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Rockall score

The Rockall score is a clinical risk stratification tool designed to predict mortality, rebleeding, and other adverse outcomes in patients presenting with acute upper gastrointestinal bleeding (UGIB).^[1] Developed in 1996 based on a prospective UK national audit involving 4185 patients, it incorporates both pre-endoscopic and post-endoscopic variables to categorize patients into low-, medium-, or high-risk groups, with scores ranging from 0 to 11; higher scores correlate with increased risk of death (e.g., 0% mortality for scores of 0–2 versus up to 41% for scores ≥8).^[1] The score comprises two parts: the pre-endoscopic Rockall score, which assesses age (0 points for <60 years, 1 for 60–79, 2 for ≥80), hemodynamic shock (0 for no shock, 1 for tachycardia without hypotension, 2 for hypotension with tachycardia), and comorbidity (0 for no major, 2 for cardiac failure or ischemic heart disease, 3 for renal or hepatic failure or malignancy), yielding a maximum of 7 points; and the complete score, which adds endoscopic findings including diagnosis (0 for peptic ulcer, Mallory-Weiss tear, or no lesion; 2 for other diagnoses including malignancy) and stigmata of recent hemorrhage (0 for clean-based ulcer; 2 for active bleeding, visible vessel, or adherent clot), for a total maximum of 11 points.^[1] This system was derived from multivariate analysis of audit data to identify independent predictors of mortality, enabling early identification of low-risk patients (score ≤2) suitable for outpatient management or early discharge, while guiding intensive monitoring and intervention for higher-risk cases.^[2] Prospectively validated in an additional 1625 patients from the same audit, the Rockall score demonstrated strong discriminative ability (area under the receiver operating characteristic curve of 0.84 for mortality prediction) and has since been externally validated in diverse populations, including studies in Canada, Asia, and Europe as of 2025, confirming its utility primarily for mortality prediction despite some limitations in predicting rebleeding alone compared to other scores like the Glasgow-Blatchford.^[1]^[3]^[4] Its integration into clinical guidelines, such as those from the American College of Gastroenterology for post-endoscopic management of high-risk patients, underscores its role in standardizing UGIB management, though ongoing refinements address evolving endoscopic practices and patient demographics.^[5]

Background

Definition and Purpose

The Rockall score is a multivariate risk scoring system developed to predict the risk of mortality and re-bleeding in patients with acute upper gastrointestinal (UGI) bleeding. It integrates clinical and endoscopic variables to provide a numerical assessment, enabling clinicians to quantify prognosis based on readily available data.^[6] Originally derived from a large prospective audit of over 4,000 cases, the score emphasizes independent predictors such as age, hemodynamic status, comorbidities, bleeding source, and endoscopic findings, particularly in non-variceal UGI bleeding where it demonstrates strong prognostic utility.^[7] The primary purpose of the Rockall score is to stratify patients into risk categories, facilitating informed clinical decisions on hospitalization, the timing of endoscopy, and the need for intensive care unit admission. By identifying high-risk individuals early, it supports targeted interventions to improve outcomes, such as aggressive resuscitation or endoscopic therapy, while allowing low-risk patients to be considered for early discharge or outpatient management, thereby optimizing resource allocation.^[6] This risk stratification also aids in audit and research by standardizing case-mix comparisons across institutions.^[7] The score applies specifically to adults presenting with signs of acute UGI bleeding, such as hematemesis, melena, or syncope due to blood loss, and is distinct from tools designed for lower gastrointestinal bleeding, which involve different anatomical and etiological considerations.^[6] It is most relevant in non-variceal cases, like peptic ulcers or erosions, though it can be applied more broadly to UGI hemorrhage.^[7] In structure, the Rockall score comprises pre-endoscopic factors for initial assessment and endoscopic variables added post-procedure, resulting in a total score ranging from 0 to 11, with higher values indicating greater risk.

