Review Article

Utility of the Shock Index and Other Risk-Scoring Tools in Patients with Gastrointestinal Bleeding

Authors: Atul Ratra, MD, Supannee Rassameehiran, MD, Sreeram Parupudi, MD, Kenneth Nugent, MD

Abstract

Patients with upper gastrointestinal (GI) bleeding frequently require hospitalization and have a mortality rate that ranges from 6% to 14%. These patients need rapid clinical assessment to determine the urgency of endoscopy and the need for endoscopic treatment. Riskscoring tools, such as the Rockall score and the Glasgow-Blatchford score, are commonly used in this assessment. These tools clearly help identify high-risk patients but do not necessarily have good predictive value in identifying important outcomes. Their diagnostic accuracy in identifying rebleeding and mortality ranges from poor to fair. The shock index (heart rate divided by systolic blood pressure) provides an integrated assessment of the cardiovascular status. It can be easily calculated during the initial evaluation of patients and monitoring after treatment. The shock index has been used in a few studies in patients with acute GI bleeding, including studies to determine which patients need emergency endoscopy, to predict complications after corrosive ingestions, to identify delayed hemorrhage following pancreatic surgery, and to evaluate the utility of angiograms to identify sites of GI bleeding. Not all studies have found the shock index to be useful in patients with GI bleeding, however. This may reflect the unpredictable natural history of various etiologies of GI bleeding, comorbidity that may influence blood pressure and/or heart rate, and inadequate data acquisition. The shock index needs more formal study in patients with GI bleeding admitted to medical intensive care units. Important considerations include the initial response to resuscitation, persistent bleeding following initial treatment, and rebleeding following a period of stabilization. In addition, it needs correlation with other risk-scoring tools.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Kanwal F, Barkun A, Gralnek IM, et al. Measuring quality of care in patients with nonvariceal upper gastrointestinal hemorrhage: development of an explicit quality indicator set. Am J Gastroenterol 2010;105:1710-1718.
 
2. Rollhauser C, Fleischer DE. Nonvariceal upper gastrointestinal bleeding. Endoscopy 2004;36:52-58.
 
3. Czernichow P, Hochain P, Nousbaum JB, et al. Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas. Eur J Gastroenterol Hepatol 2000;12:175-181.
 
4. Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol 2012;18:1202-1207.
 
5. De Groot NL, Bosman JH, Siersema PD, et al. Prediction scores in gastrointestinal bleeding: a systematic review and quantitative appraisal. Endoscopy 2012;44:731-739.
 
6. Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974;2:394-397.
 
7. Kovacs TO, Jensen DM. Recent advances in the endoscopic diagnosis and therapy of upper gastrointestinal, small intestinal, and colonic bleeding. Med Clin North Am 2002;86:1319-1356.
 
8. Cannon CM, Braxton CC, Kling-Smith M, et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 2009;67:1426-1430.
 
9. McNab A, Burns B, Bhullar I, et al. An analysis of shock index as a correlate for outcomes in trauma by age group. Surgery 2013;154:384-387.
 
10. Rady MY, Nightingale P, Little RA, et al. Shock index: a re-evaluation in acute circulatory failure. Resuscitation 1992;23:227-234.
 
11. Tseng J, Nugent K. Utility of the shock index in patients with sepsis. Am J Med Sci 2015;349:531-535.
 
12. Blatchford O, Murray WR, Blatchford M. A risk score to predict the need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318-321.
 
13. Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38:316-321.
 
14. Bryant RV, Kuo P, Williamson K, et al. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013;78:576-583.
 
15. Wang CH, Chen YW, Young YR, et al. A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding. Am J Emerg Med 2013;31:775-778.
 
16. Reed EA, Dalton H, Blatchford O, et al. Is the Glasgow Blatchford score useful in the risk assessment of patients presenting with variceal haemorrhage? Eur J Gastroenterol Hepatol 2014;26:432-437.
 
17. Birkhahn RH, Gaeta TJ, Terry D, et al. Shock index in diagnosing early acute hypovolemia. Am J Emerg Med 2005;23:323-326.
 
18. Schulz F, Hanusch J, Starlinger M, Schiessel R. Significance of emergency endoscopy in severe upper gastrointestinal hemorrhage. Wien Klin Wochenschr 1986;98:233Y237. [Article in German] .
 
19. Su JM, Hsu HK, Chang HC, et al. Management for acute corrosive injury of upper gastrointestinal tract. Zhonghua Yi Xue Za Zhi (Taipei) 1994;54:20-25.
 
20. Nakahara O, Takamori H, Ikeda O, et al. Risk factors associated with delayed haemorrhage after pancreatic resection. HPB (Oxford) 2012;14:684-687.
 
21. Mueller X, Rothenbuehler JM, Amery A, et al. Bleeding peptic ulcer: an audit of conservative management. J R Soc Med 1994;87:132-134.
 
22. Sakaki M, Iwao T, Oho K, et al. Prognostic factors in cirrhotic patients receiving long-term sclerotherapy for the first bleeding from oesophageal varices. Eur J Gastroenterol Hepatol 1998;10:21-26.
 
23. Eckert P, Eichfuss HP, Knipper A. Haemodynamics and shock prevention in acute haemorrhage from the upper intestinal tract (author’s translation). Prakt Anaesth 1978;13:535-543. [Article in German] .
 
24. Mine T, Murata S, Nakazawa K, et al. Glue embolization for gastroduodenal ulcer bleeding: contribution to hemodynamics and healing process. Acta Radiol 2013;54:934-938.
 
25. Nakasone Y, Ikeda O, Yamashita Y, et al. Shock index correlates with extravasation on angiographs of gastrointestinal hemorrhage: a logistics regression analysis. Cardiovasc Intervent Radiol 2007;30:861-865.
 
26. Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012;10:1130Y1135. e1.
 
27. Chiu PW, Ng EK, Cheung FK, et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol 2009;7:311-316.
 
28. Guglielmi A, Ruzzenente A, Sandri M, et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 2002;34:778-786.
 
29. Villanueva C, Balanzo J, Espinos JC, et al. Prediction of therapeutic failure in patients with bleeding peptic ulcer treated with endoscopic injection. Dig Dis Sci 1993;38:2062-2070.