Scoring systems used to predict mortality in patients with acute upper gastrointestinal bleeding in the ED

Risk analysis of 30-day rebleeding in acute non-variceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

This study aimed to compare the prognostic value of ABC, Glasgow-Blatchford, Rockall and AIMS65 scoring systems in predicting rebleeding rate within 30 days after endoscopic treatment of acute non-variceal upper gastrointestinal bleeding (ANVUGIB).

PATIENTS AND METHODS

A total of 93 patients with ANVUGIB were selected as the study subjects and they were divided into groups according to whether there was rebleeding in the 30 days' follow-up period. 7 patients with rebleeding within 30 days were included in the rebleeding group, and the other 86 patients without rebleeding were included in the non-rebleeding group.

RESULTS

By drawing ROC curve, we found that ABC scoring system had the highest accuracy (area under the receiver operating characteristic (AUROC) curve [95% confidence interval (CI), 0.65]) in predicting rebleeding within 30 days compared with the AIMS65 (0.56; P < 0.001), RS (0.51; P < 0.001), and GBS (0.61; P < 0.001). ABC scoring system showed the highest risk of rebleeding in 30 days. When the 4 scoring standards were judged as medium-high risk patients, the efficacy of the ABC scoring system in predicting the risk of rebleeding at 30 days for ANVUGIB was found to be the best in diagnostic sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy.

CONCLUSION

Comprehensive evaluation showed that ABC score had the highest prediction accuracy. The negative differential significance of each evaluation method was great, that is, the risk of rebleeding was generally low when judged as low risk patients, while the value of predicting rebleeding was limited when judged as medium and high risk patients.

The Accuracy of Pre-Endoscopic Scores for Mortality Prediction in Patients with Upper GI Bleeding and No Endoscopy Performed

(1) Background: The assessment of mortality and rebleeding rate in upper gastrointestinal bleeding (UGIB) is essential, and several prognostic scores have been proposed. Some patients with UGIB did not undergo endoscopy, either because they refused the procedure, suffered from alcohol withdrawal symptoms or altered general status, or because the bleeding was severe enough to cause death before the endoscopy. The mortality risk in the subgroup of patients without endoscopy is poorly evaluated in the literature. (2) Methods: The purpose of the study was to identify the most useful scores for the assessment of in-hospital mortality in patients with UGIB with no endoscopy performed and no known etiology. A total of 198 patients with UGIB and no endoscopy performed were admitted between January 2017 and December 2021 and the accuracy of 12 prognostic scores and the Charlson comorbidity index for in-hospital mortality prediction were analyzed, as well as Child-Pugh Turcotte (CPT) and Meld scores in patients with cirrhosis. (3) Results: The mortality rate was 37.9%, higher than in variceal (21.9%, p < 0.0001) and non-variceal bleeding (7.4%, p < 0.0001). The most accurate scores by AUC were the International Bleeding score (INBS, 0.844), Glasgow Blatchford (0.783), MAP score (0.78), Iino (0.766), AIM65 and modified N-score (0.745 each), modified Glasgow-Blatchford (0.73), H3B2 and N-score (0.701); Rockall, Baylor, and T-score had an AUC below 0.7. MELD score was superior to CPT in patients with cirrhosis (AUC 0.811 versus 0.670). (4) Conclusions: The mortality rate in UGIB with no endoscopy was higher than in both variceal and non-variceal bleeding and was higher in the pandemic period but with no statistical significance (45.3% versus 32.14%, p = 0.0586), mainly because of positive cases. Only one case of rebleeding was noted; the hospitalization period was significantly shorter. The most accurate score was International Bleeding Score; the MELD score had a higher but moderate accuracy compared with CPT in patients with cirrhosis.

