MH-STRALP: A scoring system for prognostication in patients with upper gastrointestinal bleeding

doi:10.4240/wjgs.v16.i3.790

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Study

World J Gastrointest Surg. Mar 27, 2024; 16(3): 790-806
Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.790

Table 1 Characteristics of the patients in the training cohort

	GP group (n = 460)	PP group (n = 131)	P value
Sex			0.710
Male, n (%)	351 (76.3)	102 (77.9)
Female, n (%)	109 (23.7)	29 (22.1)
Age (yr), median (IQR)	63.0 (21.0)	65.0 (16.0)	0.020
Height (cm), median (IQR)	170.0 (11.0)	170.0 (11.0)	0.126
Weight (kg), median (IQR)	70.0 (15.3)	65.0 (20.0)	0.006
BMI (kg/m²), median (IQR)	22.0 (5.0)	21.0 (7.0)	0.008
Smoke, n (%)	130 (28.3)	46 (35.1)	0.089
Drink, n (%)	76 (16.5)	23 (17.6)	0.717
Previous UGIB history, n (%)	125 (27.2)	48 (36.6)	0.036
Etiology, n (%)
Peptic ulcer	323 (72.2)	47 (35.9)	< 0.001
EGVB	43 (9.3)	47 (35.9)	< 0.001
UGIC	29 (6.3)	23 (17.5)	< 0.001
Acute erosive hemorrhagic gastritis	30 (6.5)	4 (3.1)	0.197
Mallory-Weiss syndrome	17 (3.7)	2 (1.5)	0.337
Dieulafoy’s disease	6 (1.3)	2 (1.5)	1.000
Bleeding due to endoscopic operations	2 (0.4)	1 (0.8)	1.000
Biliary bleeding	0	2 (1.5)	0.049
Pancreatic bleeding	0	1 (0.8)	0.222
Polyp bleeding	1 (0.2)	0	1.000
Comorbidities, n (%)
Hypertension	202 (43.9)	64 (48.9)	0.316
Diabetes	108 (23.5)	39 (29.8)	0.142
Coronary atherosclerotic heart disease	81 (17.6)	21 (16.0)	0.673
Chronic liver disease	71 (15.4)	43 (32.8)	< 0.001
Liver cirrhosis	48 (10.4)	44 (33.6)	< 0.001
Respiratory disease	22 (4.9)	11 (8.4)	0.112
Gallstones	15 (3.3%)	11 (8.4%)	0.011
Chronic kidney disease	26 (5.7)	9 (6.9)	0.602
Hematologic disease	2 (0.4)	0	1.000
Autoimmune disease	3 (0.7)	4 (3.1)	0.074
Cerebral infarction	46 (10.0)	25 (19.1)	0.005
Stroke	50 (10.9)	26 (19.8)	0.007
Malignancy	49 (10.7)	42 (32.1)	< 0.001
Multi-organ failure	8 (1.7)	10 (7.6)	0.001
Heart failure	89 (19.3)	26 (19.8)	0.899
Liver failure	46 (10.0)	47 (35.9)	< 0.001
Renal failure	24 (5.2)	9 (6.9)	0.467
Respiratory failure	0 (0.0)	2 (1.5)	0.049
Helicobacter pylori infection, n (%)	155 (33.7)	22 (16.8)	0.490
Drugs, n (%)
Antiplatelet drugs	107 (23.3)	28 (21.4)	0.641
Anticoagulants	5 (1.1)	3 (2.3)	0.533
Glucocorticoids	1 (0.2)	0	1.000
NSAIDS	5 (1.1)	4 (3.1)	0.224
Operation, n (%)
Surgery	30 (6.5)	15 (11.5)	0.061
EMR or ESD	4 (0.9)	0	0.580
Time from symptom onset to admission (h), median (IQR)	24.0 (65.0)	12.0 (70.0)	0.033
Symptoms at admission, n (%)
Haematemesis	184 (40.0)	90 (68.7)	< 0.001
