What is the Zargar grading system used for in patients with bleeding ulcers?

Zargar Grading System for Caustic Injuries, Not Bleeding Ulcers

The Zargar grading system is not used for bleeding ulcers but rather for classifying the severity of caustic injuries to the esophagus and stomach. The evidence provided does not contain information about the Zargar grading system as it relates to bleeding ulcers.

Correct Classification Systems for Bleeding Ulcers

For bleeding peptic ulcers, the following classification systems are used instead:

1. Forrest Classification

This is the primary endoscopic classification system for bleeding ulcers:

• Forrest Ia: Active spurting bleeding
• Forrest Ib: Active oozing bleeding
• Forrest IIa: Non-bleeding visible vessel
• Forrest IIb: Adherent clot
• Forrest IIc: Flat pigmented spot
• Forrest III: Clean ulcer base

2. Risk Stratification Scores for UGIB Management

Several scoring systems are used to risk-stratify patients with upper gastrointestinal bleeding:

Glasgow Blatchford Score (GBS)

• Pre-endoscopic score that predicts need for intervention
• Includes: hemoglobin, BUN, systolic blood pressure, pulse, melena, syncope, liver disease, and heart failure
• GBS ≤1 identifies low-risk patients who can be safely managed as outpatients 1
• Superior predictive ability (AUC 0.90-0.96) compared to Rockall score 1

Rockall Score

• Includes pre-endoscopic (age, shock, comorbidities) and post-endoscopic components (diagnosis, stigmata of bleeding)
• Validated in most studies for predicting rebleeding and mortality 2
• Less accurate than GBS for predicting need for intervention

Management Based on Endoscopic Findings

The management of bleeding ulcers depends on the endoscopic findings:

1. High-risk stigmata (active bleeding, visible vessel, adherent clot):

   • Require endoscopic therapy with thermocoagulation or sclerosant injection (strong recommendation) 2
   • Hemoclips are also suggested (conditional recommendation) 2
   • PPI therapy via IV loading dose followed by continuous infusion is recommended after successful endoscopic therapy 2

2. Low-risk stigmata (flat spot or clean base):

   • Do not routinely require endoscopic therapy 2

Rebleeding Risk Factors

The Rebleeding-Nagoya University scoring system identifies four independent risk factors for rebleeding after endoscopic hemostasis 3:

• Blood transfusion requirement
• Albumin <2.5 g/dL
• Duodenal ulcer location
• Diameter of exposed vessel ≥2 mm

Important Clinical Considerations

1. Timing of endoscopy: Perform within 24 hours of presentation for most patients with UGIB 2, 1

2. Interobserver variability: There is significant variability in the endoscopic classification of bleeding ulcers, with kappa values ranging from poor (0.29 for spurting) to very good (0.68 for oozing) 4

3. Mortality prediction: Advanced age, comorbidities, hypovolemic shock, in-hospital bleeding, rebleeding, and need for surgery are significant predictors of mortality in patients with bleeding peptic ulcers 5

Conclusion

When evaluating and managing patients with bleeding ulcers, clinicians should use the Forrest classification for endoscopic findings and validated risk scores like Glasgow Blatchford Score and Rockall Score for clinical decision-making, not the Zargar grading system which is specifically for caustic injuries.