ORIGINAL ARTICLE: Clinical Endoscopy

Risk stratification in acute upper GI bleeding: comparison of the

AIMS65 score with the Glasgow-Blatchford and Rockall
scoring systems
Marcus Robertson, MBBS(Hons),1 Avik Majumdar, MBBS(Hons),1 Ray Boyapati, MBBS(Hons),1
William Chung, MBBS,1 Tom Worland, MBBS,1 Ryma Terbah, MBBS,1 James Wei, MBBS,1
Steve Lontos, MBBS, MD,1 Peter Angus, MBBS, MD,1,2 Rhys Vaughan, MBBS, PhD1,2
Heidelberg, Victoria, Australia

Background and Aims: The American College of Gastroenterology recommends early risk stratification in pa-
tients presenting with upper GI bleeding (UGIB). The AIMS65 score is a risk stratification score previously vali-
dated to predict inpatient mortality. The aim of this study was to validate the AIMS65 score as a predictor of
inpatient mortality in patients with acute UGIB and to compare it with established pre- and postendoscopy
risk scores.
Methods: ICD-10 (International Classification of Diseases, Tenth Revision) codes identified patients presenting
with UGIB requiring endoscopy. All patients were risk stratified by using the AIMS65, Glasgow-Blatchford score
(GBS), pre-endoscopy Rockall, and full Rockall scores. The primary outcome was inpatient mortality. Secondary
outcomes were a composite endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic, or surgical
intervention; blood transfusion requirement; intensive care unit (ICU) admission; rebleeding; and hospital length
of stay. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.
Results: Of the 424 study patients, 18 (4.2%) died and 69 (16%) achieved the composite endpoint. The AIMS65
score was superior to both the GBS (AUROC, 0.80 vs 0.76, P < .027) and the pre-endoscopy Rockall score (0.74,
P Z .001) and equivalent to the full Rockall score (0.78, P Z .18) in predicting inpatient mortality. The AIMS65
score was superior to all other scores in predicting the need for ICU admission and length of hospital stay.
AIMS65, GBS, and full Rockall scores were equivalent (AUROCs, 0.63 vs 0.62 vs 0.63, respectively) and superior
to pre-endoscopy Rockall (AUROC, 0.55) in predicting the composite endpoint. GBS was superior to all other
scores for predicting blood transfusion.
Conclusion: The AIMS65 score is a simple risk stratification score for UGIB with accuracy superior to that of GBS
and pre-endoscopy Rockall scores in predicting in-hospital mortality and the need for ICU admission. (Gastroint-
est Endosc 2016;83:1151-60.)

Upper GI bleeding (UGIB) is the most common GI emer-
gency and is associated with substantial morbidity and mortal-
ity. Traditionally quoted as between 3% and 10%,1,2 more
recent studies have shown improved inpatient mortality rates
of 2% to 2.5%,3,4 although significant geographic variation
exists.5,6 The American College of Gastroenterology and inter-
national consensus guidelines recommend early risk stratifi-
cation in patients presenting with UGIB to facilitate accurate
triage and assist in decisions such as timing of endoscopy,
discharge planning, and level of care.7-9

Abbreviations: AUROC, area under the receiver-operating characteristic
curve; ED, emergency department; GBS, Glasgow-Blatchford score; ICU,
intensive care unit; UGIB, upper GI bleeding.
DISCLOSURE: All authors disclosed no financial relationships relevant
to this publication.
Copyright ª 2016 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
http://dx.doi.org/10.1016/j.gie.2015.10.021
Received April 28, 2015. Accepted October 11, 2015.
Current affiliations: Department of Gastroenterology and Liver Transplant
Unit, Austin Hospital (1), Department of Medicine, The University of
Melbourne, Austin Health (2), Heidelberg, Victoria, Australia.
Reprint requests: Marcus Robertson, MBBS(Hons), Austin Hospital Liver
Transplant Unit, 145 Studley Road, Heidelberg, Victoria, Australia 3084.
If you would like to chat with an author of this article, you may contact
Dr Robertson at marcus.Robertson@austin.org.au.

