MELD Score as a Predictor of Esophageal Varices Re-Bleeding Risk

Abstract

Purpose: Upper gastrointestinal bleeding secondary to esophageal varices in patients with end-stage liver disease (ESLD) is unpredictable with approximately 30% of these having at least one event. The 1-year risk of re-bleeding could be as high as 70%. The severity of underlying liver disease has been previously identified as a risk factor for re-bleeding, therefore we conducted an analysis of MELD score among patients with history of variceal bleeding and no bleeding in an effort to identify those at highest risk of re-bleeding based on this new parameter. Aim: To establish an association between the severity of MELD score and the risk of re-bleeding in patients with ESLD. Methods: Retrospective data analysis of patients with ESLD that presented to our institution with at least one episode of UGI bleeding (UGIB) from 1997 to 2002. There were 94 patients with complete database which we matched to 71 patients with ESLD and no history of bleeding (NUGIB). Results: A total of 166 patients with ESLD were evaluated. Of those, 94 had at least one episode of variceal bleeding. The mean age was 55.7 years. Etiologies of liver disease included ETOH: 100, ETOH/HCV: 34, HCV: 13, Co-Infection: 4, and Other: 15. The MELD score among patients with history of UGIB and NUGIB was 11.5 vs. 14.8 (p = 0.08) and CTP score of 7.93 vs. 8.4 (p = 0.13). There was no age difference among groups. (p = NS) Subgroup analysis of patients with history of UGIB who had further episodes of UGIB vs. those with only one episode of UGIB showed a MELD score of 14.9 in the rebleeding vs. 11.9 in the non-rebleeding groups (p = 0.04) and a CTP score of 8.59 vs. 7.52 (p = 0.013). The likelihood ratio for a repeat bleeding episode in the MELD >14 group was 1.54. Conclusions: Analysis of ESLD patients with history of variceal bleed vs. re-bleed showed a statistically significant higher MELD score in the re-bleeding group when compared to patients with only one episode of bleeding. However, it appears that MELD score is not a good overall predictor of index variceal bleeding in patients with ESLD as previously shown for CTP score. Patients with a MELD score over 14 were 50% more likely of having two or more UGI bleeding episodes. We propose that history of variceal bleeding and a MELD score >14 might identify those patients at risk of variceal re-bleeding. Table: MELD Score and Rebleeding