Gut 1996; 38: 316-321

Risk assessment after acute upper gastrointestinalhaemorrhage

T A Rockall, R F A Logan, H B Devlin, T C Northfield, and the steering committee andmembers of the National Audit of Acute Upper Gastrointestinal Haemorrhage

AbstractThe aim of this study was to establish therelative importance of risk factors formortality after acute upper gastrointesti-nal haemorrhage, and to formulate asimple numerical scoring system that cat-egorises patients by risk. A prospective,unselected, multicentre, population basedstudy was undertaken using standardisedquestionnaires in two phases one yearapart. A total of 4185 cases of acute uppergastrointestinal haemorrhage over the ageof 16 identified over a four month periodin 1993 and 1625 cases identified sub-sequently over a three month period in1994 were included in the study. It wasfound that age, shock, comorbidity, diag-nosis, major stigmata of recent haemor-rhage, and rebleeding are all independentpredictors of mortality when assessedusing multiple logistic regression. Anumerical score using these parametershas been developed that closely followsthe predictions generated by logisticalregression equations. Haemoglobin, sex,presentation (other than shock), and drugtherapy (non-steroidal anti-inflamma-tory drugs and anticoagulants) are notrepresented in the final model. Whentested for general applicability in a secondpopulation, the scoring system was foundto reproducibly predict mortality in eachrisk category. In conclusion, a simplenumerical score can be used to categorisepatients presenting with acute uppergastrointestinal haemorrhage by risk ofdeath. This score can be used to determinecase mix when comparing outcomes inaudit and research and to calculate riskstandardised mortality. In addition, thisrisk score can identify 15% ofall cases withacute upper gastrointestinal haemorrhageat the time of presentation and 26% ofcases after endoscopy who are at low riskof rebleeding and negligible risk of deathand who might therefore be consideredfor early discharge or outpatient treat-ment with consequent resource savings.(Gut 1996; 38: 316-321)

Keywords: gastrointestinal haemorrhage, riskassessment.

Correspondence to:Mr T Rockall, The SurgicalEpidemiology and AuditUnit, The Royal College ofSurgeons of England, 35-43Lincoln's Inn Fields, LondonWC2A 3PN.

Accepted for publication7 September 1995

Acute upper gastrointestinal haemorrhage is acommon medical emergency with an incidencein England of approximately 100 per 100 000adults per year and a mortality amongunselected cases in the region of 14%. 1 The

important factors influencing the outcome ofacute upper gastrointestinal haemorrhage havebeen the focus of much research and debatesince the 1940s but, although the risk factorsassociated with both rebleeding and death arewell known, different researchers have put adifferent emphasis on each of these accordingto their experiences.2-16 Age, comorbidity,shock, diagnosis, admission haemoglobinvalues, presentation, ulcer size, stigmata ofrecent haemorrhage, and blood transfusionrequirements have all been described as signifi-cant risk factors for further haemorrhage anddeath. Further haemorrhage has been con-sistently described as the most important riskfactor for mortality. It is generally acceptedthat the risk of rebleeding and death is relatedto many factors, which are not entirelyindependent of each other.

While previous studies have served to indi-cate which variables are important in deter-mining the risk of rebleeding and death, fewattempts have been made to devise a simpleand therefore clinically useful risk scoringsystem that makes use of readily availableclinical information to categorise patients byrisk. We have used a large uniform database toanalyse the risk factors for mortality and wehave used the analysis to construct a simplenumerical risk scoring system. The primarypurpose of this score is to allow case mixassessment for comparative audit. An under-standing of the risk associated with any partic-ular patient is an important initial step in themanagement process. Most cases of acuteupper gastrointestinal haemorrhage are treatedby junior staff in the setting of busy casualtydepartments and a simple scoring system maybe a useful aid to the clinical judgement of risk,especially as there is evidence of considerabledisagreement as to what the important prog-nostic factors are, even within the BritishSociety of Gastroenterology.17 The develop-ment of treatment protocols and the selectionof patients for clinical trials are other areaswhere a risk index might be of benefit.