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Risk stratification in acute upper GI bleeding
Multiple algorithms have been developed to predict
outcomes in UGIB. Currently, the most widely used risk
stratification tools are the Glasgow-Blatchford score10
(GBS) and the Rockall11 scores (Table 1). The GBS
(range 0-23) was developed in 2000 from a United
Kingdom patient cohort to predict the need for
hospital-based intervention or death after UGIB (a com-
posite of inpatient mortality, in-hospital rebleeding, sub-
stantial decrease in hemoglobin concentration after
admission, endoscopic or surgical intervention, and blood
transfusion). However, the GBS has limitations: weighting
makes calculation difficult and some of the criteria from
the patient’s medical history lack clear definitions.
The Rockall score was developed in 1996 from a large
population-based study designed to identify factors that
predicted mortality in patients presenting with UGIB. It
is calculated by using pre-endoscopic and endoscopic vari-
ables12 (Table 1). The Rockall score is limited by weighting,
which leads to complexity in calculation and contains
subjective variables such as the severity of systemic
diseases. Additionally, it requires endoscopic data for
completion, rendering it impossible to use at the time of
presentation. An abbreviated pre-endoscopy or admission
Rockall score has also been developed; however, there
has been debate about its accuracy and clinical
applicability.13,14
Despite recommendations to incorporate risk stratifica-
tion scores in UGIB, neither the GBS nor the Rockall
scores have been routinely adopted into clinical practice.15
One contributing factor is undoubtedly the cumbersome
nature of score calculation.
The AIMS65 score is a new risk stratification score
derived and validated to predict in-hospital mortality in
patients presenting with UGIB.16 The AIMS65 score
assigns 1 point for each of the following: albumin
level <30 g/L, international normalized ratio >1.5, altered
mental status, systolic blood pressure <90 mm Hg, and
age older than 65 years (Table 1). Compared with
existing scores, the AIMS65 score has the advantages of
being unweighted, simple to remember, and easy to
calculate with laboratory values routinely obtainable in
the emergency department. It is also does not rely on
poorly defined medical history criteria. In a recent study,
the AIMS65 score was shown to be superior to the GBS
in predicting in-hospital mortality.17 We present the first
comparison of the AIMS65 score with the GBS, the
pre-endoscopy Rockall score, and the full Rockall risk
stratification score.
The study objectives were to validate the AIMS65 score
as a predictor of in-hospital mortality in patients presenting
with acute UGIB in an Australian patient cohort and to
compare the AIMS65 score with established pre-
endoscopy (GBS and pre-endoscopy Rockall score) and
post-endoscopy (full Rockall score) risk stratification
scores.
1152 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 6 : 2016
Robertson et al
METHODS
Patient selection and data collection
ICD-10 (International Classification of Diseases, Tenth
Revision) diagnosis codes were used to identify patients
presenting with UGIB requiring endoscopy to the Austin
Hospital, a tertiary referral center, over a 42-month period
from January 2010 to June 2013. Patients were excluded if
the data required for calculation of risk stratification scores
were incomplete or if medical records revealed an alterna-
tive diagnosis. Each medical record was independently
examined by 2 reviewers (W.C., R.T.) to confirm the pres-
ence of UGIB. Discrepancies between data collected by the
2 reviewers were referred to a third reviewer (M.R.). The
study was approved by the Human Research Ethics Com-
mittee at Austin Health.
For each patient, the following data were collected
through manual chart review: age, sex, length of hospital
stay, intensive care unit (ICU) admission, discharge desti-
nation, symptoms on admission (hematemesis, coffee
ground vomiting, melena, syncope, lethargy, confusion),
medical comorbidities, medication use (including oral or
intravenous proton pump inhibitor, histamine-2 receptor
antagonist, antiplatelet agents, anticoagulant therapy,
nonsteroidal anti-inflammatory agents), vital signs
including Glasgow Coma Scale score, laboratory results (al-
bumin level, international normalized ratio, urea, creati-
nine, hemoglobin), endoscopy findings, and the need for
endoscopic intervention, blood transfusion, repeat endos-
copy, embolization, or surgery. For patients with multiple
laboratory tests or vital signs collected in the emergency
department, the most abnormal values were used.
Per previous studies involving the AIMS65 risk stratifica-
tion score, a patient was considered to have a change in
mental state if the Glasgow Coma Scale score on presenta-
tion to the emergency department (ED) was less than 14 or
a designation of disoriented, lethargy, stupor, or coma was
documented in the chart by a treating physician.
All patients were risk stratified by using the AIMS65,
GBS, Rockall and pre-endoscopy Rockall scores. The pri-
mary outcome was in-hospital mortality. Secondary out-
comes were a composite endpoint of inpatient mortality,
in-hospital rebleeding; endoscopic, radiologic, or surgical
intervention; blood transfusion requirement; ICU admis-
sion; rebleeding; and length of hospital stay.
Statistical analysis
Data analysis was primarily performed by using SPSS sta-
tistical software Version 22 (IBM, Armonk, NY). The area un-
der the receiver-operating characteristic curve (AUROC)
was calculated for each scoring system and binomial
outcome. For each scoring system, a cutoff point was calcu-
lated that maximized the sum of sensitivity and specificity in
predicting the primary and secondary endpoints. Patients
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Robertson et al Risk stratification in acute upper GI bleeding

