Comparison of the performance of risk scoring systems for tumor bleeding in patients with inoperable gastric cancer

Abstract

Background The Glasgow – Blatchford bleeding score (GBS) and admission and full Rockall scores are widely used risk scoring systems to stratify risk and determine the need for intervention in patients with upper gastrointestinal bleeding. We evaluated the performance of these risk scoring systems in patients with gastric cancer and tumor bleeding.

Methods This retrospective study included patients with inoperable gastric cancer who presented with tumor bleeding at the National Cancer Center, Korea, between 2001 and 2015. The GBS, and admission and full Rockall scores were calculated. Primary outcome was the performance of the risk scoring systems in predicting the need for urgent interventions (endoscopic therapy, transarterial embolization, and surgery). The risk factors associated with urgent intervention were analyzed.

Results Of 357 patients with tumor bleeding, 118 (33.1 %; 116 endoscopic therapy, 2 trans-arterial embolization) required urgent intervention. The full Rockall score was better at predicting the need for urgent intervention (area under the receiver operating characteristic curve = 0.78; P < 0.001) than the GBS (0.56) and admission Rockall score (0.56). Hemostatic intervention was not performed in patients with a full Rockall score ≤ 6 (103 patients, 28.9 %). On multivariate analysis, endoscopic stigmata of recent hemorrhage of Forrest classes Ia – IIb were significant factors associated with urgent intervention.

Conclusions The full Rockall score was superior to the GBS and admission Rockall score in predicting the need for urgent intervention for tumor bleeding. Thus, endoscopic evaluation is required to determine the need for urgent intervention in patients with gastric cancer and tumor bleeding.

Publication History

Received: 01 September 2019

Accepted: 15 January 2020

Article published online:
25 February 2020

• References

• 1 Savides TJ, Jensen DM, Cohen J. et al. Severe upper gastrointestinal tumor bleeding: endoscopic findings, treatment, and outcome. Endoscopy 1996; 28: 244-248
• 2 Sheibani S, Kim JJ, Chen B. et al. Natural history of acute upper GI bleeding due to tumours: short-term success and long-term recurrence with or without endoscopic therapy. Aliment Pharmacol Ther 2013; 38: 144-150
• 3 Maluf-Filho F, Martins BC, de Lima MS. et al. Etiology, endoscopic management and mortality of upper gastrointestinal bleeding in patients with cancer. United European Gastroenterol J 2013; 1: 60-67
• 4 Schatz RA, Rockey DC. Gastrointestinal bleeding due to gastrointestinal tract malignancy: natural history, management, and outcomes. Dig Dis Sci 2017; 62: 491-501
• 5 Imbesi JJ, Kurtz RC. A multidisciplinary approach to gastrointestinal bleeding in cancer patients. J Support Oncol 2005; 3: 101-110
• 6 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-46
• 7 Sung JJ, Chiu PW, Chan FKL. et al. Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018. Gut 2018; 67: 1757-1768
• 8 Kumar NL, Travis AC, Saltzman JR. Initial management and timing of endoscopy in nonvariceal upper GI bleeding. Gastrointest Endosc 2016; 84: 10-17
• 9 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107: 345-360
• 10 National Institute for Health and Care Excellence. Acute upper gastrointestinal bleeding in over 16s: management. Clinical guideline [GC141]; 2012 Available from [updated August 2016]: https://www.nice.org.uk/guidance/cg141
• 11 Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000; 356: 1318-1321
• 12 Stanley AJ, Ashley D, Dalton HR. et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009; 373: 42-47
• 13 Rockall TA, Logan RF, Devlin HB. et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321
• 14 Vreeburg EM, Terwee CB, Snel P. et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999; 44: 331-335
• 15 Rockall TA, Logan RF, Devlin HB. et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996; 347: 1138-1140
• 16 Stanley AJ, Laine L, Dalton HR. et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017; 356: i6432
• 17 Laursen SB, Dalton HR, Murray IA. et al. Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding. Clin Gastroenterol Hepatol 2015; 13: 115-121
• 18 Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397
• 19 Laine L, Spiegel B, Rostom A. et al. Methodology for randomized trials of patients with nonvariceal upper gastrointestinal bleeding: recommendations from an international consensus conference. Am J Gastroenterol 2010; 105: 540-550
• 20 Kim YI, Choi IJ, Cho SJ. et al. Outcome of endoscopic therapy for cancer bleeding in patients with unresectable gastric cancer. J Gastroenterol Hepatol 2013; 28: 1489-1495
• 21 Muller MP, Tomlinson G, Marrie TJ. et al. Can routine laboratory tests discriminate between severe acute respiratory syndrome and other causes of community-acquired pneumonia?. Clin Infect Dis 2005; 40: 1079-1086
• 22 DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988; 44: 837-845
• 23 Ahn S, Lim KS, Lee YS. et al. Blatchford score is a useful tool for predicting the need for intervention in cancer patients with upper gastrointestinal bleeding. J Gastroenterol Hepatol 2013; 28: 1288-1294
• 24 Loftus EV, Alexander GL, Ahlquist DA. et al. Endoscopic treatment of major bleeding from advanced gastroduodenal malignant lesions. Mayo Clin Proc 1994; 69: 736-740
• 25 Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012; 10: 1130-1135
• 26 Van Belle SJ, Cocquyt V. Impact of haemoglobin levels on the outcome of cancers treated with chemotherapy. Crit Rev Oncol Hematol 2003; 47: 1-11
• 27 Ramaekers R, Mukarram M, Smith CA. et al. The predictive value of preendoscopic risk scores to predict adverse outcomes in emergency department patients with upper gastrointestinal bleeding: a systematic review. Acad Emerg Med 2016; 23: 1218-1227
• 28 Allum WH, Brearley S, Wheatley KE. et al. Acute haemorrhage from gastric malignancy. Br J Surg 1990; 77: 19-20