Development and validation of a prognostic index predicting death after upper gastrointestinal bleeding in patients with liver cirrhosis: A multicenter study

A. Gatta, C. Merkel, P. Amodio, S. Bellon, A. Bellumat, M. Bolognesi, L. Borsato, M. Butto, F. F. Casson, G. Cavallarin, R. Cielo, P. Cristina, E. Cucci, C. Donada, V. Donadon, E. Enzo, R. Marin, C. Mazzaro, R. Miori

Research output: Contribution to journalArticlepeer-review


Prognostic factors of the outcome of upper gastrointestinal bleeding in patients with cirrhosis are insufficiently defined. Pertinent clinical, biochemical, and endoscopic data of 332 upper gastrointestinal bleedings in 268 patients with cirrhosis observed in the participating centers during 31 months were recorded. Clinical data were analyzed until 40 days after bleeding. A further set of 82 bleedings was used as a validation group. Ninety-two of the 268 patients died within the time of the study, and 28 of the 82 patients of the validation group died. According to a stepwise logistic regression analysis, s-creatinine, ascites on admission, previous diagnosis of hepatocellular carcinoma, s-bilirubin, prothrombin index, varices as definite or probable source of bleeding, gender, and presentation with hemathemesis were the best set of covariates for predicting outcome. From them a prognostic index was developed and validated in the 82 further bleedings. Sensitivity and specificity in the cumulated training and test sets were 75 and 80%, respectively. In the present material, the prognostic index was significantly more efficient than Child-Pugh score or the prognostic index proposed by Garden et al. These data show that it is possible to predict the outcome of upper gastrointestinal bleeding in cirrhosis on the basis of few easily available data. The prognostic index we proposed and validated may become useful to predict the outcome of a bleeding and to select or stratify patients in clinical trials. Upper gastrointestinal bleeding (UGIB) is an important and frequent complication of liver cirrhosis and accounts for more than 25% of the overall mortality of patients with cirrhosis (1, 2). The risk of death after a single episode of bleeding ranges 25-50% (2-4). According to the majority of published series, the most ominous bleeding is that arising from esophageal varices (2, 5, 6), but the opposite has also been reported (7). The risk of death is elevated in the first few wk after the bleeding (3, 8, 9), so the 40-day death rate is considered the death rate related to bleeding (10). Few studies examined the course of UGIB and its short-term prognostic factors (6, 11-14), and fewer prognostic indexes for survival were derived (11, 14). Results obtained are not concordant, in particular because of unsatisfactory sample size in some series, differences in the definitions of events, and the conditions in which patients' data were collected (e.g., use of referred patients with possible referral bias (9)). In a single study (11), the prognostic index the authors developed to predict outcome of bleeding from data obtained on admission was subsequently tested in another sample, but the size of the test sample was insufficient to definitely assess the clinical usefulness of the prognostic index. In a recent consensus report, information in this field was considered largely insufficient (15). More precise data on this topic would be very important, because they would allow definition of patients with more severe prognosis, on whom therapeutic efforts could be concentrated. In addition, a clinically validated and stable prognostic index would allow stratification of patients in different risk classes, to obtain more homogeneous groups to be compared in therapeutic clinical trials, and may be of value in correcting for possible imbalance in prognostic factors in nonstratified trials. The aim of the present multicenter study was to develop and validate a prognostic index to predict death within 40 days of bleeding.

Original languageEnglish
Pages (from-to)1528-1536
Number of pages9
JournalAmerican Journal of Gastroenterology
Issue number9
Publication statusPublished - 1994

ASJC Scopus subject areas

  • Gastroenterology


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