TABLE 1. Comparison of the AIMS65, Glasgow-Blatchford, and Rockall risk stratifications scores

Glasgow-Blatchford Risk Score

AIMS65 Score Risk factor Score

Albumin <3.0 mg/dL 1 BUN, mg/dL

INR >1.5 1 18.2 to <22.4 2
Altered mental status 1 22.4 to <28.0 3
Systolic BP <90 mm Hg 1 28.0 to <70.0 4
Age >65 y 1 70.0 6
Maximum score 5 Hemoglobin, men g/dL
12.0 to <13.0 1
10.0 to <12.0 3
<10.0 6
Hemoglobin, women g/dL
10.0 to <12.0 1
<10.0 6
Systolic BP, mm Hg
100–109 1
90–99 2
<90 3
Other markers
Pulse 100 (bpm) 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2
Maximum score 23

Rockall Score Preadmission Rockall Score

Age, y Age, y
<60 0 <60 0
60–79 1 60–79 1
>80 2 >80 2
Shock Shock
No shock 0 No shock 0
Pulse >100 bpm, systolic BP >100 mm Hg 1 Pulse >100 bpm, systolic BP >100 mg Hg 1
Systolic BP <100 mm Hg 2 Systolic BP <100 mm Hg 2
Comorbidity Comorbidity
No major 0 No major 0
CCF, IHD, or major comorbidity 2 CCF, IHD, or major comorbidity 2
Renal failure, liver failure, metastatic cancer 3 Renal failure, liver failure, metastatic cancer 3
Diagnosis Maximum score 7
Mallory-Weiss tear or no lesion and no stigmata 0
All other diagnoses 1
GI malignancy 2
Evidence of bleeding
No stigmata or dark spot on ulcer 0
Blood in upper GI tract, adherent clot, visible or spurting vessel 2
Maximum score 11
GBS, Glasgow-Blatchford score; BUN, blood urea nitrogen; INR, international normalized ratio; BP, blood pressure; bpm, beats per minute; CCF, congestive cardiac failure;
IHD, ischemic heart disease; y, years.

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Risk stratification in acute upper GI bleeding Robertson et al