Performance of Six Clinical Physiological Scoring Systems in Predicting In-Hospital Mortality in Elderly and Very Elderly Patients with Acute Upper Gastrointestinal Bleeding in Emergency Department

Background and Objectives: The aim of this study is to compare the performance of six clinical physiological-based scores, including the pre-endoscopy Rockall score, shock index (SI), age shock index (age SI), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS), in predicting in-hospital mortality in elderly and very elderly patients in the emergency department (ED) with acute upper gastrointestinal bleeding (AUGIB). Materials and Methods: Patients older than 65 years who visited the ED with a clinical diagnosis of AUGIB were enrolled prospectively from July 2016 to July 2021. The six scores were calculated and compared with in-hospital mortality. Results: A total of 336 patients were recruited, of whom 40 died. There is a significant difference between the patients in the mortality group and survival group in terms of the six scoring systems. MEWS had the highest area under the curve (AUC) value (0.82). A subgroup analysis was performed for a total of 180 very elderly patients (i.e., older than 75 years), of whom 27 died. MEWS also had the best predictive performance in this subgroup (AUC, 0.82). Conclusions: This simple, rapid, and obtainable-by-the-bed parameter could assist emergency physicians in risk stratification and decision making for this vulnerable group.

The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study

BACKGROUND

Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients.

OBJECTIVE

To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding.

DESIGN AND SETTING

Prospective cohort study in an emergency department in Bursa, Turkey.

METHODS

Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated.

RESULTS

A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001).

CONCLUSION

The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.

How Can Patient's Risk Dictate the Timing of Endoscopy in Upper Gastrointestinal Bleeding?

INTRODUCTION

Although upper gastrointestinal bleeding (UGIB) management has improved substantially in the last decades, there is still much controversy regarding the optimal timing for performance of endoscopy. Recent guidelines suggest performing an early endoscopy within 24 h of nonvariceal UGIB (NVUGIB) presentation, although its impact on patients with different bleeding risks remains unclear.

AIM

To evaluate the impact of performing endoscopy within 24 h on NVUGIB outcomes and to compare it in patients with lower-risk vs. higher-risk bleeding.

METHODS

This is a retrospective cohort study including consecutive patients undergoing upper endoscopy for suspected NVUGIB over 4 years. Demographic, clinical, biochemical, endoscopic, and outcome data were collected. Lower-risk bleeding was defined as a Glasgow-Blatchford score (GBS) <12 and higher-risk bleeding was defined as a GBS ≥12.

RESULTS

A total of 298 patients with suspected NVUGIB were included, 55% of whom had higher-risk bleeding. Endoscopy was performed within 24 h in 62.1% of the patients. In lower-risk bleeding patients, performance of endoscopy within 24 h was associated with a higher need for endoscopic treatment (OR = 2.6; 95% CI 1.2-5.7; p = 0.004), a lower 30-day mortality (OR = 0.41; 95% CI 0.27-0.63; p = 0.03), and a lower need for transfusion (OR = 0.58; 95% CI 0.36-0.92; p = 0.02). In higher-risk bleeding patients, there were no statistically significant differences in NVUGIB outcomes in performing endoscopy within 24 h.

CONCLUSION

Endoscopy within 24 h of presentation was associated with a lower need for transfusion, a higher need for endoscopic treatment, and a lower 30-day mortality in lower-risk NVUGIB patients. Thus, performing endoscopy within the first 24 h of presentation can have a positive impact on NVUGIB outcomes even in lower-risk bleeding.

Comparison of AIMS65 and Glasgow Blatchford scores in predicting mortality in patients with upper gastrointestinal bleeding

OBJECTIVE

Several mortality prediction scores are available for patients with upper gastrointestinal bleeding who visited the emergency department; however, most of the available scores include endoscopic data. Endoscopy is difficult or impossible to access for many emergencies departments worldwide. The aim of this study was to evaluate and compare the performance of the albumin, INR, alteration in mental status, systolic blood pressure and age 65 score and the Glasgow-Blatchford score in predicting mortality in patients with upper gastrointestinal bleeding who visited the emergency department and for which endoscopic data were not required.

METHODS

The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were retrospectively analyzed. The data were obtained from the hospital automation system using the international classification of disease codes via computer registration. The prediction accuracy of AIMS65 and Glasgow-Blatchford score was compared using the area under the receiver operating characteristic curve method.

RESULTS

There were 422 patients in total; the mean age of these patients was 68.5 while 62.6% were males. The mortality rate was 30 (7.1%). The AIMS65 score performed better with an AUC 0.706 [95%CI 0.660-0.749; p<0.001] compared with the Glasgow-Blatchford score (AUC 0.542; 95%CI 0.4693-0.576; p=0.11).