Black stool	367 (79.8)	89 (67.9)	0.004
Abdominal pain	156 (33.9)	41 (31.3)	0.575
Palpitations	192 (41.7)	89 (67.9)	< 0.001
Amaurosis	40 (8.7)	20 (15.3)	0.028
Syncope	38 (8.3)	15 (11.5)	0.260
Sweat	94 (20.4)	44 (33.6)	0.002
Altered mental status	3 (0.7)	4 (3.1)	0.074
Body signs at admission
Pulse, median (IQR)	84.0 (13.8)	95.0 (27.0)	< 0.001
SBP, median (IQR)	124.0 (22.0)	120.0 (30.0)	0.011
DBP, median (IQR)	74.0 (14.0)	68.0 (16.0)	< 0.001
Anemia appearance, n (%)	201 (43.7)	99 (75.6)	< 0.001
Abdominal tenderness, n (%)	63 (13.7)	23 (17.6)	0.269
Laboratory findings at admission
RBC, ×10¹²/L, median (IQR)	3.0 (1.0)	3.0 (1.0)	< 0.001
WBC, ×10⁹/L, median (IQR)	9.0 (4.0)	9.0 (6.0)	0.952
Neutrophil, ×10⁹/L, median (IQR)	6.0 (5.0)	6.0 (6.0)	0.141
Lymphocyte, ×10⁹/L, median (IQR)	2.0 (1.00)	1.0 (1.0)	< 0.001
MCV (fl), median (IQR)	92.0 (7.0)	90.0 (12.0)	0.012
HCT, median (IQR)	31.0 (12.0)	25.0 (11.0)	< 0.001
Hemoglobin (g/L), median (IQR)	104.0 (43.0)	81.0 (39.0)	< 0.001
PLT (×10⁹/L), median (IQR)	215.0 (107.0)	174.0 (153.0)	< 0.001
Reticulocyte (×10⁹/L), median (IQR)	89.0 (60.0)	110.0 (92.0)	0.219
CRP, median (IQR)	2.0 (4.0)	3.0 (16.0)	< 0.001
PT (s), median (IQR)	12.0 (1.0)	13.0 (3.0)	< 0.001
INR, median (IQR)	1.0 (0)	1.0 (0)	0.002
Fibrinogen (g/L), median (IQR)	2.0 (1.0)	2.0 (1.0)	0.002
D-dimer (mg/L), median (IQR)	0 (1.0)	1.0 (3.0)	< 0.001
Albumin (g/L), median (IQR)	37.0 (8.0)	30.0 (8.0)	< 0.001
Urea (mmol/L), median (IQR)	9.0 (8.0)	10.0 (10.0)	0.250
Creatinine (μmol/L), median (IQR)	79.0 (31.0)	75.0 (37.0)	0.040
Serum iron (μmol/L), median (IQR)	10.0 (12.0)	8.0 (9.0)	0.030
Ferritin (μg/L), median (IQR)	107.5 (188.5)	115.0 (253.5)	0.947
Timing of endoscopy after admission (d), median (IQR)	36.0 (56.0)	12.0 (31.0)	< 0.001
Endoscopic appearance, n (%)
Dark spots	25 (5.4)	14 (10.7)	0.033
Bleeding	80 (17.4)	61 (46.6)	< 0.001
Adherent thrombosis	144 (31.3)	91 (69.5)	< 0.001
Visible vessels	97 (21.1)	68 (51.9)	< 0.001
Lesion diameter ≥ 2 cm	54 (11.7)	25 (19.1)	0.001
SRH	192 (41.7)	109 (83.2)	< 0.001
Treatment, n (%)
Blood transfusion	74 (16.1)	92 (70.2)	< 0.001
Proton pump inhibitor	459 (99.8)	131 (100.0)	1.000
Somatostatin and its analogs	328 (71.3)	121 (92.4)	< 0.001
Endoscopic treatment	110 (23.9)	75 (57.3)	< 0.001
Local injection of Adrenaline	17 (3.7)	4 (3.1)	0.934
Thermocoagulation	47 (10.2)	23 (17.6)	0.022
Local injection of a sclerosing agent	25 (5.4)	35 (26.7)	< 0.001
Ligation	24 (5.2)	33 (25.2)	< 0.001
Titanium clip	39 (8.5)	24 (18.3)	0.001
Rebleeding, n (%)	15 (3.3)	26 (19.8)	< 0.001