MethodsThe data presented were collected as part of anational audit of the management and out-come of acute upper gastrointestinal haemor-rhage. Four health regions in England (NorthWest Thames, South West Thames, Trent,and the West Midlands) were recruited tothis prospective study, undertaken under theauspices of the British Society of Gastro-enterology, the Royal College of Surgeons ofEngland, the Royal College of Physicians of

316

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

Risk assessment after acute upper gastrointestinal haemorrhage

TABLE I Factors analysed in relation to rebleeding and mortality with odds ratios and 95% confidence intervals

Rebleed Dead

Variable Type of data Categorisation Cases No % No % Odds 95% CI

All cases 4185 643/4119 15-6 585/4142 14-1

Age

Sex(4 missing)

Shock(74 missing)

Haemoglobin

NSAID

Anticoagulants

SRH(all cases)

Further haemorrhage(62 missing)

SRH(peptic ulcergroup only)n=1300

Diagnosis

Comorbidity

Continuous <6060-79>=80

Categorical MaleFemale

Ordinal No shockTachycardiaBP< 100BP<70BP<50

Continuous Hb>=10Hb<10

Categorical NoYes

Categorical NoYes

Categorical Nonen=3047 Present

Categorical NoYes

Categorical NoneBlood in UGITAdherent clotVisible vesselSpurting vesselDark spot

Categorical None madePeptic ulcerMalignancyVaricesMallory-WeissErosive diseaseOesophagitisOther

Categorical NoneCardiac failureIschaemic heart diseaseAsthmaCOADDiabetes mellitusRheumatoid arthritisLiver failureRenal failureDisseminated malignancyOtherPneumoniaDementiaRecent major operationMalignancyCVA/TIAHaematological malignancyHypertensionTrauma/burnsOther cardiac diseaseMajor sepsisOther liver disease

SRH=stigmata of recent haemorrhage, UGIT=upper gastrointestinal tract, COAD=chronic obstructive airway disease, CVAITIA=cerebrovascular accident/transient ischaemic attack.

London, and the Association of Surgeons ofGreat Britain and Ireland. Seventy four'acute' hospitals participated in the initialaudit.A lead consultant at each site (usually a

member of the British Society of Gastro-enterology) represented the project locally. Theidentification of subjects and administration ofthe questionnaire was undertaken by an auditcoordinator at each hospital. Patients wereidentified daily in the accident and emergencydepartmnent, the wards, the endoscopy unit, theoperating theatre, and from blood transfusionrecords and admission data. The questionnairewas generally completed by medical staff andthe audit coordinator was then responsible forchecking and returning a completed question-naire for each patient correctly identified. Thedata collected incorporated patient detailsincluding known risk factors, treatment includ-ing the use of endoscopy, endoscopic findings,details of surgical involvement, diagnosis, com-plications, and mortality. Data were entered

into a computer database using a validatedoptical scanning device.18 19The risk scoring system was validated using

data collected during the second phase of thenational audit in 1994, which used an identi-cal methodology at 45 'acute' hospitals fromthree health regions over a period of threemonths.

Statistical methodsMultiple logistic regression analysis20 was

undertaken using SPSS computer software.21Continuous variables were categorised to avoidmultiplicative errors and variables with more

than two categories were recorded using an

appropriate indicator variable coding scheme.Variables were entered into the initial models ifthe crude odds ratios were significantly differ-ent from 1. The models were developed usinga forward stepwise selection procedure. Avariable was included at each step if the score

statistics was less than 005 and was removed if

(66 missing)151/1290291/1741201/1088379/2366263/1749330164943015

299314423/2820220/1299595/384148/278178298

66/674103/31679/23822/979/3417/115

1252674767836375618484107184843326129538312222427322818420614

2376176228976873476034

25541362

3864278197610783387730

10141450155180214447429253165337865913628027716817812317246388176120119253109179621414269

11-716-718-516-015-011-423-927-150.044011-723-315-016-915-517-390

27-8

9-832-633-222-726-514-812-518-529-737.03.78-18-6

22-811-222-616-513-317-615-919-035.524-430.018-014-112-520-523-713-125-710-26-914-514-623-3