CONCLUSION

In this study, it was revealed that AIMS65, which is a score that can be easily calculated only with the data in the emergency department, outperformed Glasgow-Blatchford score in predicting mortality in patients with acute upper gastrointestinal bleeding who visited the emergency department.

Comparing the Performance of the ABC, AIMS65, GBS, and pRS Scores in Predicting 90-day Mortality Or Rebleeding Among Emergency Department Patients with Acute Upper Gastrointestinal Bleeding: A Prospective Multicenter Study

Background and Objectives

Acute upper gastrointestinal bleeding (UGIB) is a common problem that can cause significant morbidity and mortality. We aimed to compare the performance of the ABC score (ABC), the AIMS65 score (AIMS65), the Glasgow-Blatchford score (GBS), and the pre-endoscopic Rockall score (pRS) in predicting 90-day mortality or rebleeding among patients with acute UGIB.

Methods

This was a prospective multicenter study conducted at 20 tertiary hospitals in China. Data were collected between June 30, 2020 and February 10, 2021. An area under the receiver operating characteristic curve (AUC) analysis was used to compare the performance of the four scores in predicting 90-day mortality or rebleeding.

Results

Among the 1072 patients included during the study period, the overall 90-day mortality rate was 10.91% (117/1072) and the rebleeding rate was 12.03% (129/1072). In predicting 90-day mortality, the ABC and pRS scores performed better with an AUC of 0.722 (95% CI 0.675-0.768; P<0.001) and 0.711 (95% CI 0.663-0.757; P<0.001), respectively, compared to the AIMS-65 (AUC, 0.672; 95% CI, 0.624-0.721; P<0.001) and GBS (AUC, 0.624; 95% CI, 0.569-0.679; P<0.001) scores. In predicting rebleeding in 90 days, the AUC of all scores did not exceed 0.70.

Conclusion

In patients with acute UGIB, ABC and pRS performed better than AIMS-65 and GBS in predicting 90-day mortality. The performance of each score is not satisfactory in predicting rebleeding, however. Newer predictive models are needed to predict rebleeding after UGIB.

Novel and Simple Criteria for Predicting Mortality of Peptic Ulcer Disease

Objective Conventional risk scores of peptic ulcer disease (PUD) are based on many parameters, and their application in clinical practice is therefore limited. The aim of this study was to establish simple and reliable criteria for predicting PUD-associated mortality. Methods A total of 499 patients with PUD were divided into 2 groups: the training cohort (n=333) and the validation cohort (n=166). To minimize selection bias due to missing values, we used imputed datasets generated by the multiple imputation method (training-cohort dataset, n=33,300; validation-cohort dataset, n=16,600). Results In the training-cohort dataset, the heart rate-to-systolic blood pressure ratio (HR/SBP) and serum albumin (s-Alb) level were significant independent predictive factors for mortality according to the multivariate analysis [HR/SBP, odds ratio (OR): 1.72; 95% confidence interval (CI), 1.06-2.80, p=0.028; s-Alb, OR: 0.23, 95% CI, 0.11-0.51, p<0.001]. The model comprising HR/SBP and s-Alb was able to detect mortality due to PUD with an area under the curve (AUC) of 0.855. In the validation-cohort dataset, this model also showed good efficacy with an AUC of 0.835. The novel criteria combining HR/SBP and s-Alb developed by a decision tree analysis showed 73.3% sensitivity and 87.6% specificity for predicting mortality in the total-cohort dataset. Our criteria were superior to the Glasgow Blatchford and Rockall scores and similar to the AIMS65 and Progetto Nazionale Emorragia Digestiva scores for predicting mortality. Conclusion The combination of the HR/SBP ratio and s-Alb level is a good predictor of mortality in patients with PUD.

Comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems for the prediction of the risk of in-hospital death among patients with upper gastrointestinal bleeding

OBJECTIVE

the aim of this study was to compare the AIMS65, Glasgow-Blatchford score (GBS) and Rockall score for the prediction of the risk of in-hospital death among patients with upper gastrointestinal bleeding (UGIB).