TABLE 2. Patient characteristics* RESULTS

Characteristic Patient characteristics
Overall 424 (100) ICD-10 codes identified 481 patients with a primary
Male 278 (65.6) diagnosis of acute UGIB, 424 of whom were included in
Comorbidities the study. Fifty-seven patients were excluded from the
study: review of the medical records of 46 patients showed
Ischemic heart disease 114 (26.9)
they did not experience UGIB and 9 patients were
Congestive cardiac failure 53 (12.5)
excluded due to incomplete available data to calculate
Chronic obstructive airways disease 51 (12.0) risk scores. The median age was 71 years (range 15-93
Cerebrovascular disease 56 (13.2) years), and 66% of the patients were male. A total of 293
Diabetes mellitus 115 (27.1) patients (69%) were using antiplatelet or anticoagulant
Malignancy 64 (15.1) medications on admission (154 [36%] aspirin, 48 [11%]
Chronic renal impairment 88 (20.8) clopidogrel, and 90 [21%] warfarin or clexane); 209 pa-
Liver disease 71 (16.7) tients (49%) were taking a proton pump inhibitor. Patient
characteristics are shown in Table 2.
Medications
Aspirin 146 (34.4)
Aspirin and dipyridamole 8 (1.9) Mortality
Clopidogrel 48 (11.3)
The overall in-hospital mortality rate was 4.2% (18 pa-
tients) with a median age of 71 years (interquartile range,
Warfarin 81 (19.1)
58-81 years). Variceal hemorrhage was the cause of death
Therapeutic low molecular weight heparin 9 (2.1)
in 3 of these patients. All patients were treated with intra-
Dabigatran 1 (0.2) venous proton pump inhibitor therapy, and all patients
Nonsteroidal anti-inflammatory drugs 34 (8.0) with variceal hemorrhage received vasoactive therapy
Proton pump inhibitor 209 (49.3) with either terlipressin or octreotide. There was no differ-
Histamine-2 receptor antagonist 5 (1.2) ence in antiplatelet or anticoagulant use between survivors
Score components and nonsurvivors.
Age at admission, y 71 (58–81)
Mortality increased with increasing AIMS65 score
(Fig. 1), and no deaths were recorded in patients with an
Albumin 32 (28–36)
AIMS65 score of 0. The AIMS65 score was superior to
Coffee ground vomiting 67 (15.8)
both the GBS and pre-endoscopy Rockall score in predict-
International normalized ratio 1.2 (1.1–1.6) ing in-hospital mortality, with an AUROC of 0.80 versus
Mental state change 40 (9.4) 0.76 (P Z .03) and 0.74 (P Z.001), respectively (Fig. 2).
Systolic blood pressure, mm Hg 107 (95–120) There was no significant difference between the AIMS65
Hematemesis 106 (25) and the full Rockall scores in predicting mortality
Hemoglobin 93 (76–118) (AUROC, 0.80 vs 0.78; P Z .18) (Fig. 2, Table 3).
The cutoff threshold that maximized sensitivity and
Heart rate, bpm 91 (80–105)
specificity and hence defined low- and high-risk groups
Melena 323 (76.2)
for mortality was 3 for the AIMS65 score (sensitivity,
Urea 10.8 (6.3–18.4) 0.72; specificity, 0.77; total, 1.49). The mortality rate in
Syncope 47 (11.1) the high-risk group was 12.1% compared with 1.6% in
Liver disease 71 (16.7) the low-risk group (P < .001) (Table 4).
Congestive cardiac failure 53 (12.5)
bpm, Beats per minute. Composite clinical endpoint
*Proportions are presented as number (percentage) and continuous variables are
presented as median (interquartile range). Sixty-nine patients (16.3%) achieved at least 1 compo-
nent of the composite clinical endpoint. Eighteen (4.2%)
patients died, 41 (9.7%) experienced rebleeding, 46
were stratified into low- or high-risk groups by using the cut- (10.8%) required repeat endoscopy, 8 (1.9%) required
off threshold. The Fisher exact test was used to compare radiologic embolization, and 4 (0.9%) required surgery.
low- and high-risk groups. All P values were 2 sided, with a The AIMS65, GBS, and full Rockall score could all predict
threshold of .05 denoting statistical significance. Somer’s the composite clinical endpoint, with AUROCs of 0.63,
D statistic was used to compare the predictive accuracies 0.62, and 0.69, respectively (Table 3). When comparing
of continuous variables such as length of hospital stay. the AUROCs of the AIMS65 score, GBS, and the full
AUROCs were compared with the DeLong method by using Rockall score for the composite clinical endpoint, no
XLSTAT software Version 2013.5 (Addinsoft, New York, NY). significant differences between the scores was noted

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Robertson et al Risk stratification in acute upper GI bleeding

9 100.0%

8 90.0%

80.0%
7

70.0%
6
60.0%

Length of Stay (Days)

5

Mortality (%)
50.0%
4
40.0%
3
30.0%

2
20.0%

1 10.0%

0 0.0%
0 1 2 3 4 5
Median Length of Stay (Days) 3 4 5 7 8 *
Mortality (%) 0.0% 1.7% 2.2% 7.2% 26.1% 100.0%

AIMS65 score

Figure 1. Inpatient mortality rate and length of stay by AIMS65 score. Inpatient mortality and length of stay increased with increasing AIMS65 score.
*Only 1 patient presented with an AIMS65 score of 5, and death occurred within the first day.

(AIMS65 vs GBS, P Z .83; AIMS65 vs full Rockall, P Z .46). 0.66; P < .001). The cutoff threshold for high risk and low
The pre-endoscopy Rockall score did not achieve statistical risk for blood transfusion was 2 for the AIMS65 score, 10
significance in predicting the composite endpoint for the GBS, 4 for the pre-endoscopy Rockall score, and
(Table 3). 5 for the full Rockall score (Table 4).