Historical Development

The Rockall score was developed by Tim Rockall and colleagues in the United Kingdom as part of the National Audit of Acute Upper Gastrointestinal Haemorrhage, a prospective, multicentre study conducted in 1993 that prospectively collected data on 4,185 patients aged over 16 years across 74 hospitals in four English health regions.^[8] This audit aimed to provide a comprehensive, population-based assessment of the incidence, management, and outcomes of acute upper gastrointestinal haemorrhage to inform national standards and improvements in care.^[8] The score was first described in 1996 in a seminal paper published in the journal Gut, where the authors used multivariate logistic regression analysis on the audit data to identify independent predictors of mortality, including age, shock, comorbidity, endoscopic diagnosis, and stigmata of recent haemorrhage.^[2] This analysis enabled the formulation of a simple numerical scoring system to stratify patients by risk of death following acute upper gastrointestinal bleeding.^[2] In the same 1996 study, the score was internally validated on a subsequent cohort of 1,625 patients from a 1994 audit phase, demonstrating reproducible prediction of mortality rates across risk categories and identifying low-risk groups suitable for early discharge.^[2] The framework included a pre-endoscopic component for initial risk assessment prior to endoscopy, facilitating timely clinical decision-making without delaying procedures.^[2] By the early 2000s, the Rockall score had gained widespread acceptance and was incorporated into clinical guidelines, including those from the American College of Gastroenterology, for risk stratification in upper gastrointestinal bleeding management.^[5] Although subsequent research has proposed minor adaptations to enhance specificity for certain outcomes, the original scoring system continues to serve as the standard prognostic tool due to its validated simplicity and prognostic reliability.

Components of the Score

Pre-Endoscopic Factors

The pre-endoscopic factors in the Rockall score consist of three clinical variables assessed prior to endoscopy to evaluate initial risk in patients with acute upper gastrointestinal bleeding: age, hemodynamic status (shock), and comorbidities.^[9] Age is scored as 0 points for patients under 60 years, 1 point for those aged 60-79 years, and 2 points for individuals 80 years or older, reflecting the increased mortality risk associated with advanced age in this population.^[9] Shock is evaluated based on vital signs, with 0 points for no shock (systolic blood pressure ≥100 mmHg and pulse <100 bpm), 1 point for tachycardia (pulse ≥100 bpm with systolic blood pressure ≥100 mmHg), and 2 points for hypotension (systolic blood pressure <100 mmHg), indicating the severity of hypovolemia and its prognostic implications.^[9] Comorbidities are graded as 0 points for no major comorbidity, 2 points for conditions such as ischemic heart disease, cardiac failure, or other significant comorbidities, and 3 points for severe states including renal failure, liver failure, or disseminated malignancy, capturing the burden of underlying disease on outcomes.^[9] These factors were identified through multivariate logistic regression analysis of data from a national audit involving 2,531 patients with acute upper gastrointestinal hemorrhage, demonstrating their independent association with rebleeding and mortality independent of the bleeding source.^[9] In the derivation cohort, patients scoring 0-2 on these pre-endoscopic variables (29.4% of cases) experienced low rates of rebleeding (4.3%) and mortality (0.1%), supporting their use for early risk stratification.^[9] Assessment of these pre-endoscopic factors occurs at the time of patient presentation in emergency or admission settings, enabling rapid triage and initial management decisions without requiring endoscopic evaluation.^[9]

Variable	Score 0	Score 1	Score 2	Score 3
Age (years)	<60	60-79	≥80	-
Shock	No shock (systolic BP ≥100 mmHg, pulse <100 bpm)	Tachycardia (pulse ≥100 bpm, systolic BP ≥100 mmHg)	Hypotension (systolic BP <100 mmHg)	-
Comorbidity	Nil major	-	Ischemic heart disease, cardiac failure, or other major comorbidity	Renal failure, liver failure, or disseminated malignancy

Endoscopic Factors

The endoscopic factors in the Rockall score are incorporated after upper gastrointestinal endoscopy to enhance prognostic precision by identifying lesion characteristics and bleeding signs that correlate with rebleeding and mortality risk. These factors consist of two variables: the endoscopic diagnosis and the stigmata of recent hemorrhage. For diagnosis, a score of 0 is assigned to Mallory-Weiss tear or no identifiable lesion, 1 point to all other diagnoses (such as peptic ulcer, esophagitis, or gastritis), and 2 points to upper gastrointestinal tract malignancy, reflecting the increased mortality associated with neoplastic lesions. The stigmata of recent hemorrhage are scored as 0 for absence or presence of only a dark spot in the ulcer base, and 2 points for more ominous findings including blood in the upper gastrointestinal tract, adherent clot, visible vessel, or spurting vessel, which signal higher rebleeding potential.