(43 missing)74/1294255/1754256/1094313/2376272/1762288134952827

275/2554258/1362417/2834168/1308536/386449/27810319329327225/67468/32139/24012/976/3511/117

20017058416

293546731291251967623368568978302827335430191720135

5.714-523-413-215-49.919-327-145.971-110-818-914-712-813-917-65-217-98-7

37.33.7

21-216-312-317-19.419-711-737.422-82-86-58-218-24.4

34-119-014-023-922-419-638-245.551-716-834-115-922-527-721.327-510-627-414-231-07-2

Reference2-805.04

Reference1-20

Reference2-173.377.70

22-3Reference1-94

Reference0-85

Reference1-33

Reference3.97

Reference6-24

Reference6-985.043-665.372-691-750.733.931-850-170.390-511-38

Reference7.734.303-165-425.074.458-6510-311-73-817-723-605.096-284-836-232-406-213-217-011-64

2-14to 3-673-83 to 6-62

1-01 to 1-43

1-73 to 2-71258 to 4394-59 to 12-910-9 to 45-4

1-61 to 2-33

0-71 to 1-04

0-96 to 1-83

3-08 to 5- 10

5-15 to 7-56

4-31 to 11-32-98 to 8-531-78 to 7-562-05 to 14-11-29 to 5-641-45 to 2-11060 to 0882-80 to 5.50129 to 266007 to 0380-27 to 0-580-36 to 0 730.99 to 1-93

5-68 to 10-53-17 to 5-811-85 to 5.403-80 to 7-733-53 to 7-282-86 to 6-916-01 to 12-56-96 to 15-38-28 to 16-62-73 to 5-334-80 to 12-42-27 to 5-72316 to 8224.0 to 9-86330 to 7043-91 to 9-941-42 to 4.073-46 to 11-21-9 to 5-423-61 to 13-6064 to 419

317

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

Rockall, Logan, Devlin, Northfield

TABLE II Significant predictor variables for mortality

Initial model Complete model

Variable b SE Significance Exp(B) b SE Significance Exp(B)

Age<60 Reference <0-0001 <0-000160-79 0-92 0-17 <0-0001 2-5 0-85 0-22 0-0001 2-3480+ 1-53 0-18 <0-0001 4-6 1-49 0-24 <0-0001 4-43

Shock - none Reference <0-0001 0-0363Tachycardia (p>= 100) 0-76 0-13 <0-0001 2-15 0-34 0-18 0.0570 1-40BP<100 0-89 0-16 <0-0001 2-43 0.50 0-21 0-0199 1-65BP<70 1-75 0.30 <0.0001 5-60 0 77 0.39 0-0517 2-15BP<50 2-75 0.43 <0-0001 15-69 0-83 0-61 0-1759 2-28

ComorbidityNone -1-04 0-16 <0-0001 0.35 -1-06 0-20 <0.0001 0.35Cardiac failure 0-72 0-15 <0-0001 2-06 0 59 0-21 0-0051 1-81Renal failure 1-55 0-21 <0-0001 4-72 1-68 0-29 <0-0001 5.40Liver failure 1-04 0-22 <0.0001 2-84 NSDisseminated malignancy 1-83 0-19 <0-0001 6-22 1-43 0-28 <0-0001 4-18Pneumonia 0-92 0-29 0-0017 2-50 NSMalignancy 0.59 0-28 0.0370 1-80 NSHaematological malignancy 0-76 0-28 0-0061 2-13 0 77 0.35 0-0292 2-15

DiagnosisNo lesion identified, no SRH Reference 0.0005No lesion identified, SRH present -0-16 0-38 0-6710 0-85Peptic ulcer -0-16 0-14 0-2549 0-85Malignancy 1-14 0-25 <0-0001 3-14Varices -0.40 0-28 0-1419 0-67Mallory-Weiss -0.33 0.47 0-4792 0-71Erosive disease -0-24 0-25 0-3225 0-78Oesophagitis 0-29 0-21 0-1685 1-34Other -0 09 0-28 0-7589 0-91

