Menoufia Medical Journal

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 31  |  Issue : 1  |  Page : 317--323

Prognostic value of AIMS65 score in patients with chronic liver diseases with upper gastrointestinal bleeding


Gamal S El-Deeb, Moamena S EL-Hamouly, Mahmoud S Abdel-Hakeem 
 Department of Tropical, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Menoufia Governorate, Egypt

Correspondence Address:
Mahmoud S Abdel-Hakeem
Department of Tropical, Egyptian Railway Medical Center, 50 EL-Galaa Street, Ramses- Cairo
Egypt

Abstract

Objective This work is a prospective study to emphasize the prognostic value of AIMS65 score in chronic liver disease patients presenting with upper gastrointestinal bleeding (UGIB). Background To optimize the management of UGIB, multiple clinical prediction models have been proposed as a tool to identify patients at risk for poor outcome. Patients and methods This prospective study involved 90 adult patients with chronic liver disease presenting with UGIB, selected from patients admitted in Tropical Medicine Department, Faculty of Medicine, Menoufiya University, Shebeen El-Kom, Menoufiya Governorate, Egypt, during the period from November 2015 to July 2016. Eighty-four of them were male and six were female; their ages ranged from 35 to 79 years. We excluded patients who had melena due to causes other than upper gastrointestinal pathology. AIMS65 score, Glasgow–Blatchford score, Rockall score, Modified Rockall score, Child–Pugh score, and Model for End-Stage Liver Disease score were calculated for each patient. Results The current study showed the following: ICU admission was accurately predicted by AIMS65 score [area under curve (AUC) was 0.946;= 0.0001]. In this study, an AIMS65 score less than 2 excluded ICU admission. Rebleeding was accurately predicted by AIMS65 score (AUC was 0.844;= 0.0001). In the current study, an AIMS65 score less than 1 excluded rebleeding. In-hospital mortality was accurately predicted by AIMS65 score (AUC was 0.973;= 0.0001). AIMS65 score was superior to other scores in predicting mortality. In this study, an AIMS65 score less than 3 excluded in-hospital mortality. Conclusion AIMS65 is accurate, nonendoscopic score for the prediction of ICU admission, rebleeding, in-patient mortality, and cost of hospital stay. Its easy clinical application makes the AIMS65 a good option for some of the clinical outcomes to be predicted in clinical practice.



How to cite this article:
El-Deeb GS, EL-Hamouly MS, Abdel-Hakeem MS. Prognostic value of AIMS65 score in patients with chronic liver diseases with upper gastrointestinal bleeding.Menoufia Med J 2018;31:317-323


How to cite this URL:
El-Deeb GS, EL-Hamouly MS, Abdel-Hakeem MS. Prognostic value of AIMS65 score in patients with chronic liver diseases with upper gastrointestinal bleeding. Menoufia Med J [serial online] 2018 [cited 2020 Apr 1 ];31:317-323
Available from: http://www.mmj.eg.net/text.asp?2018/31/1/317/234255


Full Text



 Introduction



Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition and the most common medical emergency managed by gastroenterologists. Despite being one of the most antique medical problems, recent studies have been slowly changing the management of these patients, which should nowadays include not only initial resuscitation but also risk stratification, pre-endoscopic therapy, endoscopy treatment, and postprocedure care [1]. Liver cirrhosis is a major health problem; it represents the final common pathway for a wide variety of chronic liver diseases [2]. Patients with liver cirrhosis have significantly reduced life expectancy compared with noncirrhotic patients due to complications such as ascites, bleeding of esophageal varices, hepatic encephalopathy, hepatorenal or hepatopulmonary syndrome, and hepatocellular carcinoma [3]. The majority of patients with cirrhosis have elevated portal pressure gradient, with more than one-third developing esophageal varices [4]. Portal hypertension is a manifestation of increased resistance to portal blood flow, resulting most commonly from structural and dynamic changes within a fibrotic liver [5]. The incidence of esophageal varices in cirrhotic patients is predicted to be between 60 and 80% depending on the severity and etiology of liver diseases [6]. Esophageal varices are generally the most common clinical manifestation of portal hypertension, and ruptured esophageal varices are a dreaded complication of portal hypertension [7]. The development of endoscopic therapies and acid-suppressing agents (proton pump inhibitors) has reduced mortality and disease-associated morbidity, but UGIB is still associated with high mortality rates, and the cost of treatment is high [8].

However, previous risk scales (i.e., Rockall score) [9] include clinical and endoscopic components and are therefore unsuitable for pre-endoscopic triage, and Glasgow–Blatchford score (GBS) [10] for gastrointestinal bleeding is complex and difficult to use; hence, physicians often find it difficult to make rapid risk assessments, which may be used for pre-endoscopic triage.