Endoscopic Variable	Scoring Categories	Points
Diagnosis	Mallory-Weiss tear or no lesion	0
	All other diagnoses	1
	Malignancy of upper GI tract	2
Stigmata of Recent Hemorrhage	None or dark spot in ulcer base	0
	Blood, adherent clot, visible or spurting vessel	2

The rationale for these endoscopic components stems from their identification as independent predictors of mortality in a large prospective study of over 4,000 patients, where multivariate analysis confirmed their prognostic value beyond clinical factors alone. Specifically, the stigmata classification draws from the Forrest system for peptic ulcer bleeding, which categorizes endoscopic appearances (e.g., active bleeding or non-bleeding visible vessel) as indicators of imminent rebleeding risk, extended here to broader upper gastrointestinal lesions. Assessment of these factors occurs during upper endoscopy, which is recommended within 24 hours of presentation for patients at high risk of adverse outcomes, allowing timely evaluation and potential therapeutic intervention.32509-7/fulltext) These endoscopic findings are then integrated with pre-endoscopic variables to compute the complete Rockall score.

Calculation Method

Pre-Endoscopic Score

The pre-endoscopic Rockall score is computed by summing points assigned to three clinical variables: age, hemodynamic status (shock), and comorbidities, resulting in a total ranging from 0 to 7 points.^[2] This partial score enables rapid risk stratification in patients presenting with acute upper gastrointestinal bleeding prior to endoscopic evaluation.^[10] To calculate the score, follow these steps: (1) Categorize the patient's age and assign points—0 for under 60 years, 1 for 60–79 years, and 2 for 80 years or older; (2) Assess vital signs for shock—0 points if systolic blood pressure is at least 100 mmHg and pulse is under 100 beats per minute, 1 point if pulse is 100 beats per minute or higher with systolic blood pressure at least 100 mmHg (indicating tachycardia), and 2 points if systolic blood pressure is below 100 mmHg (indicating hypotension); (3) Evaluate medical history for major comorbidities—0 points if none, 2 points for conditions such as ischemic heart disease or cardiac failure, and 3 points for severe conditions like renal failure, liver failure, or disseminated malignancy; (4) Add the points from all three variables to obtain the total score.^[2] The following table summarizes the point assignments for each variable:

Variable	0 Points	1 Point	2 Points	3 Points
Age	<60 years	60–79 years	≥80 years	-
Shock	No shock (SBP ≥100 mmHg and pulse <100 bpm)	Tachycardia (SBP ≥100 mmHg and pulse ≥100 bpm)	Hypotension (SBP <100 mmHg)	-
Comorbidities	None	-	Cardiac failure, ischemic heart disease, or other major comorbidity	Renal failure, liver failure, or disseminated malignancy

This score facilitates bedside or emergency department triage, allowing clinicians to identify patients at higher risk who require hospitalization and prompt endoscopic intervention.^[10] Guidelines recommend upper endoscopy within 24 hours after resuscitation for most patients with acute upper gastrointestinal bleeding.^[10] For example, a 70-year-old patient presenting with mild tachycardia (pulse ≥100 bpm, systolic blood pressure ≥100 mmHg) and no major comorbidities would receive 1 point for age, 1 point for shock, and 0 points for comorbidities, yielding a total pre-endoscopic score of 2.^[2] Endoscopic factors, such as diagnosis and stigmata of recent hemorrhage, are added later to form the complete Rockall score.^[2]