Major SRH 1-05 0-17 <0-0001 2-87Rebleeding 1-71 0-15 <0-0001 5-57Constant (B0) -1-22 0-13 <0-0001 -2-98 0-24 <0.0001

B represents the variable coefficient in the logistic regression equation and Bo represents a constant. SE is the standard error ofthe coefficient B. Significance is the statistical significance for the hypothesis that the coefficient is different from zero. Exp(B)represents the factor change in the odds that death will occur. For the categorised variables the value should only be interpreted

within each variable. The prediction of mortality is calculated using the equation P=' + e (Bo+BX+B2X2+B3X3+.BpX where p isthe probability of death and X represents the variable, where X=0 if absent and 1 if present. SRH=stigmata of recenthaemorrhage, NS=not significant.

the log likelihood ratio test statistic was greaterthan 01. Confidence interval analysis wasundertaken using CIA software.22

*Mortality data were missingin a total of 43 cases and insix cases in the groupsustaining furtherhaemorrhage.

ResultsUtilisation of all the principal risk factors thatdetermine outcome necessitates the develop-ment of two related models. Important predic-tive variables such as diagnosis and the presenceof stigmata of recent haemorrhage are usuallyonly available once endoscopy has been per-formed. An initial predictive model has beendeveloped based upon the information derivedfrom the history, examination, and simple bloodtests. A second more complete model includes,in addition, risk factors derived from endo-scopic information and further haemorrhage.

Data were drawn from 4185 cases present-ing with an acute upper gastrointestinal haem-orrhage. Overall mortality was 14% (585 of4142*). Further haemorrhage (continuedbleeding necessitating operation or rebleeding)occurred in 18% (736) and was associated with

a 37% (272 of 730*) mortality. The initialmodel was based upon 3981 cases for whom allinvestigated variables were recorded. Thesecond complete model was based upon 2956cases that had, in addition, undergone diag-nostic endoscopy or emergency surgery.

Table I lists the factors considered in thisstudy with crude odds ratios and 95% confi-dence intervals. Continuous variables havebeen categorised.

Age, sex, comorbidity, shock, and haemo-globin had a crude odds ratio significantly dif-ferent form 1 and were entered into a logisticregression analysis with death as the dependantvariable. After forward stepwise analysis, 'sex'and 'haemoglobin < 10 g/dl' were excludedfrom the model.

Diagnosis, stigmata of recent haemorrhage,and rebleeding were then entered into a secondanalysis together with the significant variablesfrom the first analysis.

Table II gives the B coefficients for bothmodels with the standard error and signifi-cance. Age, shock, comorbidity, diagnosis,

TABILE III Numerical risk scoring system

Score

Variable 0 1 2 3

Age <60 Years 60-79 Years >=80 YearsShock 'No shock', systolic BP > = 100, 'Tachycardia', systolic BP >= 100, 'Hypotension', systolic BP < 100

pulse <100 pulse >=100Comorbidity No major comorbidity Cardiac failure, ischaemic heart disease, Renal failure, liver failure,

any major comorbidity disseminated malignancyDiagnosis Mallory-Weiss tear, no lesion All other diagnoses Malignancy of upper GI tract

identified and no SRHMajor SRH None or dark spot only Blood in upper GI tract, adherent clot,

visible or spurting vessel

Maximum additive score prior to diagnosis=7. Maximum additive score following diagnosis= 1 1.

318

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

Risk assessment after acute upper gastrointestinal haemorrhage

stigmata of recent haemorrhage, and rebleed-ing are all independently significant factorsin the prediction of mortality in thesemodels.A simple risk score has been devised using

only these significant variables. An integerscore was attributed to each category of each