ICU admission Rebleeding

The majority of patients were managed on a general
ward, with 56 (13.2%) requiring ICU admission. The
AIMS65 score was superior to all other scores in predict-
ing the need for ICU admission: AUROC, 0.74 versus 0.70
for GBS (P Z .005); 0.62 for the pre-endoscopy Rockall
score (P < .001); and 0.71 for the Rockall score
(P < .001). The cutoff value for low- and high-risk groups
was 2 for AIMS65 score, 9 for the GBS, 4 for the pre-
endoscopy Rockall score, and 6 for the full Rockall score
(Table 4).
Blood transfusion requirement
A total of 264 patients (62.3%) required red cell transfu-
sion, with a median transfusion requirement of 2 units (in-
terquartile range, 0-4). The GBS was the best predictor
with an AUROC of 0.90 compared with the AIMS65 score
(AUROC, 0.72; P < .001), the full Rockall score (AUROC,
0.68; P < .001); and pre-endoscopy Rockall score (AUROC,
The overall inpatient rebleeding rate was 9.7%
(41 patients). The full Rockall (AUROC 0.64), GBS
(AUROC 0.64) and AIMS65 (AUROC 0.61) scores were
predictors of rebleeding (Table 3). When the AUROCs
for these scores were compared, no significant
differences were noted (AIMS65 vs GBS, P Z .54;
AIMS65 vs full Rockall, P Z .35). The pre-endoscopy
Rockall score did not achieve statistical significance
(AUROC, 0.58). For inpatient rebleeding, the cutoff point
that maximized the sum of the sensitivity and the speci-
ficity was 2 for the AIMS65 score, 11 for the GBS, and
6 for the full Rockall score (Table 4).
Length of hospital stay
The median length of hospital stay was 5 days (inter-
quartile range, 3-10) and increased with increasing
AIMS65 score (Fig. 1). The AIMS65 score was superior to
the GBS, pre-endoscopy Rockall, and full Rockall scores

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Risk stratification in acute upper GI bleeding Robertson et al

1.0 previous studies and in the largest cohort of patients stud-

AIMS65 ied since the AIMS65 score was developed. We found the
Pre-Rockall AIMS65 score to be superior to other pre-endoscopy risk
0.8 GBS
scores in predicting in-hospital mortality and, impressively,
as accurate as the best validated post-endoscopy risk score.
0.6
In addition, the AIMS65 score had superior predictive abil-
Sensitivity

ity in terms of length of hospital stay and need for ICU

admission and equivalent accuracy in predicting a compos-
0.4 ite clinical endpoint of in-hospital mortality, rebleeding,
and endoscopic, radiologic, or surgical intervention
(Table 3).
0.2 The findings of this study are in agreement with those
of a retrospective analysis by Hyett et al17 that found the
AIMS65 score to be superior to the GBS for predicting
0.0
0.0 0.2 0.4 0.6 0.8 1.0 in-hospital mortality and equivalent for predicting length
A 1 - Specificity of hospital stay, time to endoscopy, rebleeding, and ICU
admission. The AIMS65 score, but not the GBS, was also
1.0 found to be an independent predictor of overall survival
AIMS65 in a Japanese cohort of patients presenting with acute
Full Rockall GI bleeding. This study included patients with both lower
0.8
and upper GI bleeding and concluded that the AIMS65
score was the best risk stratification score in predicting
Sensitivity

0.6 the prognosis of patients with acute GI bleeding.18 A

further study by Yaka et al19 found the AIMS65 score to
be equivalent to the GBS in predicting in-hospital mortal-
0.4 ity; however, the GBS had superior sensitivity in identi-
fying patients who were not likely to require endoscopic
0.2 intervention. As some studies have previously shown
that the Rockall score is superior to the GBS in predicting
patient mortality,20-22 we elected to compare AIMS65
0.0 score with both the GBS and Rockall risk stratification
0.0 0.2 0.4 0.6 0.8 1.0
B 1 - Specificity
scores.