Complete Rockall Score

The complete Rockall score is computed by integrating the pre-endoscopic subtotal with endoscopic findings to provide a comprehensive prognostic assessment for patients with acute upper gastrointestinal bleeding.^[2] This full score sums points from five key factors: age, shock status, comorbidities (pre-endoscopic), endoscopic diagnosis, and stigmata of recent hemorrhage (endoscopic).^[2] The total ranges from 0 to 11 points, with higher scores indicating greater risk.^[2] The step-by-step process begins with calculating the pre-endoscopic subtotal, which assigns points based on initial clinical presentation: age (<60 years = 0, 60-79 years = 1, ≥80 years = 2), shock (0 for no shock: systolic blood pressure ≥100 mm Hg and pulse <100 bpm; 1 for tachycardia: systolic blood pressure ≥100 mm Hg and pulse ≥100 bpm; 2 for hypotension: systolic blood pressure <100 mm Hg), and comorbidities (none = 0, major such as ischemic heart disease or cardiac failure = 2, severe such as renal failure, liver failure, or disseminated malignancy = 3), yielding a subtotal from 0 to 7.^[2] Next, upper endoscopy is performed to evaluate the bleeding source, assigning points for diagnosis (Mallory-Weiss tear, no lesion, or no stigmata of recent hemorrhage = 0; all other non-malignant lesions such as peptic ulcer = 1; upper gastrointestinal malignancy = 2) and stigmata of recent hemorrhage (none or dark spot in ulcer base = 0; blood in upper gastrointestinal tract, adherent clot, visible vessel, or active bleeding = 2), contributing 0 to 4 additional points.^[2] The complete score is then obtained by adding the pre-endoscopic subtotal to the endoscopic points.^[2] This summation can be represented as: Total Score = Age + Shock + Comorbidities + Diagnosis + Stigmata where each term reflects the assigned points from the respective factors.^[2] For illustration, consider a patient aged 70 years (1 point for age) with no shock (0) and no comorbidities (0), yielding a pre-endoscopic subtotal of 1; if endoscopy reveals a peptic ulcer (1 for diagnosis) with an adherent clot (2 for stigmata), the complete score totals 4.^[2]

Interpretation and Risk Stratification

Score Categories and Outcomes

The complete Rockall score stratifies patients with upper gastrointestinal bleeding into four risk categories based on their total score, each associated with distinct rates of rebleeding and mortality derived from the original validation study involving 1,622 patients.^[11] These categories facilitate risk assessment primarily for non-variceal upper gastrointestinal bleeding, guiding prognostic expectations.^[11] Low-risk patients (score 0) exhibit minimal adverse outcomes, with a rebleeding rate of 0% and 0% mortality.^[11] Moderate-risk patients (score 1-3) face elevated risks, including 3.4% rebleeding and 0.1% mortality.^[11] High-risk patients (score 4-7) show further increases, with 15.4% rebleeding and 2.9% mortality.^[11] Very high-risk patients (score ≥8) experience the most severe outcomes, marked by 34.1% rebleeding and 41.1% mortality.^[11] Mortality rates rise exponentially across categories, reflecting the cumulative impact of risk factors such as age, comorbidities, and endoscopic stigmata.^[11] Rebleeding rates, while increasing overall, peak in the very high-risk group, underscoring the score's utility in identifying those needing intensive monitoring.^[11]

Risk Category	Score Range	Rebleeding Rate	Mortality Rate
Low	0	0%	0%
Moderate	1-3	3.4%	0.1%
High	4-7	15.4%	2.9%
Very High	≥8	34.1%	41.1%

Prognostic Accuracy

The Rockall score exhibits strong prognostic accuracy for predicting mortality in upper gastrointestinal bleeding, with area under the receiver operating characteristic curve (AUC) values of approximately 0.8 in validation studies and meta-analyses. At cutoffs of ≥5, the score achieves reasonable sensitivity and specificity for identifying fatal outcomes, enabling effective risk stratification for death. In contrast, its performance for rebleeding is moderate, with pooled AUC values around 0.7 across meta-analyses of validation studies.^[12] A key strength of the Rockall score lies in its excellent prediction of 30-day mortality, particularly with the complete post-endoscopy version, which incorporates diagnostic findings to refine risk assessment. This capability allows clinicians to identify low-risk patients (typically complete score ≤2) who can be safely managed as outpatients, reducing unnecessary hospitalizations without compromising safety. The score's integration of both pre- and post-endoscopic factors enhances its utility in guiding early decision-making during acute presentations.^[1] Despite these advantages, the Rockall score shows limitations in predicting the need for interventions, such as surgery or blood transfusions, where discrimination is poorer compared to mortality endpoints. It also performs better in non-variceal bleeding than in variceal cases, where alternative scoring systems may be more appropriate due to differing pathophysiology.^[13]^[14] Overall, the Rockall score has been extensively validated as superior to unaided clinical judgment for risk stratification, providing a structured, evidence-based approach that improves outcomes in upper gastrointestinal bleeding management.^[1]

