Peptic ulcer bleeding patients with Rockall scores ≥6 are at risk of long‐term ulcer rebleeding: A 3.5‐year prospective longitudinal study

Abstract

Background and Aim: Patients with high Rockall scores have increased risk of rebleeding and mortality within 30 days after peptic ulcer bleeding, but long-term outcomes deserve follow-up after cessation of proton pump inhibitors. The paper aimed to validate whether patients with high Rockall scores have more recurrent ulcer bleeding in a 3.5-year longitudinal cohort. Methods: Between August 2011 and July 2014, 368 patients with peptic ulcer bleeding were prospectively enrolled after endoscopic hemostasis to receive proton pump inhibitors for at least 8 to 16 weeks. These subjects were categorized into either a Rockall scores ≥6 group (n = 257) or a Rockall scores <6 group (n = 111) and followed up until July of 2015 to assess recurrent ulcer bleeding. Results: The proportion of patients with rebleeding during the 3.5-year follow-up was higher in patients with Rockall scores ≥6 than in those with scores <6 (10.51 vs. 3.63 per 100 person-year, P = 0.004, log-rank test). Among patients with Rockall scores ≥6, activated partial thromboplastin time prolonged ≥1.5-fold (P = 0.045), American Society of Anesthesiologists physical status class ≥III (P = 0.02), and gastric ulcer (P = 0.04) were three additional independent factors found to increase rebleeding risk. The cumulative rebleeding rate was higher in patients with Rockall scores ≥6 with more than or equal to any two additional factors than in those with fewer than two additional factors (15.69 vs. 7.63 per 100 person-year, P = 0.012, log-rank test). Conclusions: Patients with Rockall scores ≥6 are at risk of long-term recurrent peptic ulcer bleeding. The risk can be independently increased by the presence of activated partial thromboplastin time prolonged ≥1.5-fold, American Society of Anesthesiologists class ≥III, and gastric ulcer in patients with Rockall scores ≥6.

The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6

“…All participants were consecutively assessed for eligibility and enrolled from August of 2011 to July of 2016 after signing an informed consent. This study extended our original database to prove our hypothesis and was one of the studies analyzing the short-term and long-term outcomes in bleeding peptic ulcer populations based on our database [11][12][13][14].…”

“…The criteria of the Forrest classification [2,3] and the Rockall score [7] a We modified the diagnostic criteria of comorbidities as follows to make this variable clearer to be scored than it was according to the old criteria b Cardiac failure included congestive heart failure with New York Heart Association Function I to IV c Any major comorbidity included lung disease (chronic obstructive pulmonary disease, pulmonary tuberculosis, pneumonia, or empyema), chronic kidney disease stage III (estimated glomerular filtration rates between 30 and 60 mL/min/1.73 m 2 ), rheumatoid arthritis, sepsis, newonset cerebrovascular accident, intensive care unit stay, mechanical ventilator support for > 24 h, or any major surgery (on the central nervous system, thorax, abdomen, long bones or spinal bones) within 14 days prior to bleeding d Liver failure included liver cirrhosis, Child-Pugh A, B, or C e Renal failure included chronic kidney disease stage IV (estimated glomerular filtration rates between 15 and 30 mL/min/1.73 m 2 ), stage V (estimated glomerular filtration rates < 15 mL/min/1.73 m 2 ) with or without maintenance dialysis, or acute kidney injury with estimated glomerular filtration rates < 30 mL/min/1.73 m 2 Previous studies have shown that comorbid patients have impaired tissue healing on peptic ulcers [8][9][10]. Studies have also shown that patients' Rockall scores are often ≥ 6 in those with comorbidities, who also exhibit an increased risk of recurrent peptic ulcer bleeding [11,12]. Therefore, we propose that patients with Rockall scores ≥ 6 are still at risk of recurrent bleeding after initial treatment partially because of impaired tissue healing, which results in delayed fading out of the Forrest lesions.…”

Rockall Score Larger Than 7 as a Reliable Criterion for the Selection of Indications for Preventive Transarterial Embolization in a Subgroup of High-Risk Elderly Patients After Primary Endoscopic Hemostasis for Non-Variceal Upper Gastrointestinal Bleeding

“…A 3.5-year prospective longitudinal study revealed that re-bleeding during the follow-up period was higher in patients with the Rockall score 2. Additional independent risk factors included disturbances of the clotting system and ASA physical status class [ 31 ]. The full Rockall score is better for 1-month mortality prediction while the Glasgow-Blatchford system is better for predicting other outcomes [ 27 ].…”

An extended 36-week oral esomeprazole improved long-term recurrent peptic ulcer bleeding in patients at high risk of rebleeding

“…In this study, we used Rockall scores ≥ 6 to define patients who were at high risk of rebleeding [6][7][8][9]. The parameters of the Rockall score are listed in Supplementary Table 1 and the definitions for the co-morbidities in the score were listed in previous studies in more detail [6,9].…”

“…The Rockall score contains five parameters with total scores from 0 to 11, including age, shock, comorbidity, endoscopic diagnosis, and endoscopic evidence of bleeding (Supplementary Table 1) [6,7]. Previous studies showed that patients with Rockall scores ≥6 had an increased risk of short-term and long-term recurrent ulcer bleeding [6][7][8][9].…”