Recently, Saltzman et al. [11] developed a risk score that predicts in-hospital mortality, length of stay, and cost in patients with acute UGIB. The scoring system was named AIMS65 because it consists of the following components:

Albumin level less than 3.0 g/dl, international normalized ratio more than 1.5, altered mental status, systolic blood pressure up to 90 mmHg, and age more than 65 years.

The mortality rate increased significantly as the number of risk factors present increased:

Zero risk factors: 0.3%One risk factor: 1%Two risk factors: 3%Three risk factors: 9%Four risk factors: 15%Five risk factors: 25%.

Saltzman et al. [11] defined altered mental status as a Glasgow Coma Scale score less than 14 or a designation of disorientation, lethargy, stupor, or coma by a physician. Hypoalbuminemia, low international normalized ratio, and gastroesophageal varices are the main complications of severe liver cirrhosis, which has a poor prognosis. This may be one of the reasons for the superiority of the AIMS65 score in predicting mortality.

The aim of this study was to evaluate the prognostic value of AIMS65 score in patients with chronic liver diseases presenting with UGIB.

 Patients and Methods



The study protocol was approved by the ethical-committee of Menoufia university. A written consent was obtained from each participant. This prospective study was conducted on 90 adult patients with chronic liver disease presenting with UGIB, selected from patients admitted in Tropical Medicine Department, Menoufiya University Hospital, and Tropical Medicine Department at Egyptian Railway Medical Center, Cairo, Egypt, during the period from November 2015 to July 2016. Eighty-four (93.3%) were male and six (6.7%) were female patients, and their ages ranged from 35 to 79 (with a mean age of 59.74 ± 10.03) years.

Patients who were 18 years of age or older with chronic liver diseases presenting with bleeding varices (esophageal, fundal, or both) in the form of hematemesis, melena, and or bloody fluids either as vomitus or drained through nasogastric tube were included in the study.

Patients who had lower gastrointestinal (GI) bleeding, small bowel bleeding, cancer-associated bleeding, and patients with incomplete medical charts were excluded from the study.

The variables examined included demographic factors (age and sex), underlying comorbidity status (cardiovascular, hepatic, renal, chronic inflammatory, hematologic disease, heart failure, diabetes mellitus, and malignant neoplasm), medications, previous GI bleeding or surgery, coffee-ground or bloody vomitus, blood in stool or melena, presence of syncope, vital signs (pulse, systolic blood pressure, diastolic blood pressure, temperature, and respiratory rate), mental status, results of laboratory test results on the day of admission, including routine chemistry and hematology, imaging such as pelviabdominal ultrasound, endoscopic findings, and admission period (length of hospital stay) were recorded.

Definitions of the terms used in this study were as follows:

Altered mental status was defined as a Glasgow Coma Scale score of less than or equal to 14, as in the original study of the AIMS65 scoreAll-cause deaths occurring during the index hospitalization were determined as in-hospital mortalityHospital course included the length of hospital stay, ICU admission, requirement of blood transfusion, episode of rebleeding, in-hospital mortality, and cost of hospitalizationRebleeding is defined as recurrent vomiting of blood, and/or melena with shock and/or decrease of at least 2 g/dl in hemoglobin concentration after initial treatment, resuscitation and/or indicated endoscopic therapy.

AIMS65 score, GBS, Rockall score, Modified Rockall score, Child–Pugh score, and Model for End-Stage Liver Disease score were calculated for each patient.

Statistical analysis

The collected data were revised, coded, tabulated, and introduced into a PC using statistical package for the social science (SPSS 20, SPSS Inc., Chicago, Illinois, USA). Data were presented and suitable analysis was performed according to the type of data obtained for each parameter.

The sensitivity and specificity of the scoring systems were calculated. The area under the receiver-operating characteristic curve of the scores were compared.

 Results



There were 90 patients in the study, of whom 84 (93.3%) were men. The median age was 59 years. Eighty-five (94.4%) of them presented with hematemesis. Thirty-one (34.4%) of them presented with hepatic encephalopathy. Eighty-five (94.4%) patients had hepatitis C virus-related chronic liver disease. Among the patients, 77 (85.5%) patients underwent endoscopy: 62 of them were variceal hemorrhages (61 of them needed rubber band ligation and one needed injection sclerotherapy), six were fundal varix that needed injection (Histoacryl), and nine were GAVE. Sixteen (17.8%) patients had AIMS65 score 0, 20 (22%) had score 1, 14 (15.6%) had score 2, 14 (15.6%) had score 3, 20 (22%) had score 4, and 6 (6.7%) had score 5; there were no deaths among patients with AIMS65 scores of 0, 1, and 2. There was no episode of rebleeding among patients with AIMS65 score 0. For AIMS65 scores of 3, 4, and 5, mortality rates were 24.28, 85, and 100%, respectively. For AIMS65 scores of 1, 2, and 3, rebleeding rates were 15, 50, and 71.4%, respectively. The mean duration of melena 'days' was 2.96–1.12. The mean length of in-hospital stay was 5.88–4.16 days. The mean cost of hospital stay was 10142.6–7475.96 LE. Sixty-two (68.8%) patients received blood transfusions. Thirty-one (34.4%) of them were admitted in the ICU. Rebleeding was observed in 20 (30.7%) patients. Twenty-five (27.7%) of them suffered in-hospital mortality [Figure 1], [Figure 2], [Figure 3] and [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6].{Figure 1}{Figure 2}{Figure 3}{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}

 Discussion



On receiver-operating characteristic analyses, AIMS65 was a better score predicting ICU admission, rebleeding, and in-hospital mortality.