Clinical Applications

Use in Patient Management

The pre-endoscopic Rockall score facilitates triage and disposition decisions in patients presenting with upper gastrointestinal (UGI) bleeding. A score of 0 identifies very low-risk individuals who may be suitable for outpatient endoscopy or observation without immediate hospitalization, provided hemodynamic stability and absence of ongoing bleeding, though the Glasgow-Blatchford score is preferred for this assessment.^[15] In contrast, scores ≥3 indicate higher risk, warranting hospital admission and endoscopy within 24 hours, with more urgent evaluation if hemodynamically unstable.^[6] In resource allocation, the complete Rockall score guides targeted interventions for high-risk patients. Those with scores ≥5 require intensive measures, including potential intensive care unit (ICU) monitoring for hemodynamic instability, blood transfusions to target hemoglobin levels above 7 g/dL, and initiation of high-dose proton pump inhibitors (PPIs) to reduce rebleeding risk.^[5] This approach aligns with American College of Gastroenterology (ACG) recommendations for managing ulcer-related UGI bleeding, emphasizing escalated care based on post-endoscopic findings.^[5] Post-endoscopic monitoring involves ongoing clinical assessment to track changes in patient status after therapeutic interventions, enabling adjustments in care intensity.^[1] This is particularly valuable in multidisciplinary teams managing elderly or comorbid patients, where vigilant monitoring helps detect evolving risks such as rebleeding.^[16] The Rockall score is always integrated with clinical judgment to individualize management, avoiding rigid application in complex cases. For instance, a low complete score (≤2) may support early discharge with scheduled follow-up, balancing score-based risk with patient-specific factors like social support.^[1] Risk categories from the score—low (0–2), intermediate (3–5), and high (≥6)—provide a framework for these decisions without overriding bedside evaluation.^[1]

Comparison with Other Scores

The Rockall score, which incorporates both pre-endoscopic and endoscopic variables to predict mortality in upper gastrointestinal (UGI) bleeding, differs from the Glasgow-Blatchford Score (GBS), a pre-endoscopic tool ranging from 0 to 23 that primarily assesses the need for clinical interventions such as transfusion or endoscopy.^[17] The GBS excels in identifying low-risk patients suitable for outpatient management, with an area under the receiver operating characteristic curve (AUC) of approximately 0.9 for predicting the need for blood transfusion, outperforming the Rockall score in this domain.^[18] In contrast, the Rockall score demonstrates superior performance for mortality prediction compared to the GBS, particularly in its complete form after endoscopy.^[19] Another pre-endoscopic alternative is the AIMS65 score, which ranges from 0 to 5 and focuses on predicting in-hospital mortality and the need for intensive care unit admission using simple variables like albumin levels and mental status, without requiring endoscopic findings.^[20] The AIMS65 shows comparable accuracy to the full Rockall score for mortality prediction, with an AUC of around 0.80 versus 0.74-0.80 for Rockall, but its simplicity makes it more practical for initial emergency department triage.^[20] However, the Rockall score's inclusion of endoscopic stigmata provides additional prognostic refinement beyond what AIMS65 offers.^[21] For lower gastrointestinal bleeding, the Oakland score serves as a specialized tool to identify low-risk patients for safe discharge, emphasizing variables like heart rate and comorbidities, but it is not designed for UGI bleeding where the Rockall score applies.^[22] The Rockall score remains unique among UGI tools for its post-endoscopic enhancement, which improves overall risk stratification.^[14] Studies indicate that hybrid approaches, such as combining the Rockall score with the GBS, can enhance predictive accuracy for composite outcomes like rebleeding and mortality by leveraging the strengths of both pre- and post-endoscopic assessments.^[23] Clinicians typically select the Rockall score for comprehensive post-endoscopy prognostication in UGI bleeding, while preferring the GBS or AIMS65 for rapid, pre-endoscopic triage in emergency settings to guide immediate decisions on hospitalization or intervention.^[24]