Figure 2. Receiver-operating characteristic curves (AUROCs) for risk

stratification scores as predictors of inpatient mortality. A, The AIMS65
score compared with pre-endoscopy risk scores (Glasgow-Blatchford,
pre-endoscopy Rockall). B, The AIMS65 score compared with the full
Rockall score. AUROCs for the AIMS65 score was superior to other pre-
endoscopy risk scores and equivalent to the postendoscopy full Rockall
score.
in predicting length of hospital stay with Somer’s D statis-
tics of 0.28 (P < .001), 0.21 (P < .001), 0.20 (P < .001), and
0.24 (P < .001), respectively.
DISCUSSION
The AIMS65 risk stratification score was derived and
validated as a predictor of in-hospital mortality by Saltzman
et al in 2011.16 Our study is the first to compare the
AIMS65 score with both the most commonly used and
best validated pre-endoscopy (GBS and pre-endoscopy
Rockall score) and post-endoscopy (full Rockall score)
risk stratification scores for UGIB. It also validates the
AIMS65 score in a different population from that of
Use of risk stratification scores
Multiple guidelines and consensus statements recom-
mend the use of risk stratification tools to guide UGIB
management. Despite these recommendations, use of
risk scores remains poor, and no single score has been
routinely adopted in the clinical setting, leading to varia-
tion in practice.15 Risk stratification scores must be
accurate but also easy to remember and calculate if there
is to be widespread adoption of them in clinical practice.
The ideal risk stratification score for UGIB should be
simple and easily applied at the bedside, should make
use of clinical data that are routinely available at hospital
presentation, and should offer independent prognostic
information.23,24 The best validated UGIB risk scores
(GBS and Rockall) have limitations including complexity
in calculation, weighting, and the need for endoscopic
data for completion, all of which contribute to poor physi-
cian uptake. Modified scores have been developed in an
attempt to address these issues. For example, a modified
GBS was developed by Romagnuolo et al,25 which aimed
to eliminate subjective elements of the full score.
However, this modified risk stratification tool is also

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Robertson et al Risk stratification in acute upper GI bleeding

TABLE 3. Comparison of AIMS65, GBS, and Rockall scores with significant clinical endpoints

Outcomes AIMS65 GBS Pre-endoscopy Rockall score Full Rockall score

Mortality 0.80, P < .001 0.76, P < .001 0.74, P Z .001 0.78, P < .000
AUC (95% CI) (0.69–0.91) (0.64–0.89) (0.65-0.83) (0.69-0.88)
Composite clinical endpoint 0.62, P Z .002 0.62, P Z .01 0.55* 0.63, P Z .01
AUC (95% CI) (0.55–0.70) (0.55–0.69) (0.48–0.62) (0.56–0.71)
ICU admission 0.74, P < .001 0.70, P < .001 0.62, P Z .004 0.71, P < .001
AUC (95% CI) (0.68–0.80) (0.64–0.77) (0.55–0.69) (0.64–0.77)
Transfusion 0.72, P < .001 0.90, P < .001 0.66, P < .001 0.68, P < .001
AUC (95% CI) (0.67–0.77) (0.87–0.93) (0.61–0.72) (0.63–0.73)
Rebleeding 0.61, P Z .03 0.64, P Z .04 0.58* 0.64, P Z .003
AUC (95% CI) (0.51–0.70) (0.55–0.73) (0.50–0.67) (0.56–0.73)
Length of hospital stay, Somer’s D 0.28, P < .001 0.21, P < .001 0.20. P < .001 0.24, P < .001
GBS, Glasgow-Blatchford score; AUC, area under the curve; CI, confidence interval; ICU, intensive care unit.
*Did not reach statistical significance.

TABLE 4. Comparison of AIMS65, GBS, and Rockall scores with cutoff values, high-risk and low-risk groups

Total
Sensitivity Specificity (sensitivity D High Low
Score Cutoff value (95% CI) (95% CI) specificity) risk, % risk, % P value

