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    Rockall Score for Upper GI Bleeding (Pre-Endoscopy)

    Determines severity of GI bleeding, prior to endoscopy.
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    INSTRUCTIONS

    Use this score for upper GI bleed patients who have NOT yet had endoscopy. Use the Complete Rockall Score for patients who have had endoscopy.
    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with clinical upper GI bleeding, prior to endoscopy.

    • The pre-endoscopy Rockall Score estimates mortality in patients with active upper GI bleed who have not had endoscopy.
    • It is supported by multiple validation studies, most showing moderate prediction of death at higher risk.
    • It can predict very low risk patients, but with less accuracy.
    • The pre-endoscopy score is calculated based on clinical bleeding (i.e., without endoscopy results).
    • Upper GI bleeding may present in different degrees of severity, from minor bleeding that can be managed outpatient to severe, life-threatening hemorrhage.
    • The pre-endoscopy Rockall Score can help stratify which patients need endoscopy and intensive care. It is less accurate at identifying low-risk patients (e.g. those who may be treated as outpatients).

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    • The Rockall Score predicts mortality better than does chance alone, but overall should be interpreted with caution—a score of ‘0’ in some studies suggested very low mortality, but in others was not a consistent indicator.
    • Other scores such as the Glasgow-Blatchford Score may perform better, particularly for identifying very low risk patients. According to the American College of Gastroenterology’s management guidelines for patients with overt upper GI bleeding, neither the Rockall nor Glasgow-Blatchford scores can reliably predict which individual patients will need an intervention, except for patients with a Glasgow-Blatchford Score of 0 (< 1% chance of requiring intervention).

    Management

    • Consider diagnostic endoscopy for patients with high risk of mortality from upper GI bleeding.
    • Consider ICU level of care for patients who are hemodynamically unstable from upper GI bleeding.
    • Note: The pre-endoscopy Rockall Score has not been shown to clearly identify individual patients who require intervention.

    Critical Actions

    Patients with a high mortality or risk of rebleeding should be considered for intervention and/or monitoring.

    Formula

    Addition of selected points.

    Facts & Figures

    Score interpretation:

    Mortality rates, by pre-endoscopy score
    Score % Chance of mortality
    0 0.2%
    1 2.4%
    2 5.6%
    3 11%
    4 24.6%
    5 39.6%
    6 48.9%
    7 50%

    Adapted from Rockall et al.

    Comorbidities were defined as any of the following:

    • Cardiac failure
    • Ischaemic heart disease
    • Asthma
    • COPD
    • Diabetes mellitus
    • Rheumatoid arthritis
    • Liver failure
    • Renal failure
    • Disseminated malignancy
    • Other
    • Pneumonia
    • Dementia
    • Recent major operation
    • Malignancy
    • CVA/TIA
    • Haematological malignancy
    • Hypertension
    • Trauma/burns
    • Other cardiac disease
    • Major sepsis
    • Other liver disease

    Evidence Appraisal

    • The pre-endoscopy Rockall Score was developed from prospectively collected data on 3,981 patients presenting with acute upper GI bleeding at 74 hospitals in the United Kingdom as part of a national audit. The outcomes examined were rebleeding and death.
    • Data from an additional 2,956 patients who had undergone an intervention, either endoscopy or emergency surgery, were used to develop the complete Rockall Score.
    • The score was validated by a second set of data including 1,625 patients as a subsequent part of the national audit.
    • Vreeburg and colleagues conducted a validation study in the Netherlands looking at 951 patients at 12 hospitals presenting with upper GI bleed. They found that the Rockall Score could reliably stratify patients into low or high risk for mortality, but it was not accurate in predicting rebleeding risk (which has also been studied as an independent predictor for mortality).
    Dr. Timothy Rockall

    About the Creator

    Timothy Rockall, MD, is a consultant surgeon at the Royal Surrey County Hospital in Guildford. He specializes in gastrointestinal surgery and the management of colorectal disease. He has a particular interest in the development and practice of laparoscopic surgery and has developed an international reputation in the practice of laparoscopic resection for colorectal disease including bowel cancer. Dr. Rockall is also the creator of the Complete Rockall Score for Upper GI Bleeding.

    To view Dr. Timothy Rockall's publications, visit PubMed

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