Validation and Limitations

Key Validation Studies

The original validation of the Rockall score was conducted in the United Kingdom in 1996 using data from a national audit involving 5,810 patients with acute upper gastrointestinal bleeding, confirming its ability to predict mortality, with rates increasing from less than 1% for scores of 0–2 to over 40% for scores ≥8. Subsequent international validations have supported its reliability in diverse populations. A 2006 Canadian study of 1,869 patients with non-variceal upper gastrointestinal bleeding found the score provided good calibration and an acceptable discriminative ability for predicting death (AUC 0.73, 95% CI 0.69–0.78), though it performed poorly for rebleeding (AUC 0.59).^[13] Similarly, a 2013 prospective Brazilian study of 656 patients with non-variceal upper gastrointestinal bleeding reported acceptable accuracy for mortality prediction using the complete score (AUC 0.69), highlighting its utility in assessing complications such as the need for intervention, despite limitations in forecasting rebleeding (AUC 0.52).^[25] More recent validations continue to affirm the score's performance, particularly in specific cohorts. A 2024 prospective cohort study in Egypt involving 400 patients with upper gastrointestinal bleeding demonstrated that the Rockall score exhibited the highest sensitivity for predicting in-hospital mortality compared to other scores like AIMS65 and Glasgow-Blatchford, though its specificity was moderate.^[24] In elderly patients, a 2023 Taiwanese study of 336 individuals aged over 65 with acute upper gastrointestinal bleeding showed the pre-endoscopic Rockall score effectively differentiated mortality risk (p=0.03 in univariate analysis), with consistent prognostic value, albeit outperformed by scores like MEWS in discriminative power; performance was noted to vary in variceal bleeding cases across reviewed literature.^[26] A 2025 multicenter study comparing risk scores in patients with upper gastrointestinal bleeding found the pre-endoscopic Rockall score most effective for predicting mortality and readmission, with superior discriminative ability (AUC 0.85).^[4]

Criticisms and Limitations

The Rockall score has been criticized for its limited ability to predict rebleeding and the need for surgical interventions in patients with upper gastrointestinal bleeding, with area under the curve (AUC) values as low as 0.59 for rebleeding and 0.60 for surgery in a prospective cohort study of 1,869 patients.^[13] This poor performance is attributed to the score's primary focus on mortality prediction during its development, rather than other adverse outcomes that are now more relevant with advances in endoscopic therapy.^[13] The score demonstrates reduced accuracy in cases of variceal bleeding, where it fails to reliably predict 6-week rebleeding or mortality, with AUC values ≤0.66, limiting its utility in this subgroup that comprised only a small portion of the original validation cohort.^[27] Additionally, developed in 1996 when mortality rates exceeded 10%, the Rockall score tends to overestimate risk in contemporary settings, where overall mortality has declined to 2–10% due to improved resuscitation, pharmacological prophylaxis, and endoscopic techniques, such as those achieving successful hemostasis that the score does not account for.^[7]^[28] A key criticism is the requirement for endoscopic findings to compute the full score, which delays early risk stratification and triage in acute settings, as the pre-endoscopic version alone has lower discriminatory power for interventions compared to alternatives like the Glasgow-Blatchford score (GBS).^[28] The comorbidity component, categorized simply as none, major (e.g., cardiac, renal, or liver disease), or disseminated malignancy, introduces subjectivity in clinical assessment, potentially leading to inconsistent scoring across providers.^[29] The Rockall score has not been validated for lower gastrointestinal bleeding, where tools like the Oakland score are preferred, further restricting its applicability beyond upper gastrointestinal contexts.^[30] Guidelines, such as the 2021 European Society of Gastrointestinal Endoscopy (ESGE) update on non-variceal upper gastrointestinal bleeding, highlight these gaps and advocate for hybrid approaches combining the Rockall score with more sensitive pre-endoscopic tools like the GBS to enhance overall accuracy.^[28] Future improvements may involve integrating the Rockall score with emerging technologies, such as artificial intelligence models or biomarkers (e.g., those assessing coagulation or inflammation), to address its shortcomings in dynamic risk prediction and adapt to evolving therapeutic landscapes.^[28]

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