The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6

Er-Hsiang Yang, Chung-Tai Wu, Hsin-Yu Kuo, Wei-Ying Chen, Bor-Shyang Sheu, Hsiu-Chi Cheng, Er-Hsiang Yang, Chung-Tai Wu, Hsin-Yu Kuo, Wei-Ying Chen, Bor-Shyang Sheu, Hsiu-Chi Cheng

Abstract

Background: The Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer with a Forrest IIc lesion because it has low rebleeding risk even without endoscopic therapy, ranging from 0 to 13%. However, the risk ranges widely and it is unclear who is at risk of rebleeding with such a lesion. This study assessed whether the Rockall score, which evaluates patients holistically, could indicate the risk of recurrent bleeding among patients with a Forrest IIc lesion at the second-look endoscopy.

Methods: Patients who had peptic ulcer bleeding with Ia-IIb lesions received endoscopic hemostasis at the primary endoscopy, and they were enrolled if their Ia-IIb lesions had been fading to IIc at the second-look endoscopy after 48- to 72-h intravenous proton pump inhibitor (PPI) infusion. Primary outcomes were rebleeding during the 4th-14th day and 4th-28th day after the first bleeding episode.

Results: The prospective cohort study enrolled 140 patients, who were divided into a Rockall scores ≥ 6 group or a Rockall scores < 6 group. The rebleeding rates in the Rockall scores ≥ 6 group and the Rockall scores < 6 group during the 4th-14th day and the 4th-28th day were 13/70 (18.6%) versus 2/70 (2.9%), p = 0.003 and 17/70 (24.3%) versus 3/70 (4.3%), p = 0.001, respectively, based on an intention-to-treat analysis and 5/62 (8.1%) versus 0/68 (0%), p = 0.023 and 6/59 (10.2%) versus 0/67 (0%), p = 0.009, respectively, based on a per-protocol analysis. The Kaplan-Meier curves showed that the Rockall scores ≥ 6 group had a significantly lower cumulative rebleeding-free proportion than the Rockall scores < 6 group (p = 0.01).

Conclusions: Combined Rockall scores ≥ 6 on arrival with a Forrest IIc lesion at the second-look endoscopy can identify patients at risk of recurrent peptic ulcer bleeding following initial endoscopic and intravenous PPI treatment. Trial registration Trial registration identifier: NCT01591083.

Keywords: Forrest classification; Peptic ulcer bleeding; Recurrent bleeding; Rockall score; Second-look endoscopy.

Conflict of interest statement

Drs. Er-Hsiang Yang, Chung-Tai Wu, Hsin-Yu Kuo, Wei-Ying Chen, Bor-Shyang Sheu, and Hsiu-Chi Cheng have no conflict of interest or financial ties to disclose.

Figures

Fig. 1
Fig. 1
The schematic flow chart for the study design
Fig. 2
Fig. 2
The cumulative rebleeding-free proportion from the 4th to the 28th day after the first bleeding event. The Rockall scores ≥ 6 group had a significantly lower cumulative rebleeding-free proportion as compared to the Rockall scores p = 0.01)

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