Prospective Validation of the Rockall Risk Scoring System for Upper GI Hemorrhage in Subgroups of Patients With Varices and Peptic Ulcers D. S. Sanders, M.R.C.P., M. J. Carter, M.R.C.P., R. J. Goodchap, M.B.B.S., S. S. Cross, M.D., M.R.C.Path., D. C. Gleeson, M.D., F.R.C.P., and A. J. Lobo, M.D., F.R.C.P. Gastroenterology and Liver Unit and Department of Histopathology, The Royal Hallamshire Hospital, Sheffield, United Kingdom OBJECTIVES: The Rockall risk assessment score was devised to allow prediction of the risk of rebleeding and death in patients with upper GI hemorrhage. The score was derived by multivariate analysis in a cohort of patients with upper GI hemorrhage and subsequently validated in a second cohort. Only 4.4% of patients included in the initial study had esophageal varices, and analysis was not performed accord- ing to the etiology of the bleeding. Our aim was to assess the validity of the Rockall risk scoring system in predicting rebleeding and mortality in patients with esophageal varices or peptic ulcers. METHODS: Admissions (n = 358) over 32 months to a single specialist GI bleeding unit were scored prospectively. The distribution of episodes of rebleeding and mortality by Rockall score were statistically analyzed using Fisher’s ex- act test with 99% CIs calculated using a Monte Carlo method. The Child-Pugh score was determined in patients with esophageal varices. RESULTS: The Rockall score was predictive of both rebleed- ing and mortality in patients with variceal hemorrhage (both ps  0.0005), as was the Child-Pugh score (p = 0.001 and p  0.0005, respectively). The initial Rockall score was predictive of mortality in patients with peptic ulcers (p = 0.01), although the complete score was not (p  0.05). The complete score did, however, predict rebleeding in these patients (p = 0.001). CONCLUSION: This is the first study to validate the Rockall score in specific subgroups of patients with esophageal varices or peptic ulcers and suggests that it is particularly applicable to variceal hemorrhage. (Am J Gastroenterol 2002;97:630 – 635. © 2002 by Am. Coll. of Gastroenterol- ogy) INTRODUCTION Acute upper GI hemorrhage (UGIH) is a common reason for emergency hospital admission, with an incidence in the United Kingdom of between 50 and 150 per 100,000 adults per year (1–3). The mortality of UGIH has been reported to vary from 4% to 14% (3–7). Scoring systems have been derived to identify patients at greatest risk for UGIH (8 –10). Among these, the largest epidemiological study in the United Kingdom was con- ducted by Rockall et al. on behalf of the steering committee of the National Audit for UGIH (3). This was a multicenter study involving 4185 adult cases of UGIH from 74 hospi- tals. After this initial study a numerical scoring system was derived that included as independent predictors of mortality advancing age, shock, comorbidity, endoscopic diagnosis, major stigmata of recent hemorrhage,and rebleeding (Table 1) (11). Subsequently, a second cohort of 1625 patients was tested for applicability and the scoring system demonstrated a reproducible prediction of mortality (11). The original Rockall study did not analyze whether the scoring system was applicable to subgroups of patients categorized according to diagnosis. In addition, esophageal varices accounted for only 180 cases (4.4%) of UGIH, and in the second cohort the number of patients with this diag- nosis was not specified. The Child-Pugh score is a widely accepted and validated grading system used for the prognostic assessment of pa- tients with liver cirrhosis and esophageal varices (12, 13). The aim of our study was therefore to assess the validity of the Rockall score for the prediction of rebleeding and death in patients with peptic ulceration or esophageal vari- ces. In addition, we assessed the value of the Child-Pugh score for patients with esophageal varices. PATIENTS AND METHODS Our university hospital provides a subregional tertiary ser- vice for patients with esophageal varices. Patients with suspected UGIH are admitted to a dedicated unit with 24-h on-call and review by either a gastroenterology specialist registrar or a consultant. There are endoscopy facilities on the unit. We recommend that all patients have gastroscopies performed within 24 h of their UGIHs. There are standardized guidelines for the management of THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 97, No. 3, 2002 © 2002 by Am. Coll. of Gastroenterology ISSN 0002-9270/02/$22.00 Published by Elsevier Science Inc. PII S0002-9270(01)04103-X