Alexandrino, G

Carvalho, R

Reis, J

Gut and Liver

English

Unidade Local de Saúde Amadora / Sintra

Letter to  the editorGut and Liver, Vol. 12, No. 1, January 2018, pp. 111-113To the Editor:The authors read with interest the article about the perfor-mance of three risk stratifying scores in patients with upper gastrointestinal bleeding (UGIB) applied in a Korean population, by Choe et al.,1 recently published in Gut and Liver.UGIB is one of the most common emergencies for gastro-enterologists, and, as previously discussed in the mentioned article, early risk stratification is important to determine priori-ties and define which patients benefit from early endoscopy and more aggressive clinical intervention. Although there are risk scores to predict clinical outcomes in UGIB, the most used be-ing the Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65), uncertainty still exists about the op-timal score that could be uniformly applied in clinical practice. In addition, because most studies about risk scoring excluded patients with variceal bleeding, few data are available on the use of this scores in patients with variceal bleeding.We recently conducted a retrospective single-center study which compared the performance of three scoring systems (GBS, RS, and AIMS65) in Portuguese patients. The consecutive pa-tients admitted to our institution’s emergency department with UGIB over a period of 12 months (between January 2016 and December 2016) were included. Both patients with variceal and nonvariceal bleeding were included. Two major endpoints were considered: (1) composite endpoint–need for any clinical inter-vention (transfusion, endoscopic therapy, surgery or radiologi-cal intervention) and (2) UGIB related mortality at 30 days after admission. The accuracy of each scoring system for the consid-ered endpoints was calculated using the area under the receiver operating characteristic curve (AUROC), with 95% confidence interval. Statistical analysis was performed on MedCalc® statis-tical software (Medcalc Software, Mariakerke, Belgium).A total of 202 patients were included, the majority (75%)  This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.Comparison of the AIMS65 Score with Other Risk Stratification Scores in Upper Variceal and Nonvariceal Gastrointestinal BleedingGonçalo Alexandrino, Rita Carvalho, and Jorge ReisGastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, PortugalTable 1. Characteristics and Clinical Outcomes of the Study Popula-tion (n=202)Variable ValueAge, yr 67 (31–94)Male sex 151 (75)Comorbidities    Heart failure 38 (19)    Chronic liver disease 55 (27)    Chronic kidney disease 20 (10)    Metastatic malignancy 24 (12)Endoscopic findings    None 12 (6)    Erosive disease*  32 (16)    Gastric or duodenal ulcer  75 (37)    Variceal bleeding  49 (24)    Malignancy of the upper GI tract 14 (7)    Dieulafoy 6 (3)    Mallory-Weiss tear 6 (3)    Gastric/duodenal angiodysplasia 8 (4)Mean time of hospital stay, day  8.9 (0–32)Treatments    Blood transfusion  93 (46)    Endoscopic treatment 101 (50)    Surgery 12 (6)Outcome    30-Day mortality 14 (7)Mean score    Glasgow-Blatchford 10.1 (0–20)    AIMS65 1.5 (0–4)    Rockall  5.8 (0–11)Data are presented as mean (range) or number (%).GI, gastrointestinal.*Esophagitis, gastritis, and duodenitis.Correspondence to: Gonçalo AlexandrinoGastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, IC 19, Amadora 2720-276, PortugalTel: +351-966199616, Fax: +351-214345566, E-mail: goncaloalexandrino@gmail.comReceived on August 18, 2017. Accepted on September 19, 2017.pISSN 1976-2283  eISSN 2005-1212  https://doi.org/10.5009/gnl17380112  Gut and Liver, Vol. 12, No. 1, January 2018being male, with a mean age of 67 years. The mean time from admission to endoscopy was 15.8 hours. The main endoscopic findings were peptic ulcer disease (37%), variceal bleeding (24%) and erosive disease (16%). Six percent of patients had normal endoscopy. The overall rate of 30-day mortality directly related to the UGIB was 7%. The characteristics and the outcomes of the series of patients are described in Table 1. For the composite endpoint (need for clinical intervention), the AUROCs of GBS, RS, and AIMS65 were, respectively, 0.833, 0.781 and 0.636 in nonvariceal bleeding versus 0.630, 0.543 and 0.620 in variceal bleeding (Figs 1 and 2). For 30-day mortality, the AUROCs of RS, AIMS65 and GBS were, respectively, 0.864, 0.822 and 0.807 in nonvariceal bleeding and 0.783, 0.826 and 0.793 in variceal bleeding (Figs 3 and 4). GBS was the only effective score to predict the need for clini-cal intervention, but in our population that was only true for patients with nonvariceal bleeding. Regarding mortality, the three scores showed a reasonable performance for both variceal and nonvariceal bleeding, but AIMS65 outperformed GBS. As in the Korean study, GBS seems superior in its ability to predict need for clinical intervention in the nonvariceal bleeding group. Although we had a similar percentage of patients with variceal bleeding as the Korean study, we could not conclude the same in that specific group of patients. GBS seems the best score to predict need for clinical intervention in patients with nonvariceal bleeding, but we would not recommend its use in the variceal group in the Portuguese population. As in the Korean population, AIMS65 does not seem good to predict clinical intervention in patients admitted with UGIB in the Portuguese population. However, it outperformed GBS and seems a good score to predict mortality both in the nonvariceal and variceal bleeding patients. In fact, AIMS65 was designed to Fig. 1. Area under the receiver operating characteristic curve (AUROC) of Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65) in predicting need for clinical intervention in non-variceal upper gastrointestinal bleeding.020 40 60 80 100Sensitivity80604020100-Specificity0100GBSRSAIMS65Fig. 2. Area under the receiver operating characteristic curve (AUROC) of Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65) in predicting need for clinical intervention in variceal upper gastrointestinal bleeding.020 40 60 80 100Sensitivity80604020100-Specificity0100GBSRSAIMS65Fig. 3. Area under the receiver operating characteristic curve (AUROC) of Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65) in predicting 30-day mortality in nonvariceal upper gastrointestinal bleeding.020 40 60 80 100Sensitivity80604020100-Specificity0100GBSRSAIMS65Fig. 4. Area under the receiver operating characteristic curve (AUROC) of Glasgow-Blatchford score (GBS), Rockall score (RS), and AIMS65 score (AIMS65) in predicting 30-day mortality in variceal upper gas-trointestinal bleeding.020 40 60 80 100Sensitivity80604020100-Specificity0100GBSRSAIMS65Alexandrino G, et al: Risk Scoring Systems in Upper Gastrointestinal Bleeding  113determine predictors of mortality.2 We should keep in mind that each score was developed to determine a specific, and some-times different, outcome. Regarding RS, contrary to GBS and AIMS65, it requires endoscopic features, so it is not useful to stratify patients at admission.3In conclusion, in the Portuguese population, GBS seems the best score that predicts need for clinical intervention, but only in patients with nonvariceal UGIB. Although the AIMS65 score is not optimal at predicting clinical intervention, it seems a good at predicting mortality, both in the nonvariceal and variceal UGIB Portuguese population. Although these scores systems are helpful to stratify UGIB patients, its application to different pop-ulations should be used with caution, since the causes of UGIB differ considerably among countries.1 An ideal scoring system that is uniformly and universally appropriate in clinical practice is yet to be defined. CONFLICTS OF INTERESTNo potential conflict of interest relevant to this article was reported.REFERENCES1. Choe JW, Kim SY, Hyun JJ, et al. Is the AIMS 65 score useful in prepdicting clinical outcomes in Korean patients with vari-ceal and nonvariceal upper gastrointestinal bleeding? Gut Liver 2017;11:813-820.2. Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74:1215-1224.3. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-321.

