What is the difference between Glasgow Blatchford, Rockall, and AIM65 (Acute GI Bleed Score) scores for assessing upper gastrointestinal bleeding?

Differences Between Glasgow Blatchford, Rockall, and AIM65 Scores for Upper Gastrointestinal Bleeding

The Glasgow Blatchford Score (GBS) is the preferred prognostic tool for upper gastrointestinal bleeding due to its superior sensitivity (99%) in identifying patients at high risk for adverse outcomes, while the Rockall score is better for predicting mortality, and AIMS65 is not recommended for identifying low-risk patients. 1

Overview of the Three Scoring Systems

Glasgow Blatchford Score (GBS)

• Includes only clinical and laboratory data (pre-endoscopic): hemoglobin level, blood urea level, pulse, systolic blood pressure, presence of syncope or melena, and evidence of hepatic disease or cardiac failure 1
• Primarily designed to identify patients who require clinical intervention 1
• A score of ≤1 identifies patients at very low risk for rebleeding or mortality who may not require hospitalization or inpatient endoscopy 1
• Has excellent sensitivity (98.6%) for detecting high-risk patients, misclassifying ≤1% of high-risk patients as low risk 1, 2
• Superior to both Rockall scores in predicting need for transfusion (AUROC 0.944 vs. 0.756 for admission Rockall) 3

Rockall Score

• Exists in two forms:
  • Pre-endoscopic (admission) Rockall: uses only clinical and laboratory data before endoscopy 1
  • Complete (full) Rockall: incorporates endoscopic variables in addition to clinical data 1
• Better discriminative ability for predicting mortality than for rebleeding 1
• Has good sensitivity (93-96%) but may misclassify 4-7% of high-risk patients as low risk 1
• The full Rockall score is superior to GBS in predicting death (AUROC 0.758 vs. 0.644) and rebleeding (AUROC 0.642 vs. 0.585) 4

AIMS65 Score

• Designed primarily to identify patients at high risk for death rather than those at low risk for safe discharge 1
• Has lower sensitivity (78-82%) for identifying high-risk patients 1
• Not recommended for identifying patients who are at very low risk for rebleeding or mortality 1
• Similar to the full Rockall score in predicting mortality (AUROC 0.77) 2

Clinical Utility and Performance

For Identifying Low-Risk Patients (Safe for Outpatient Management)

• GBS is the preferred tool with a cutoff of ≤1 (sensitivity 98.6%, specificity 34.6%) 2
• A GBS of 0 has been shown to safely identify patients who can be managed as outpatients without early endoscopy 1, 2
• AIMS65 is not recommended for this purpose due to potentially misclassifying ~20% of high-risk patients as low risk 1

For Predicting Need for Intervention

• GBS is superior to the admission Rockall score (AUROC 0.858 vs. 0.705) and similar to the full Rockall score (AUROC 0.822 vs. 0.797) 3
• A GBS ≥7 is the optimal threshold to predict need for endoscopic treatment (sensitivity 80%, specificity 57%) 2
• GBS is superior to Rockall score for predicting need for surgical intervention (AUROC difference 0.21) 5

For Predicting Mortality

• Full Rockall and AIMS65 scores perform better than GBS in predicting mortality 2, 4
• Score thresholds of ≥4 for admission Rockall and ≥5 for full Rockall are optimal for predicting death 2
• AIMS65 ≥2 is optimal for predicting mortality (sensitivity 65.8-78.6%, specificity 65.0-65.3%) 2

Important Clinical Considerations

• When deciding on early discharge, consider:

  • Urban vs. rural environment
  • Access to hospital or ambulance services
  • Access to out-of-hours endoscopy
  • Patient preferences regarding hospitalization vs. outpatient management 1

• None of the scoring systems accurately predict rebleeding with high precision (all AUROC <0.80) 2, 4

• For variceal bleeding specifically, all three scoring systems perform poorly in predicting clinical outcomes, though GBS correctly identifies these patients as high risk at presentation 6