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

Abstract

Background: Upper gastrointestinal bleeding (UGIB) is a common medical emergency and early assessment of its outcomes is vital for treatment decisions.

Aim: To develop a new scoring system to predict its prognosis.

Methods: In this retrospective study, 692 patients with UGIB were enrolled from two centers and divided into a training (n = 591) and a validation cohort (n = 101). The clinical data were collected to develop new prognostic prediction models. The endpoint was compound outcome defined as (1) demand for emergency surgery or vascular intervention, (2) being transferred to the intensive care unit, or (3) death during hospitalization. The models' predictive ability was compared with previously established scores by receiver operating characteristic (ROC) curves.

Results: Totally 22.2% (131/591) patients in the training cohort and 22.8% (23/101) in the validation cohort presented poor outcomes. Based on the stepwise-forward Logistic regression analysis, eight predictors were integrated to determine a new post-endoscopic prognostic scoring system (MH-STRALP); a nomogram was determined to present the model. Compared with the previous scores (GBS, Rockall, ABC, AIMS65, and PNED score), MH-STRALP showed the best prognostic prediction ability with area under the ROC curves (AUROCs) of 0.899 and 0.826 in the training and validation cohorts, respectively. According to the calibration curve, decision curve analysis, and internal cross-validation, the nomogram showed good calibration ability and net clinical benefit in both cohorts. After removing the endoscopic indicators, the pre-endoscopic model (pre-MH-STRALP score) was conducted. Similarly, the pre-MH-STRALP score showed better predictive value (AUROCs of 0.868 and 0.767 in the training and validation cohorts, respectively) than the other pre-endoscopic scores.

Conclusion: The MH-STRALP score and pre-MH-STRALP score are simple, convenient, and accurate tools for prognosis prediction of UGIB, and may be applied for early decision on its management strategies.

Keywords: Nomogram; Post-endoscopic model; Pre-endoscopic model; Prognosis prediction; Retrospective study; Upper gastrointestinal bleeding.

Figure 1

Cohorts for the study. UGIB: Upper gastrointestinal bleeding; ICU: Intensive care unit.

Figure 2

Nomogram for the prognostic model of upper gastrointestinal bleeding (MH-STRALP). To calculate the probability of the compound outcomes, points for each parameter are assigned by corresponding values from the “points” axis, and sum of the points is plotted on “total points” axis. UGIC: Upper gastrointestinal carcinoma; SRH: Stigmata of recent hemorrhage.

Figure 3

Performance and validation of the MH-STRALP nomogram. A: The area under the curve (AUC) of the MH-STRALP nomogram for prognostic prediction of upper gastrointestinal bleeding (UGIB) in the training cohort; B: The calibration curve for the prognostic nomogram. The x-axis represents the nomogram-predicted probability and y-axis represents the actual probability of the compound outcomes. A perfect prediction would correspond to the 45° grey line. The brown line represents the entire cohort bias-corrected by bootstrapping (B = 1000 repetitions), indicating observed nomogram performance; C: The AUC of the MH-STRALP nomogram in the internal cross-validation analysis in the training cohort; D: The decision curve analysis compared the accuracy for prognostic prediction between MH-STRALP nomogram and other scoring systems; E: The AUC of the MH-STRALP nomogram for prognostic prediction of UGIB in the validation cohort. ROC: Receiver operating characteristic.

Figure 4

The area under the curve of the pre-endoscopic scoring system (pre-MH-STRALP) for prognostic prediction of upper gastrointestinal bleeding. A: The area under the curve (AUC) of the pre-endoscopic scoring system (pre-MH-STRALP) for prognostic prediction of upper gastrointestinal bleeding (UGIB) in the training cohort; B: The AUC of the pre-endoscopic scoring system (pre-MH-STRALP) for prognostic prediction of UGIB in the validation cohort. ROC: Receiver operating characteristic.