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

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

Jun-Nan Hu, Fei Xu, Ya-Rong Hao, Chun-Yan Sun, Kai-Ming Wu, Yong Lin, Lan Zhong, Xin Zeng

Jun-Nan Hu, Fei Xu, Chun-Yan Sun, Lan Zhong, Xin Zeng, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China

Ya-Rong Hao, Kai-Ming Wu, Yong Lin, Department of Gastroenterology, Shanghai Changzheng Hospital, Navy Military Medical University, Shanghai 200003, China

Co-first authors: Jun-Nan Hu and Fei Xu.

Co-corresponding authors: Lan Zhong and Xin Zeng.

Author contributions: Hu JN, Xu F were involved in investigation, acquisition, data collection, and drafting of the manuscript; Sun CY, Wu KM were involved in analysis of data; Hao YR was involved in investigation, acquisition, data collection; Lin Y was involved in concept and design, gathering conflict-of-interest forms and statements, are properly completed; Zhong L, Zeng X were involved in providing details of authorship, acquisition and interpretation of funding, ethics committee approval documentation, review and edit the manuscript. All authors were involved in the critical review of the results and have contributed to, read, and approved the final manuscript. Hu JN and Xu F contributed equally to this work as co-first authors. The reasons for designating Hu JN and Xu F as co-first authors are as follows. They have equally contributed to the project by leading and executing a critical component of the research, namely developing the computational model, solving pivotal theoretical problems. They also shared equal responsibility in the process of writing, editing, and refining the manuscript, as well as preparing the visualizations that greatly enhance the clarity and impact of the work. Zhong L and Zeng X contributed equally to this work as co-corresponding authors. The reasons for designating Zhong L and Zeng X as co-corresponding authors are as follows. Zhong L and Zeng X played a crucial role in providing author details, acquiring and interpreting funding, obtaining ethics committee approval documents, and revising and editing the manuscript. The contributions of both authors were essential for the smooth progress of the research and the writing of the final paper, reflecting their significant leadership and coordination role throughout the research process. Their expertise and contributions were indispensable in ensuring the quality and integrity of the study. By involving themselves in every key stage of the project and bearing the responsibility of ensuring the research adhered to ethical and funding body standards, the designation of co-corresponding authors serves as recognition of their significant work. Moreover, they ensured that the paper had proper technical and administrative support during the submission process and after publication, guaranteeing high standards and transparency for the research and manuscript. Therefore, appointing Zhong L and Zeng X as co-corresponding authors is a fair and appropriate reflection of their substantial contributions and corresponding responsibilities to this research. This research was completed as a result of collaborative teamwork, and designating co-first authors and co-corresponding authors accurately reflects the distribution of responsibility and the burden of time and effort required to complete the study and the manuscript. It also embodies our team’s spirit of collaboration, the equitable contributions, and the diversity present within our group.

Supported by Key Disciplines Group Construction Project of Shanghai Pudong New Area Health Commission, No. PWZxq2022-06; Medical discipline Construction Project of Pudong Health Committee of Shanghai, No. PWYgf2021-02; Joint Tackling Project of Pudong Health Committee of Shanghai, No. PW2022D08; and the Medical Innovation Research Project of the Shanghai Science and Technology Commission, No. 22Y11908400.

Institutional review board statement: The study protocol was reviewed and approved by the Institutional Ethics Committee of Shanghai East Hospital (Approval No. 2020SL018).

Informed consent statement: Given this article is a retrospective study, an informed consent form is not included.

Conflict-of-interest statement: Dr. Zeng has nothing to disclose.

Data sharing statement: The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Corresponding author: Xin Zeng, MD, PhD, Chief Doctor, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Shanghai 200120, China. zengxinmd1978@163.com

Received: December 22, 2023
Peer-review started: December 22, 2023
First decision: January 9, 2024
Revised: January 21, 2024
Accepted: February 29, 2024
Article in press: February 29, 2024
Published online: March 27, 2024
Processing time: 90 Days and 21.6 Hours

ARTICLE HIGHLIGHTS

Research background

Upper gastrointestinal bleeding (UGIB) is divided into nonvariceal UGIB (NVUGIB) and variceal UGIB (VUGIB), with rising NVUGIB cases due to an aging population and more non-steroidal anti-inflammatory drugs use, and VUGIB typically resulting from liver cirrhosis with substantial mortality. Despite medical and endoscopic progress, UGIB maintains a high morbidity and mortality rate, with persistent high hospitalization challenges and a 30-day mortality rate of 11% in China, highlighting its critical status as a healthcare emergency.

Research motivation

UGIB prognostic scoring systems are inconsistently applied in clinical practice, with limited impact on decision-making due to variances in primary outcomes and lack of validation. The absence of trial-based evidence for these scores contributes to their uncertain utility in Chinese clinical settings.

Research objectives

The goal of this study is to identify key factors that influence poor UGIB outcomes (e.g., the demand for emergency surgery or vascular intervention, being transferred to the intensive care unit, and dying during hospitalization) and develop a simplified, effective scoring system to guide risk stratification and treatment decisions in Chinese UGIB patients.

Research methods

A retrospective study used UGIB patient data from East Hospital as a training cohort and from Changzheng Hospital as a validation cohort to construct and test a new scoring model based on major predictors of UGIB outcomes, including endoscopic findings. A nomogram derived from this model was developed, validated, and compared to existing UGIB scores, with an alternative pre-endoscopic model also assessed. The study employed extensive clinical data and statistical analyses, like multivariate analysis and receiver operating characteristic (ROC) curves, to evaluate the models' effectiveness, focusing on the composite endpoint of emergency surgery, vascular intervention, ICU transfer, or in-hospital mortality.

Research results

Univariate analysis determined factors related to negative outcomes in UGIB, leading to the creation of the MH-STRALP scoring system, which incorporates seven prognostically significant factors plus the risk of rebleeding. The MH-STRALP system showed better prognostic accuracy compared to other established scoring systems (GBS, Rockall, ABC, AIMS65, and PNED), with areas under ROC curves (AUROC) of 0.899 and 0.826 in the training and validation cohorts, whilst the pre-MH-STRALP score also showed better predictive value (AUROCs of 0.868 and 0.767 in the training and validation cohorts, respectively).These two scoring systems are helpful in prognosticating Chinese UGIB patients, providing personalized appropriate treatment and management, and facilitating early clinical decision-making.

Research conclusions

With this study, we constructed new scoring systems, MH-STRALP and pre-MH-STRALP, to predict the prognosis of patients with UGIB, with compound endpoint events of undergoing emergency surgery or vascular intervention, being transferred to the ICU, or dying during hospitalization; we formulated a nomogram to present the scoring system.

Research perspectives

Since this is a retrospective study and we did not make prognostic predictions for patients with UGIB who did not undergo endoscopy, there may be bias. Further large-scale prospective studies are necessary to verify the value of the scoring systems.