GP: Good prognosis; PP: Poor prognosis; IQR: Interquartile ranges; UGIB: Upper gastrointestinal bleeding; EGVB: Esophageal and gastric variceal bleeding; UGIC: Upper gastrointestinal carcinoma; BMI: Body mass index; NSAIDS: Non-steroidal anti-inflammatory drugs; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; RBC: Red blood cell; WBC: White blood cell; MCV: Mean corpuscular volume; HCT: Hematocrit; PLT: Platelet; CRP: C reactive protein; PT: Prothrombin time; INR: International normalized ratio; SRH: Stigmata of recent hemorrhage.

Table 2 Logistic regression analysis for the prognostic factors of upper gastrointestinal bleeding

	Univariate Logistic analysis			Multivariate Logistic stepwise forward analysis
	OR	P value	95%CI	OR	z value	P value	95%CI
Age	1.017	0.010	1.004-1.030
Weight	0.974	0.004	0.957-0.992
BMI	0.916	0.002	0.866-0.968
Previous UGIB history	1.550	0.036	1.028-2.337
Liver disease	2.677	< 0.001	1.718-4.173
Cirrhosis	4.341	< 0.001	2.713-6.945
Autoimmune diseases	4.798	0.042	1.060-21.715
Cerebral infarction	2.123	0.006	1.247-3.612
Stroke	2.030	0.008	1.207-3.416	1.710	1.45	0.148	0.826-3.540
Liver failure	5.036	< 0.001	3.149-8.052	2.370	2.66	0.008	1.254-4.480
Hematemesis	3.293	< 0.001	2.177-4.980
Black stool	0.537	0.005	0.349-0.827
Palpitation	2.958	< 0.001	1.961-4.462
Amaurosis	1.892	0.030	1.063-3.366
Sweat	1.969	0.002	1.284-3.020
Altered mental status	4.798	0.042	1.060-21.715
Systolic blood pressure	0.986	0.006	0.976-0.996
Diastolic blood pressure	0.959	< 0.001	0.942-0.976
Pulse	1.044	< 0.001	1.031-1.057	1.039	4.73	< 0.001	1.023-1.055
Anemia appearance	3.971	< 0.001	2.560-6.161
Neutrophil count	1.061	0.010	1.014-1.110
Lymphocyte count	0.647	< 0.001	0.509-0.823
RBC	0.436	< 0.001	0.341-0.557
MCV	0.969	0.007	0.947-0.991
HCT	0.901	< 0.001	0.876-0.927
Hemoglobin	0.972	< 0.001	0.964-0.980
CRP	1.009	0.007	1.002-1.015
Fibrinogen	0.768	0.013	0.624-0.947
D-dimer	1.081	0.006	1.023-1.142
Albumin	0.814	< 0.001	0.780-0.851	0.912	-3.37	0.001	0.864-0.962
Ferritin	1.001	0.004	1.000-1.001
Blood transfusion	12.305	< 0.001	7.849-19.290	4.387	5.00	< 0.001	2.458-7.831
Somatostatin and its analogs	4.870	< 0.001	2.477-9.572
Peptic ulcer	0.225	< 0.001	0.150-0.339
UGIC	3.165	< 0.001	1.761-5.690	3.795	3.32	0.001	1.727-8.337
EGVB	5.426	< 0.001	3.373-8.729
Dark spots	2.082	0.036	1.049-4.132
Bleeding	4.139	< 0.001	2.721-6.297
Adherent thrombosis	4.992	< 0.001	3.278-7.604
Visible vessels	4.039	< 0.001	2.682-6.083
Lesion diameter ≥ 2 cm	2.609	0.001	1.492-4.559
SRH	6.916	< 0.001	4.219-11.336	4.089	4.43	<0.001	2.192-7.626
Rebleeding	7.417	< 0.001	3.794-14.500	2.071	1.69	0.090	0.892-4.809

BMI: Body mass index; UGIB: Upper gastrointestinal bleeding; RBC: Red blood cell; MCV: Mean corpuscular volume; HCT: Hematocrit; CRP: C reactive protein; UGIC: Upper gastrointestinal carcinoma; EGVB: Esophageal and gastric variceal bleeding; SRH: Stigmata of recent hemorrhage.

Table 3 Comparison of prognostic predictive ability between MH-STRALP and other scoring systems in the training cohort

Scoring system	AUROC (95%CI)
MH-STRALP	0.899 (0.870-0.928)
ABC	0.739 (0.691-0.788)
AIMS65	0.652 (0.599-0.704)
Glasgow	0.677 (0.626-0.727)
PNED	0.752 (0.704-0.800)
Rockall	0.782 (0.743-0.822)

AUROC: Area under the receiver operating characteristic curve.

Table 4 Comparison of prognostic predictive ability between pre-MH-STRALP and other pre-endoscopic scoring systems in the training cohort

Scoring system	AUROC (95%CI)
pre-MH-STRALP	0.868 (0.832-0.904)
ABC	0.739 (0.691-0.788)
AIMS65	0.652 (0.599-0.704)
Glasgow	0.677 (0.626-0.727)
PNED	0.752 (0.704-0.800)
pre-Rockall	0.700 (0.652-0.748)

AUROC: Area under the receiver operating characteristic curve.

Citation: Hu JN, Xu F, Hao YR, Sun CY, Wu KM, Lin Y, Zhong L, Zeng X. MH-STRALP: A scoring system for prognostication in patients with upper gastrointestinal bleeding. World J Gastrointest Surg 2024; 16(3): 790-806
URL: https://www.wjgnet.com/1948-9366/full/v16/i3/790.htm
DOI: https://dx.doi.org/10.4240/wjgs.v16.i3.790