TABLE IV(A) Observed mortality by initial risk score

Score 0 1 2 3 4 5 6 7

No 595 505 641 890 859 326 141 24% 14-9 12-7 16-1 22-4 21-6 8-2 3-5 0-6

Deaths No 1 12 36 98 211 129 69 12% 0-2 2-4 5-6 11.0 24-6 39-6 48-9 50.0

TABLE IV(B) Observed rebleeding and mortality by complete risk score

Score 0 1 2 3 4 5 6 7 8+

No 144 281 337 444 528 453 312 267 190% 4.9 9 5 11-4 15.0 17-9 15-3 10-6 9.0 6-4

Rebleed No 7 9 18 50 76 83 102 113 101% 4.9 3.4 5-3 11-2 14-1 24-1 32-9 43-8 41-8

Deaths No 0 0 1 8 16 30 20 23 25(no rebleed) % 0 0 0.3 2-0 3-5 8-1 9-5 14-9 28-1

Deaths No 0 0 0 5 12 19 34 49 53(rebleed) % 0 0 0 10-0 15-8 22-9 33-3 43-4 52-5

Deaths No 0 0 1 13 28 49 54 72 78(total) % 0 0 0-2 2-9 5-3 10-8 17-3 27-0 41-1

6053

No rsleed60 - W|Rebled |650 ~~~~~~~~~~~~~~43

~40

~~~~30 ~~~~~~~~23*20-

10 ~~~ ~~~~1082

0 1 2 3 4 5 6 7 8Risk score

Figure 1: Mortality by risk score.

variable according to its relative contributionin the logistic regression model (as determinedby its regression coefficient). The score wasthen adapted so that the outcome in eachcategory most closely fitted the predictions ofthe logistic regression model.Age and degree of shock were categorised

and each attributed a score of 0, 1, or 2.Comorbidity was categorised and attributed ascore of 0, 2, or 3. This gives a maximumadditive score of 7 before diagnosis.A score of 0, 1, or 2 for diagnosis and 0 or 2

for stigmata of recent haemorrhage was thenadded to give a maximum score of 11. Scoresof 8 or more are considered as one category asthere are very few cases in these very high riskcategories. Table III shows the derived scoringsystem.The population experiencing further haem-

orrhage is considered separately from the pop-ulation without further haemorrhage in thecomplete model.

Table IV shows the observed mortality andrebleeding rate in each category for bothmodels. Figure 1 shows these data for the com-plete model. Mortality increases in a stepwisefashion as the risk score increases. The rate ofrebleeding also increases as the risk scoreincreases. There were no deaths in categories 0and 1 of the full model and only one death(0°3%) in category 2. Twenty six per cent ofthe sample were in these lowest three cate-gories. The population that rebled experienceda fivefold increase in mortality in risk group 3,which decreased to a twofold increase for riskgroup 8.

ValidationFigure 2 shows the degree of associationbetween the predictions of the full logisticalregression model and the observed mortalityin each category of the risk score. The boxplots represent the distribution of predicted

Risk a~eFigure 2: Boxplot ofcomputer predicted mortality by risk score.

319

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

Rockall, Logan, Devlin, Northfield

TABLE V(A) Predicted and observed mortality by risk score for initial model

Mortality

Audit 1 (predicted) Audit 2 (observed)

Score No % No % Difference with 95% CI

0 1/595 0-2 0/246 0 0 +0-2 -02 to +0.51 12/505 2-4 6/201 3.0 -0-6 -3.3 to +2-12 36/641 5-6 14/249 6-1 0.0 -39 to +2-93 98/890 11 0 38/311 12-1 -1-2 -5.4to +3.04 211/859 24-6 77/364 21-0 +3-4 -1-8to +8-55 129/326 39-6 47/134 35-1 +4-5 -5-2 to + 14-26 72/141 51-1 42/68 61-8 -10-7 -24-9 to +3-57 12/24 50.0 6/8 75 0 -25-0 -61-1 to +11-1Total 568/3981 14-3 230/1584 14-5

mortalities (using the logistic regression equa-tion) for cases within each risk score category.It can be seen that there is a high degreeof association between the predictions of thelogistic regression model and the greatlysimplified numerical score.The risk score has been validated in a second

population of 1625 cases collected using anidentical methodology as part of the secondphase of the National Audit. All the necessaryvariables were recorded in 1584 cases. In 1190cases, variables for endoscopic diagnosis andstigmata of recent haemorrhage were alsorecorded. It can be seen in Table V that thepredicted outcomes, based upon the observedoutcome by risk category in the first audit, arenot significantly different from the observedoutcome in the second audit in either the initialor complete models.