Comparison of the AIMS65 Score with Other Risk Stratification Scores in Upper Variceal and Nonvariceal Gastrointestinal Bleeding.

Gonçalo Alexandrino

Rita Carvalho

Jorge Reis

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Comparison of the AIMS65 Score with Other Risk Stratification Scores in Upper Variceal and Nonvariceal Gastrointestinal Bleeding

Background/AimsTo determine the prognostic value of carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 in gallbladder cancer (GBC) during palliative chemotherapy.Methods : One hundred and twenty-three patients with pathologically confirmed unresectable GBC were included. Differences in serum CEA and CA 19-9 levels before and after chemotherapy were measured. Receiver operating characteristic curve analysis, Kaplan-Meier analyses of CEA, CA 19-9, and combined changes were performed to assess the optimal cutoff values and survival rates.Results : Patients with decreased tumor markers had significantly better progression-free survival (PFS) and overall survival (OS) than patients with increased tumor markers. The pre- and postchemotherapy CA 19-9 ratio had the highest area-under-the-curve values for predicting 3-month PFS and 1-year OS. In the multivariate analysis, increases in serum CA 19-9 during palliative chemotherapy in patients with unresectable GBC was an independent prognosticator of poor PFS and OS, with hazard ratios of 2.20 (p=0.001) and 1.67 (p=0.020), respectively. Patients with increases >10-fold were considered to have progressive disease, whereas individuals with increases >3-fold were likely to benefit from early imaging follow-up.Conclusion : sCA 19-9 kinetics was a reliable prognosticator of PFS and OS in patients with unresectable GBC who underwent palliative chemotherapy

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Comparison of the AIMS65 Score with Other Risk Stratification Scores in Upper Variceal and Nonvariceal Gastrointestinal Bleeding.

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Unidade Local de Saúde Amadora / Sintra

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