METHODS

patients with UGIB admitted to the ZhongDa hospital from June 2015 to July 2017 were retrospectively collected. All patients were assessed by the AIMS65, GBS and Rockall score and the main outcomes were in-hospital mortality. Odds ratios (OR) and 95 % confidence interval (CI) were estimated to assess the association of the three scores with the risk of death using logistic regression models. Subsequently, their risk stratification accuracy were compared. Finally, their predictive power was compared using the area under the receiver operating characteristic curve (AUROC).

RESULTS

of the 284 UGIB patients enrolled in the study, 51 (18.0 %) had variceal bleeding (VUGIB) and 10 patients (3.5 %) died. AIMS65 (OR = 5.14, 95 % CI = 2.48, 10.64), GBS (OR = 1.66, 95 % CI = 1.28, 2.15) and Rockall (OR = 2.72, 95 % CI = 1.76, 4.18) scores were positively associated with death risk among all patients. The AIMS65 score (high-risk group vs low-risk group: 11.9 % vs 0.0 %, p < 0.001) was effective to classify high-risk in-hospital deaths populations. The AIMS65 score was the best approach to predict in-hospital death among all UGIB patients (AUROC: AIMS65 0.955, GBS 0.882, Rockall 0.938), NVUGIB patients (AUROC = 0.969, 95 % CI = 0.937, 0.989) or VUGIB patients (AUROC = 0.885, 95 % CI = 0.765, 0.967).

CONCLUSIONS

the AIMS65 score is the most convenient UGIB prognostic score to predict in-hospital mortality and may be more suitable for patients with NVUGIB.

Prediction model of emergency mortality risk in patients with acute upper gastrointestinal bleeding: a retrospective study

Background

Upper gastrointestinal bleeding is a common presentation in emergency departments and carries significant morbidity worldwide. It is paramount that treating physicians have access to tools that can effectively evaluate the patient risk, allowing quick and effective treatments to ultimately improve their prognosis. This study aims to establish a mortality risk assessment model for patients with acute upper gastrointestinal bleeding at an emergency department.

Methods

A total of 991 patients presenting with acute upper gastrointestinal bleeding between July 2016 and June 2019 were enrolled in this retrospective single-center cohort study. Patient demographics, parameters assessed at admission, laboratory test, and clinical interventions were extracted. We used the least absolute shrinkage and selection operator regression to identify predictors for establishing a nomogram for death in the emergency department or within 24 h after leaving the emergency department and a corresponding nomogram. The area under the curve of the model was calculated. A bootstrap resampling method was used to internal validation, and decision curve analysis was applied for evaluate the clinical utility of the model. We also compared our predictive model with other prognostic models, such as AIMS65, Glasgow-Blatchford bleeding score, modified Glasgow-Blatchford bleeding score, and Pre-Endoscopic Rockall Score.

Results

Among 991 patients, 41 (4.14%) died in the emergency department or within 24 h after leaving the emergency department. Five non-zero coefficient variables (transfusion of plasma, D-dimer, albumin, potassium, age) were filtered by the least absolute shrinkage and selection operator regression analysis and used to establish a predictive model. The area under the curve for the model was 0.847 (95% confidence interval [0.794–0.900]), which is higher than that of previous models for mortality of patients with acute upper gastrointestinal bleeding. The decision curve analysis indicated the clinical usefulness of the model.

Conclusions

The nomogram based on transfusion of plasma, D-dimer, albumin, potassium, and age effectively assessed the prognosis of patients with acute upper gastrointestinal bleeding presenting at the emergency department.

Older age and diclofenac are associated with increased risk of upper gastrointestinal bleeding in gout patients

Background

Gouty arthritis is a disease of global burden in which defective metabolism of uric acid causes arthritis. Gouty arthritis or medications used for its treatment may lead to uric acid-associated complications such as upper gastrointestinal bleeding (UGIB) and renal impairment.

Methods

In this cross-sectional study with retrospective record review, 403 established gouty arthritis patients were recruited to determine the incidence of UGIB and associated factors among gout patients who were on regular nonsteroidal anti-inflammatory drugs (NSAIDs).