DiscussionThere is a great deal more published about therisk factors for rebleeding than for mortalityafter an acute episode ofhaemorrhage from theupper gastrointestinal tract. Studies of bothrebleeding and mortality show that the riskfactors for these two outcomes are similar, withthe additional conclusion that rebleeding isitself of independent predictive value formortality.

Univariate analyses have led us to believethat rebleeding increases mortality betweenfive and 16-fold, and perhaps as a result it is

TABLE V(B) Predicted and observed mortality by risk score for complete model

Mortality

Audit 1 (predicted) Audit 2 (observed)

Score No % No % Difference with 95% CI

Cases not rebleeding0 0/137 0 0/46 0 0 01 0/272 0 0/125 0 0 02 1/319 0.3 0/131 0 +0.3 -0.3 to+0-93 8/394 2-0 2/143 1-4 +0-6 -1-7 to +3.04 16/452 3-5 9/149 6-0 -2-5 -6-7 to +1-75 30/370 8-1 9/150 6-0 +2-1 -2-6 to +6-86 20/210 9.5 9/100 9.0 +0.5 -6-4 to +7-47 23/154 14-9 12/67 17-9 -3.0 -13-7 to +7-88+ 25/89 28-1 18/56 32-1 -4.0 -19-4to +11-3Cases rebleeding0 0/7 0 0/2 0 0 01 0/9 0 0/6 0 0 02 0/18 0 0/11 0 0 03 5/50 10 0 1/19 5-3 +4-7 -8-3 to +17-84 12/76 15-8 5/27 18-5 -2-7 -19-5 to +14-15 19/83 22-9 12/49 24-5 -1-6 -16-7 to +13-56 34/102 33-3 7/37 18-9 +14-4 -1-17 to +30.07 49/113 43-4 12/39 30-8 +12-6 -45 to +29-78+ 53/101 52-5 18/33 54-5 +2-07 -21-7 to +17-5

often regarded as the harbinger of death.Indeed the thrust of modem treatment isspecifically targeted at preventing rebleedingby physical means in those lesions amenable toendoscopic haemostatic therapy in the beliefthat a reduction in mortality should follow.Although several clinical trials have shown asignificant reduction in rebleeding with thesemethods, however, the reduction in mortalityhas been much more elusive and only two trialsusing lasers have shown a significant reductionin mortality.23 Meta-analysis has suggested a30% improvement in mortality in the pepticulcer group with visible vessels.24 Althoughrebleeding is a very important sign to detectand act upon, either endoscopically orsurgically, there are many other factors thatdetermine the final outcome.Our scoring system has been developed with

a view to simplicity and ease of variableacquisition. We have shown how it can be usedto broadly categorise patients by risk and thereare several important conclusions for themodel: firstly, that the risk of rebleeding as wellas the risk of death increases as the risk scoreincreases; secondly, that patients who rebleedhave an increased mortality compared withthose who do not rebleed; thirdly, that the pro-portional increased risk of death after a rebleedis not the same in each category.

For cases scoring 0, 1, or 2 rebleedingoccurs in less than 5%/o of patients and mortal-ity is virtually zero whether rebleeding occursor not (Table IV). The scoring system can beused to identify the one quarter of patients thatare at negligible risk of dying but this can onlybe done once a diagnosis and an assessment ofstigmata of recent haemorrhage have beenmade. Rebleeding has its most profound influ-ence on mortality in the middle risk groupsthat score 3 or 4, when it is associated with anapproximately fivefold increase in mortality. Inrisk groups 5 to 7 rebleeding is associated withan approximately threefold increase in mortal-ity and for risk group 8, a twofold increase.The impact of rebleeding on outcome shouldnot be judged independently of other riskfactors.As well as the failure to investigate suffi-