ICU admission was accurately predicted by AIMS65 score [area under curve (AUC) was 0.946; 95% confidence interval: 0.877–0.983; P = 0.0001]. AUC was obtained for AIMS65 score (0.946), GBS (0.757), and RS (0.678) [Figure 4].{Figure 4}

In this study, an AIMS65 score less than 2 excluded ICU admission.

Rebleeding was accurately predicted by AIMS65 score (AUC was 0.844; 95% confidence interval: 0.730–0.923; P = 0.0001). AUC was obtained for AIMS65 score (0.844), GBS (0.544), and RS (0.684) [Figure 5].{Figure 5}

In the current study, an AIMS65 score less than 1 excluded rebleeding.

In-hospital mortality was accurately predicted by AIMS65 score (AUC was 0.973; 95% confidence interval: 0.915–0.996; P = 0.0001). AIMS65 score was superior to other scores in predicting mortality. AUC was obtained for AIMS65 score (0.973), Glasgow-Blatchford score (GBS) (0.873), and Rockall score (RS) (0.796) [Figure 6].{Figure 6}

In this study, an AIMS65 score less than 3 excluded in-hospital mortality.

In the current study, mortality rates increased with increasing AIMS65 score. There were no deaths among patients with AIMS65 scores of 0, 1, and 2. For AIMS65 scores of 3, 4, and 5 mortality rates were 24.28, 85, and 100%, respectively.

This finding is in agreement with a study by Sun et al. [12]; the AIMS65 score may be useful for predicting outcomes in patients with UGIB.

This is consistent with a study by Hyett et al. [13], who reported that the AIMS65 score was superior to the GBS in predicting inpatient mortality (area under the receiver-operating characteristic curve, 0.93 vs. 0.68; P [14], who reported that AIMS65 score is the best for predicting mortality among the above-mentioned five scores, having the highest AUC.

Similarly, Gaduputi et al. [15] reported that AIMS65 score was significantly higher in patients who died than in those who survived.

This is in agreement with a study by Nakamura et al. [16], who concluded that the AIMS65 score is useful for predicting the prognosis of patients with acute GI bleeding.

The present results are similar to the results of multiple studies [17],[18] that have shown that AIMS65 alone predicted few or all of the outcome measures in UGIB, such as mortality and cost of hospitalization.

The present results are in agreement with a study by Saltzman et al. [11], who suggested that the AIMS65 score can accurately predict in-hospital mortality and cost of treatment in cases of acute UGIB, but some studies [19] have suggested that AIMS65 score was not suitable for validating UGIB. One of these studies included only peptic ulcer bleeding.

This finding is in agreement with a study by Marwan et al. [20], who suggested that the AIMS65 score is superior to the GBRS in predicting in-hospital mortality for patients with UGIB.

This finding is in agreement with a study by Laursen et al. [21], who suggested that no scoring system (GBS and RS) seems to accurately predict patients' 30-day mortality or rebleeding.

This finding is in disagreement with a study by Marwan et al. [20], who reported that the AIMS65 score and GBS are similar in predicting rebleeding.

This finding is in disagreement with a study by Elif et al. [22], who reported that the scores (AIMS65 score and GBS score) were similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; P = 0.342).

In the current study, the risk for in-hospital mortality increases in patients with an AIMS65 score greater than or equal to 3; this cutoff point can be selected as the marker of high-risk patients; hence, AIMS65 score was better in predicting high-risk patients.

This finding is in agreement with a study by Marwan et al. [20], who reported that the cutoff value that maximized the ability to predict in-hospital mortality was three for the AIMS65 score.

 Conclusion



We concluded that AIMS65 is accurate, nonendoscopic score for the prediction of ICU admission, rebleeding, in-patient mortality, and cost of hospital stay. Its easy clinical application makes the AIMS65 a good option for some of the clinical outcomes to be predicted in clinical practice.

The risk for inpatient mortality increases in patients with an AIMS65 score more than 3; this cutoff point can be selected as the marker of high-risk patients; hence, AIMS65 score was better in predicting high-risk patients.

 Recommendations



Clinically, on the basis of the results presented, the performance of the AIMS65 score in predicting outcomes in patients with UGIB can be recommended for routine clinical practice.

We recommend testing the AIMS65 scores' performance in predicting the other outcomes presented in larger study groups and/or different settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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