Results

The mean age of the 403 gouty arthritis patients was 55.7 years old and the majority (n = 359/403; 89.1%) were male. The incidence of UGIB among gouty arthritis patients who were on NSAIDs was 7.2% (n = 29/403). Older age (p < 0.001), diclofenac medication (p = 0.003), pantoprazole medication (p = 0.003), end-stage renal failure (ESRF) (p = 0.007), smoking (p = 0.035), hypertension (p = 0.042) and creatinine (p = 0.045) were significant risk factors for UGIB among the gouty arthritis patients in univariable analysis. Older age (p = 0.001) and diclofenac medication (p < 0.001) remained significant risk factors for UGIB among the gouty arthritis patients in multivariable analysis.

Conclusions

Age and diclofenac were significantly associated with UGIB among patients with gouty arthritis on regular NSAIDs, indicating that these factors increased the risks of developing UGIB in gout patients. Hence, these high-risk groups of gouty arthritis patients should be routinely monitored to avoid the potential onset of UGIB. Our data also suggest that diclofenac should be prescribed for the shortest duration possible to minimize the risk of developing UGIB in gout patients.

Clinical utility of the Glasgow Blatchford Score in patients presenting to the emergency department with upper gastrointestinal bleeding: A retrospective cohort study

OBJECTIVE

Upper gastrointestinal bleeding (UGIB) is a common presentation to EDs. Limited Australian data are available. Study aims were to assess mortality and re-bleeding rates in patients presenting with UGIB as risk-stratified by the Glasgow Blatchford Score (GBS).

METHODS

We conducted a retrospective medical chart review of all patients presenting with UGIB to a Brisbane tertiary hospital ED over a 12-month period. This descriptive study summarised the medical characteristics related to UGIB as risk-stratified by the GBS. Non-variceal bleeding was categorised as low-risk (GBS 0-2) or high-risk (GBS 3+). Variceal bleeding was not risk stratified.

RESULTS

A total of 211 patients presented with UGIB to the ED. The median age was 57 years, 67% were male. Mortality rates at 30 days were: 0% for GBS 0-2, 3% (95% confidence interval [CI] 0-6) for GBS 3+ and 10% (95% CI 0-21) for variceal groups. The overall 30-day re-bleeding rate was 4.3% (95% CI 2-7). High-risk patients accessed endoscopy according to international best practice of less than 24 h (GBS 3+, 23.7 h; variceal bleeding, 7.3 h).

CONCLUSIONS

Mortality and re-bleeding outcomes are similar to other international UGIB cohorts. Patients with a low-risk bleed were appropriately identified and discharged home. Those at higher risk were correctly identified and accessed timely endoscopy. The GBS demonstrated clinical utility in an Australian ED cohort of UGIB bleeding patients.

Hemostatic spray powder TC-325 in the primary endoscopic treatment of peptic ulcer-related bleeding: multicenter international registry

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % - 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy.

METHODS

Data were collected prospectively (January 2016 - March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist's discretion.

RESULTS

202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P < 0.05) compared with monotherapy or rescue therapy. There were high immediate hemostasis rates across all peptic ulcer disease Forrest classifications.

CONCLUSIONS

This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.

Is Immature Granulocyte Count a Potential Prognostic Marker for Upper Gastrointestinal Tract Bleeding? A New Road to Explore

How to cite this article: Prabu NR, Patil VP. Is Immature Granulocyte Count a Potential Prognostic Marker for Upper Gastrointestinal Tract Bleeding? A New Road to Explore. Indian J Crit Care Med 2020;24(9):750-752.

Daily Usage of Proton Pump Inhibitors May Reduce the Severity of Critical Upper Gastrointestinal Bleeding in Elderly Patients

Introduction

We retrospectively examined the relationship between daily proton pump inhibitor (PPI) use and severity of upper gastrointestinal bleeding (UGIB), mainly in the elderly.

Methods

We included 97 patients with nonvariceal UGIB diagnosed at our hospital from January 2012 to October 2017. Bleeding severity was assessed using the shock index (SI) and estimated bleeding volume; 49 patients met the criterion for the mild group and 48 for the moderate/severe group. The effect of PPI use on bleeding severity was compared between the groups. The relationships of PPI use and dose with the clinical symptoms of UGIB were also analyzed.