ciently large numbers of cases, the relation ofrebleeding to other risk factors and the fact thatonly 50/O of patients that die have rebled andonly 40°/O of those that rebleed die, may explainwhy trials of therapy that reduce rebleedinghave failed to show a reduction in mortality.

This risk scoring system has been developedprimarily to determine case mix and to calcu-late risk standardised mortality for thehospitals taking part in the national audit ofacute upper gastrointestinal haemorrhage.25Systems such as this are likely to become moreimportant as the discipline of comparativeaudit expands and the threat of league tableslooms. As an adjunct to clinical judgement, itmight also be useful in the clinical setting as anindex of prognosis both before and after adefinitive endoscopic diagnosis.

It might also be used in the development oftreatment protocols. The full array of manage-ment tools for optimal care of patients with

320

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

Risk assessment after acute upper gastrointestinal haemorrhage 321

upper gastrointestinal haemorrhage is expen-sive. Rapid endoscopy by experienced endo-scopists on call 24 hours per day, highdependency units, medicosurgical collabora-tion, and on call endoscopy staff all have con-siderable financial implications. Being able toselect patients that will benefit the most fromintensive treatment is one important step in therationalisation of resources. Early discharge oreven outpatient treatment of very low riskgroups or the transfer to intensive care facilitiesof very high risk cases for whom a determinedeffort to save life is being made, might easily beincorporated into a treatment protocol, how-ever, the use of such a system in selectingpatients for surgery could only be promotedafter evidence from clinical trials.

It is important to understand that thissystem, like most predictive methods cannotpredict the outcome of any individual patient,except perhaps those in categories 0 and 1 inwhom no deaths occurred. The risk of death issimply a measurement of the number of deathsthat might be expected in a large population ofcases with those risk factors. The testing of themodel in a second large population has,however, allowed us to confirm the generalapplicability of the model based upon currentstandards of treatment.This project was undertaken under the auspices of the RoyalCollege of Physicians ofLondon, the Royal College of Surgeonsof England, the British Society of Gastroenterology, and theAssociation of Surgeons of Great Britain and Ireland. Wegratefully acknowledge the financial support of LederlePharmaceuticals and the support of South West Thames, NorthWest Thames, and Trent regional health authorities and theWest Midlands Gastroenterology services committee. We alsoacknowledge the great deal of work performed by medical andaudit staff in each of the participating units.Members of the steering group: Professor T C Northfield

(Chairman), St George's Hospital Medical School, London;Mr H B Devlin (Director), Surgical Epidemiology and AuditUnit, RCS, London; Dr R F A Logan, Queen's MedicalCentre, Nottingham; Dr J Levi, Northwick Park Hospital,London; Dr K Bardhan, Rotherham District General Hospital,Rotherham; Dr A Hamlyn, Wordsley Hospital, Wordsley; MrG Gillespie, Victoria Infirmary, Glasgow; Mr R McCloy,Manchester Royal Infirmary, Manchester; Mr D Watkin,Leicester Royal Infirmary, Leicester; Mr M Crisp, LederlePharmaceuticals. Also Mr R Leicester (chairman) and Mrs CRomaya (administrator) of the British Society of Gastro-enterology audit committee.

1 Rockall TA, Logan RFA, Devlin HB, Northfield TC.Incidence of and mortality from acute upper gastrointesti-nal haemorrhage in the UK. BMJ 1995; 311: 222-6.

2 Swain CP, Kirham JS, Salmon PR, Bown SG, NorthfieldTC. Controlled trial of Nd-YAG laser photocoagulationin bleeding peptic ulcers. Lancet 1986; i: 1113.

