIB, neither the Rockall nor the Blatchford scores were able to differentiate high- and low-risk patients identified at endoscopy. Live view VCE, however, was accurate in predicting high-risk endoscopic stigmata, and may be better suited as a risk stratification tool. Additional studies with a larger cohort will be required to validate these findings.
上消化道出血（UGIB）在美国每年导致 40 万例住院治疗。尽管取得了进展，但死亡率仍然很高，估计为 5-10%。早期治疗性内镜检查被广泛推荐作为降低发病率和死亡率的手段。Rockall 和 Blatchford 评分是用于协助对 UGIB 患者进行风险分层的临床评分系统。在之前的一项研究中，我们发现利用 Pillcam ESO(®) 进行快速现场床边胶囊内镜（VCE）可以正确识别在上消化道内镜检查中发现有高危出血迹象的患者。在这项研究中，我们比较了 Rockall 和 Blatchford 评分与 Pillcam ESO(®) 在预测高危内镜下出血迹象方面的准确性。
对 25 名（14 名男性，11 名女性）因急性 UGIB 就诊急诊室的患者进行了内镜检查前的 Blatchford 和 Rockall 评分。平均患者年龄为 66 岁。25 例患者中共有 24 例在 24 小时内进行了上消化道内镜检查。由于临床不稳定，1 例患者未进行内镜检查。内镜检查的时间取决于 12 例患者的临床参数，而取决于 13 例患者的实时 VCE 胶囊内镜检查（Pillcam ESO(®)）。阳性 VCE 定义为红色血液、凝块或咖啡渣。比较 24 例患者的平均 Rockall 和 Blatchford 评分，以确定高危和低危患者之间的潜在差异。还比较了 Rockall 和 Blatchford 评分与 VCE 结果。
在 24 例患者中，13 例在上消化道内镜检查中发现高危出血迹象。平均 Rockall 和 Blatchford 评分为 3 和 13。在 11 例无出血迹象的患者中，平均 Rockall 和 Blatchford 评分为 2 和 11。两组间 Blatchford 评分无统计学差异（95%置信区间[CI]-5.1 至 1.3；p=0.22）。两组间 Rockall 评分无统计学差异（95%CI-2.3 至 0.3；p=0.11）。在 12 例先进行 VCE 检查后再进行内镜检查的亚组中，12 例中有 8 例 VCE 检查结果阳性，均在内镜检查中得到证实。所有 4 例 VCE 检查结果阴性的患者在内镜检查中均无高危出血迹象。
在因急性 UGIB 就诊急诊室的患者中，Rockall 和 Blatchford 评分均无法区分在内镜检查中确定的高危和低危患者。然而，实时 VCE 胶囊内镜检查可准确预测高危内镜下出血迹象，可能更适合作为风险分层工具。需要更大队列的进一步研究来验证这些发现。