AIMS65 score
Mortality 3 0.72 (0.49-0.88) 0.77 (0.73-0.81) 1.49 12.1 1.6 <.001
Composite 2 0.74 (0.62-0.83) 0.45 (0.40-0.50) 1.19 20.8 10.1 .003
ICU 2 0.88 (0.78-0.95) 0.47 (0.42-0.52) 1.36 20.4 3.4 <.001
Transfusion 2 0.71 (0.65-0.76) 0.63 (0.66-0.70) 1.34 75.9 43.6 <.001
Rebleeding 2 0.76 (0.60-0.86) 0.44 (0.39-0.49) 1.20 12.7 5.6 .019
GBS
Mortality 15 0.56 (0.34-0.75) 0.87 (0.83-0.90) 1.43 15.5 2.5 <.001
Composite 12 0.56 (0.44-0.67) 0.620 (0.56-0.66) 1.18 22.6 11.7 .003
ICU 9 0.88 (0.76-0.94) 0.44 (0.39-0.49) 1.32 27.6 10.9 .001
Transfusion 10 0.76 (0.71-0.81) 0.83 (0.77-0.88) 1.59 53.3 46.7 <.001
Rebleeding 11 0.63 (0.48-0.76) 0.61 (0.56-0.66) 1.24 15.3 5.7 .001
Pre-endoscopy Rockall score
Mortality 5 0.83 (0.60-0.95) 0.64 (0.59-0.69) 1.47 9.3 1.1 <.001
Composite 3 0.85 (0.75-0.92) 0.23 (0.19-0.28) 1.08 17.8 14.5 .150
ICU 4 0.77 (0.64-0.86) 0.42 (0.37-0.47) 1.19 16.7 7.8 .008
Transfusion 4 0.71 (0.65-0.76) 0.55 (0.47-0.62) 1.26 72.1 47 <.001
Rebleeding 3 0.73 (0.58-0.84) 0.41 (0.36-0.46) 1.14 11.6 6.6 .095
Full Rockall score
Mortality 7 0.67 (0.44-0.84) 0.80 (0.76-0.83) 1.47 8.5 1.5 <.001
Composite 7 0.41 (0.30-0.53) 0.82 (0.77-0.85) 1.23 30.9 12.1 .003
ICU 6 0.68 (0.55-0.79) 0.66 (0.61-0.79) 1.33 23 6.9 <.001
Transfusion 5 0.67 (0.61-0.73) 0.61 (0.54-0.69) 1.28 74.4 46.8 <.001
Rebleeding 6 0.44 (0.30-0.59) 0.80 (0.76-0.84) 1.24 19.1 7.0 .019
GBS, Glasgow-Blatchford score; CI, confidence interval; ICU, intensive care unit.

weighted, has not been widely adopted, and only 1 other scores, such as the CHADS2 score, which estimates the
study has examined its efficacy.26 risk of stroke in patients with nonrheumatic atrial fibrilla-
This lack of uptake in the use of UGIB risk scores con- tion. CHADS2 was acclaimed for its simplicity, practicality,
trasts with widespread acceptance of other clinical risk and accuracy, which led to its incorporation within several