3 Storey DW, Bown SG, Swain CP, Salmon PR, Kirkham JS,Northfield TC. Endoscopic prediction of recurrent bleed-ing in peptic ulcers. N Engl JtMed 1981; 305: 915.

4 Northfield TC. Factors predisposing to recurrent haemor-rhage after acute gastrointestinal bleeding. BMJ3 1971; 1:26.

5 Katschinski BD, Logan RFA, Davies J, Langman MJS.Audit of mortality in upper gastrointestinal bleeding.Postgrad Med J7 1989; 65: 913.

6 Katschinski B, Logan R, Davies J, Faulkner G, Pearson J,Langman M. Prognostic factors in upper gastrointestinalbleeding. Dig Dis Sci 1994; 39: 706.

7 Jones PF, Johnston SJ, McEwan AB, Kyle J, Needham CD.Further haemorrhage after admission to hospital for gas-trointestinal haemorrhage. BMJ 1973; 3: 660.

8 Hunt PS. Mortality in patients with haematemesis andmelaena: a prospective study. BMJ 1979; 1: 1238.

9 Griffiths WJ. The visible vessel as an indicator of uncon-trolled or recurrent gastrointestinal bleeding. N Engl JMed 1979; 300: 1411.

10 Kalabakas A, Xourgias B, Karamanolis D. Incidence andsignificance of stigmata of recent haemorrhage in ulcerpatients without clinical evidence of recent bleeding. Gut1990; 31: A1206.

11 Wara P, Berg V, Amdrup E. Factors influencing mortality inpatients with bleeding ulcer. A review of 7 years experi-ence preceding therapeutic endoscopy. Acta Chir Scand1983; 149: 775.

12 Macleod IA, Mills PR. Factors identifying the probability offurther haemorrhage after acute upper gastrointestinalhaemorrhage. BrJrSurg 1982; 69: 256.

13 Bornman PC, Theodorou NA, Shuttleworth RD, Essel HP,Marks IN. Importance of hypovolaemic shock and endo-scopic signs in predicting recurrent haemorrhage frompeptic ulceration: a prospective evaluation. BMJ 1985;291 (27 July): 245.

14 Branicki FJ, Coleman SY, Fok PJ, Pritchett CJ, Fan S, LaiECS, et al. Bleeding peptic ulcer: a prospective evaluationof risk factors for rebleeding and mortality. World J Surg1990; 14: 262.

15 Clason AE, Macleod DAD, Elton RA. Clinical factors inthe prediction of further haemorrhage or mortality inacute upper gastrointestinal haemorrhage. BrJ Surg 1986;73:985.

16 Morgan AG, Clamp SE. OMGE International UpperGastrointestinal Bleeding Survey 1978-1982. Scand 7Gastroenterol Suppl 1984; 19 (suppl 95): 41.

17 Thomas GE, Cotton PB, Clark CG, Boulos PB. Survey ofmanagement in acute upper gastrointestinal haemorrhage.J7 Roy Soc Med 1980; 73: 90.

18 Emberton M, Meredith P. Caught in the act. British J7ournalof Healthcare Computing and Information Management1993; 10: 32.

19 Emberton M, Rockall TA, Meredith P. Scanning for Audit.British J7ournal of Healthcare Computing and InformationManagement 1994; 11: 23.

20 Hall GH, Round AP. Logistic regression - explanation anduse. J7R Coil Physicians Lond 1994; 28 (3): 242.

21 SPSS. Advanced statistics. 6.0.1 ed. Chicago: SPSS Inc, 1993.22 Gardner MJ, Altman DG. Statistics with confidence - confi-

dence intervals and statistical guidelines. London: BMJPublishing Group, 1989.

23 Steele RJC. Endoscopic haemostasis for non-variceal uppergastrointestinal haemorrhage. BrJ Surg 1989; 76: 219-25.

24 Sacks HS, Chalmers TC, Blum AL, Berrier J, Pagano D.Endoscopic haemostasis. An effective therapy for bleedingpeptic ulcers. JAMA 1990; 264: 494-9.

25 Variation in outcome after acute upper gastrointestinalhaemorrhage. Lancet 1995; 346: 346-50.

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from

doi: 10.1136/gut.38.3.316 1996 38: 316-321Gut

 T A Rockall, R F Logan, H B Devlin, et al. gastrointestinal haemorrhage.Risk assessment after acute upper

http://gut.bmj.com/content/38/3/316Updated information and services can be found at:

These include:

References http://gut.bmj.com/content/38/3/316#related-urls

Article cited in:

serviceEmail alerting

box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in the

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

group.bmj.com on August 7, 2011 - Published by gut.bmj.comDownloaded from