Results

Among the 97 patients, 17 (17.5%) habitually used PPIs. The rate of habitual PPI use was significantly higher in the mild group, indicating as an independent factor contributing to a reduction in the severity of UGIB in a multiple logistic regression analysis (30.6% vs. 4.2%; OR 10.147; 95% CI 2.174–47.358, P < 0.01). When analyzing data for a subgroup of patients older than 75 years, we found the protective PPI effect to be even higher in the mild UGIB group than in the moderate/severe group (37.0% vs. 5.6%; OR 10.000; 95% CI 1.150–86.951, P < 0.05). Conversely, we found no association between PPI prescription and UGIB symptoms in patients younger than 75 years. The mean estimated bleeding volume and SI in the 17 habitual PPI users were both significantly less than those among the 80 nonhabitual users, respectively (P < 0.05). The proportion of patients with mild UGIB was similar between the low- and high-dose PPI users.

Conclusions

Particularly in elderly patients with nonvariceal UGIB, habitual PPI use can alleviate the clinical symptoms of UGIB by suppressing the volume of bleeding, regardless of the adapted dose of PPIs.

Risk stratification in acute variceal bleeding: Comparison of the AIMS65 score to established upper gastrointestinal bleeding and liver disease severity risk stratification scoring systems in predicting mortality and rebleeding

BACKGROUND AND AIM

Risk stratification is recommended in all patients with acute variceal bleeding (AVB). It remains unclear whether liver disease severity or upper gastrointestinal bleeding (UGIB) scoring algorithms offer superior predictive ability. We aimed to validate the AIMS65 score as a predictor of mortality in AVB, and to compare AIMS65 with established UGIB and liver disease severity risk stratification scores.

METHODS

International Classification of Diseases, Tenth Revision codes identified patients presenting with AVB to three tertiary centers over a 48-month period. Patients were risk-stratified using AIMS65, Rockall, pre-endoscopy Rockall, Child-Pugh, Model for End-stage Liver Disease (MELD) and United Kingdom MELD (UKELD) scores. Primary outcomes were inpatient and 6-week mortality and inpatient rebleeding.

RESULTS

Two hundred and twenty-three patients were included. Inpatient and 6-week mortality were 13.9% and 15.5% respectively. Prediction of inpatient mortality by AIMS65 (area under the receiver-operating characteristic curve [AUROC: 0.84]) was equivalent to UGIB (Rockall: 0.79, pre-Rockall: 0.78) and liver risk scores (MELD: 0.81, UKELD: 0.79, Child-Pugh: 0.78). AIMS65 score ≥3 best defined high- and low-risk groups for inpatient mortality (mortality 37.7% vs 4.9%). AIMS65 (AUROC: 0.62) was equivalent to UGIB risk scores (pre-Rockall: 0.64, Rockall: 0.70) in predicting inpatient rebleeding and superior to liver risk scores (MELD: 0.56, UKELD: 0.57, Child-Pugh: 0.60).

CONCLUSIONS

AIMS65 is equivalent to established UGIB and liver disease severity risk stratification scores in predicting mortality, and superior to liver scores in predicting rebleeding.

Validation of a new risk score system for non-variceal upper gastrointestinal bleeding

BACKGROUND

Recently, a new international bleeding score was developed to predict 30-day hospital mortality in patients with upper gastrointestinal bleeding (UGIB). However, the efficacy of this newly developed scoring system has not been extensively investigated. We aimed to validate a new scoring system for predicting 30-day mortality in patients with non-variceal UGIB and determine whether a higher score is associated with re-bleeding, length of hospital stay, and endoscopic failure.

METHODS

A retrospective study was performed on 905 patients with acute non-variceal UGIB who were examined in our hospital between January 2013 and December 2017. Baseline characteristics, endoscopic findings, re-bleeding, admission, and mortality were reviewed. The 30-day mortality rate of the new international bleeding risk score was calculated using the receiver operating characteristic curves and compared to the pre-endoscopy Rockall score, AIMS65, Glasgow Blatchford score, and Progetto Nazionale Emorragia Digestiva score. To verify the variable for the 30-day mortality of the new scoring system, we performed multivariate logistic regression using our data and further analyzed the score items.