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Risk stratification in acute upper GI bleeding
widely distributed guidelines.27,28 It has become a highly
successful and widely adopted risk score that is used
throughout the world.29 Subsequent attempts to improve
this risk stratification with a weighted, points-based algo-
rithm by using the Framingham Heart Data30 was
accurate and uniquely provided a 5-year risk of stroke,
but was not widely adopted due to its complexity.
Similarly, CURB-65 is a risk stratification score validated
for predicting mortality in community-acquired pneu-
monia.31 Like CHADS2, CURB-65 can be simply and easily
calculated by using 5 routinely measured parameters. An
alternative risk stratification score for pneumonia, the
Pneumonia Severity Index, has been demonstrated to
have superior discriminatory power for short-term mortal-
ity.32 The Pneumonia Severity Index, however, is more
complicated requiring 20 variables for calculation,
including arterial blood gas sampling. Multiple
international guidelines specifically note CURB65’s
simplicity and use of easily available clinical and
biochemical data.33 The British Thoracic Society
guidelines for the assessment of severity in pneumonia
state that in clinical practice, the major limitation of the
Pneumonia Severity Index with regard to its widespread
and routine adoption in primary care, ED, or medical
admission units is the complexity involved in the
calculation of the score.34
Use of a risk stratification score such as the AIMS65
score could overcome many of these issues and facilitate
standardization in practice. AIMS65 is nonweighted and
simple to remember and calculate and uses parameters
routinely available in the ED. The AIMS65 score, like
CHADS2 and CURB65, is also acronym based, making it
easy for clinicians to remember. Importantly, this study
supports previous evidence that the AIMS65 score is a
highly accurate risk stratification score in patients present-
ing with UGIB.
Early identification of low- and high-risk
patients by using risk stratification scores
It is recommended that all patients with UGIB, with the
exception of very low risk patients, are treated with hospi-
tal admission and endoscopy within 24 hours.9,35 There is
no clear evidence of benefit from earlier endoscopy,36-39
although this requires clinical judgment on a case-by-case
basis. Risk scores in UGIB should ideally be able to differ-
entiate low-risk patients for safe early discharge from high-
risk patients who would benefit from aggressive medical
therapy.
In our analysis, the AIMS65 score was the most consis-
tent UGIB score in reproducing cutoff thresholds to differ-
entiate high- and low-risk groups for each of the clinical
endpoints (Table 4). An AIMS65 cutoff value of 2 was
established to differentiate high- and low-risk groups for
all clinical endpoints excluding mortality, for which a
threshold of 3 maximized sensitivity and specificity. Previ-
ous studies have used an AIMS65 cutoff score of 2 to define
1158 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 6 : 2016
Robertson et al
those with a higher risk of death or adverse out-
comes.16,17,40,41 Our data support an AIMS65 value of 2
as the threshold to define a patient as being at high risk
of adverse outcomes; this facilitates early triage to ensure
appropriate resource allocation and location of medical
care.
Generalizability of study findings
To be most useful in the clinical setting, a UGIB risk
stratification score should be generalizable to any patient
with UGIB regardless of etiology. For this reason, we chose
study inclusion criteria that were broad and simple. This
study included all adults with confirmed UGIB presenting
to a metropolitan tertiary referral center in Australia with
a catchment area of approximately 1 million people and
thus represents real-world data. The only exclusion crite-
rion was the absence of data to calculate risk scores, result-
ing in only 2.1% of patients being excluded from analysis.
The majority of patients presenting to the ED with acute
UGIB are elderly, have comorbidities, and are taking mul-
tiple medications. Our study population includes patients
with a high comorbidity burden, the majority of whom
were taking an antiplatelet or anticoagulant agent on pre-
sentation. In addition, our cohort contained patients with
combination of both variceal and nonvariceal bleeding.
Study limitations
This study has certain limitations that warrant discus-
sion. First, it is a retrospective, single-center study, and
thus all risk score calculations, data collection, and
outcome ascertainments were based on existing clinical re-
cords. Errors were minimized by using a small number of
data collectors who entered information into a standard-
ized database. Each medical record was independently re-
viewed by 2 researchers, and discrepancies were referred
to a third reviewer.
Second, only patients who underwent endoscopy were
included in this study, which meant that patients who
refused endoscopy or were discharged directly from the
ED were not captured. Third, the retrospective nature of
this study resulted in multiple health care workers docu-
menting the data parameters used to calculate risk stratifica-
tion scores in a nonstandardized manner. This could
potentially lead to errors in risk score calculation, especially
because the risk scores incorporate subjective parameters
that require some degree of interpretation. Four of the 5
components of the AIMS65 score involve objective data.
The only subjective component is mental status; however,
in the ED, the Glasgow Coma Scale score was recorded for
most patients, and this was the primary method used to
determine impaired mental status. The definitions of the
medical history elements that are incorporated into the
GBS and Rockall scores were more difficult to standardize.
To enable consistency and in accordance with previous
studies involving the AIMS65 score, we used the definition
www.giejournal.org
Robertson et al
that Blatchford et al10 used in their original work: the
presence of those elements in the medical chart.
Finally, different risk stratification scores for UGIB were
developed by using different endpoints, and therefore
direct comparison should be performed cautiously. The
AIMS65 and Rockall scores predict in-hospital mortality
and 30-day mortality, respectively. In comparison, the
GBS predicts the need for hospital-based intervention or
death and includes the need for blood transfusion as part
of the composite endpoint. The appropriateness of using
transfusion requirements as an endpoint for UGIB is now
controversial given its defined role in resuscitation rather
than intervention, as indicated by recommendations from
the American College of Gastroenterology and interna-
tional consensus guidelines.7,42 The paradigm shift in the
use of blood transfusion in UGIB toward a more conserva-
tive approach also raises questions as to whether blood
transfusions should be included as an endpoint.43
CONCLUSION
The AIMS65 score is a simple risk stratification score for
UGIB demonstrating accuracy superior to that of the GBS
and pre-endoscopy Rockall scores for predicting in-
hospital mortality and the need for intensive care unit
admission. The AIMS65 score is easy to remember and sim-
ple to calculate by using parameters routinely available in
the ED and importantly does not require endoscopic vari-
ables for calculation. If these results are confirmed in a pro-
spective trial, the AIMS65 score should become the new
standard of care for risk stratification of UGIB.
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