RESULTS

The new international bleeding scoring system showed higher receiver operating characteristic (ROC) curve values in predicting mortality (area under ROC curve 0.958; [95% confidence interval (CI)]), compared with such as AIMS65 (AUROC, 0.832; 95%CI, 0.806-0.856; P < 0.001), PNED (AUROC, 0.865; 95%CI, 0.841-0.886; P < 0.001), Pre-RS (AUROC, 0.802; 95%CI, 0.774-0.827; P < 0.001), and GBS (AUROC, 0.765; 95%CI, 0.736-0.793; P < 0.001). Multivariate analysis was performed using our data and showed that the 30-day mortality rate was related to multiple comorbidities, blood urea nitrogen, creatinine, albumin, syncope at first visit, and endoscopic failure within 24 h during the first admission. In addition, in the high-score group, relatively long hospital stay, re-bleeding, and endoscopic failure were observed.

CONCLUSION

This is a preliminary report of a new bleeding score which may predict 30-day mortality better than the other scoring systems. High-risk patients could be screened using this new scoring system to predict 30-day mortality. The use of this scoring system seemed to improve the outcomes of non-variceal UGIB patients in this study, through proper management and intervention.

Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Profile and outcome of patients with upper gastrointestinal bleeding presenting to urban emergency departments of tertiary hospitals in Tanzania

Background

Upper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania.

Methods

This was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality.

Results

During the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32–64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. < 3 and 3–4. No patient with scores of > 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7–29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8–22.8).

Conclusions

In this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Discharge of patients with an acute upper gastrointestinal bleed from the emergency department using an extended Glasgow-Blatchford Score

OBJECTIVE

To use an extended Glasgow-Blatchford Score (GBS) cut-off of ≤1 to aid discharge of patients presenting with acute upper gastrointestinal bleeding (AUGIB) from emergency departments.

BACKGROUND

The GBS accurately predicts the need for intervention and death in AUGIB, and a cut-off of 0 is recommended to identify patients for discharge without endoscopy. However, this cut-off is limited by identifying a low percentage of low-risk patients. Extension of the cut-off to ≤1 or ≤2 has been proposed to increase this proportion, but there is controversy as to the optimal cut-off and little data on performance in routine clinical practice.

METHODS

Dual-centre study in which patients with AUGIB and GBS ≤1 were discharged from the emergency department without endoscopy unless there was another reason for admission. Retrospective analysis of associated adverse outcome defined as a 30-day combined endpoint of blood transfusion, intervention or death.

RESULTS

569 patients presented with AUGIB from 2015 to 2018. 146 (25.7%) had a GBS ≤1 (70, GBS=0; 76, GBS=1). Of these, 103 (70.5%) were managed as outpatients, and none had an adverse outcome. GBS ≤1 had a negative predictive value=100% and the GBS had an area under receiver operator characteristic​​ (AUROC)=0.89 (95% CI 0.86 to 0.91) in predicting adverse outcomes. In 2008-2009, prior to risk scoring (n=432), 6.5% of patients presenting with AUGIB were discharged safely from the emergency department in comparison with 18.1% (p<0.001) in this cohort. A GBS cut-off ≤2 was associated with an adverse outcome in 8% of cases.

CONCLUSION

GBS of ≤1 is the optimal cut-off for the discharge of patients with an AUGIB from the emergency department.

Initial Assessment, Risk Stratification, and Early Management of Acute Nonvariceal Upper Gastrointestinal Hemorrhage

Inhospital mortality from nonvariceal upper gastrointestinal bleeding has improved with advances in medical and endoscopy therapy. Initial management includes resuscitation, hemodynamic monitoring, proton pump inhibitor therapy, and restrictive blood transfusion. Risk stratification scores help triage bleeding severity and provide prognosis. Upper endoscopy is recommended within 24 hours of presentation; select patients at lowest risk may be effectively treated as outpatients. Emergent endoscopy within 12 hours does not improve clinical outcomes, including mortality, rebleeding, or need for surgery, despite an increased use of endoscopic treatment. There may be a benefit to emergent endoscopy in patients with evidence of active bleeding.