Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage

Emergency medicine updates: Upper gastrointestinal bleeding

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diagnosis and management of this disease.

OBJECTIVE

This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician.

DISCUSSION

UGIB most frequently presents with hematemesis. There are numerous causes, with the most common peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diagnosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical intervention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several considerations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including the Glasgow Blatchford Score.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients with UGIB.

Development and validation of machine learning models to predict the need for haemostatic therapy in acute upper gastrointestinal bleeding

Background

Acute upper gastrointestinal bleeding (AUGIB) is a major cause of morbidity and mortality. This presentation however is not universally high risk as only 20-30% of bleeds require urgent haemostatic therapy. Nevertheless, the current standard of care is for all patients admitted to an inpatient bed to undergo endoscopy within 24 h for risk stratification which is invasive, costly and difficult to achieve in routine clinical practice.

Objectives

To develop novel non-endoscopic machine learning models for AUGIB to predict the need for haemostatic therapy by endoscopic, radiological or surgical intervention.

Design

A retrospective cohort study.

Method

We analysed data from patients admitted with AUGIB to hospitals from 2015 to 2020 (n = 970). Machine learning models were internally validated to predict the need for haemostatic therapy. The performance of the models was compared to the Glasgow-Blatchford score (GBS) using the area under receiver operating characteristic (AUROC) curves.

Results

The random forest classifier [AUROC 0.84 (0.80-0.87)] had the best performance and was superior to the GBS [AUROC 0.75 (0.72-0.78), p < 0.001] in predicting the need for haemostatic therapy in patients with AUGIB. A GBS cut-off of ⩾12 was associated with an accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 0.74, 0.49, 0.81, 0.41 and 0.85, respectively. The Random Forrest model performed better with an accuracy, sensitivity, specificity, PPV and NPV of 0.82, 0.54, 0.90, 0.60 and 0.88, respectively.

Conclusion

We developed and validated a machine learning algorithm with high accuracy and specificity in predicting the need for haemostatic therapy in AUGIB. This could be used to risk stratify high-risk patients to urgent endoscopy.

Scoring systems for risk stratification in upper and lower gastrointestinal bleeding

Several scoring systems have been developed for both upper and lower GI bleeding to predict the bleeding severity and discriminate between low-risk patients, who may be suitable for outpatient management, and those who would likely need hospital-based interventions and are at high risk for adverse outcomes. Risk scores created to identify low-risk patients (namely the Glasgow Blatchford Score and the Oakland score) showed very good discriminative performances and their implementation has proven to be effective in reducing hospital admissions and healthcare burden. Conversely, the performances of risk scores in identifying specific adverse events to define high-risk patients are less accurate, and whether their integration into routine clinical practice has a tangible impact on patient management remains unproven. This review describes the existing risk score systems for GI bleeding, emphasizes key research findings, elucidates the circumstances in which their utilization can be beneficial, examines their constraints when considering routine clinical application, and discuss future development.

Concern for Increased Prevalence of Heyde's Syndrome in Patients on Hemodialysis

The association between aortic stenosis and increased gastrointestinal arteriovenous malformations is known as Heyde's syndrome. An acquired von Willebrand deficiency mediates the connection between these two seemingly dispersed pathologies. As von Willebrand factor passes through a stenosed aorta, it is broken down and can no longer inhibit angiogenesis, leading to angiodysplasias. Heyde's syndrome can manifest with chronic, refractory anemia requiring multiple hospitalizations for symptomatic gastrointestinal bleeding and transfusion. Hitherto, Heyde's syndrome has been considered exceptionally rare, with 1-3% of populations with aortic stenosis. However, given that 31.7% of patients with gastrointestinal angioplasty have aortic stenosis and gastrointestinal arteriovenous malformations are not screened for in patients without anemia, the prevalence of Heyde's syndrome is most likely higher than currently reflected in the literature. Also, the prevalence of Heyde's syndrome in populations who are predisposed to angiodysplasias, such as those on hemodialysis, is understudied. We aim to impart a need for increased research on the prevalence of Heyde's syndrome, especially in high-risk patients. This case report presents a patient with severe Heyde's syndrome on hemodialysis, showing an unconsidered risk factor for Heyde's syndrome in need of further research.

Pre-Endoscopic Scores Predicting Low-Risk Patients with Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis

BACKGROUND

Several risk scores have attempted to risk stratify patients with acute upper gastrointestinal bleeding (UGIB) who are at a lower risk of requiring hospital-based interventions or negative outcomes including death. This systematic review and meta-analysis aimed to compare predictive abilities of pre-endoscopic scores in prognosticating the absence of adverse events in patients with UGIB.

METHODS

We searched MEDLINE, EMBASE, Central, and ISI Web of knowledge from inception to February 2023. All fully published studies assessing a pre-endoscopic score in patients with UGIB were included. The primary outcome was a composite score for the need of a hospital-based intervention (endoscopic therapy, surgery, angiography, or blood transfusion). Secondary outcomes included: mortality, rebleeding, or the individual endpoints of the composite outcome. Both proportional and comparative analyses were performed.

RESULTS

Thirty-eight studies were included from 2153 citations, (n = 36,215 patients). Few patients with a low Glasgow-Blatchford score (GBS) cutoff (0, ≤1 and ≤2) required hospital-based interventions (0.02 (0.01, 0.05), 0.04 (0.02, 0.09) and 0.03 (0.02, 0.07), respectively). The proportions of patients with clinical Rockall (CRS = 0) and ABC (≤3) scores requiring hospital-based intervention were 0.19 (0.15, 0.24) and 0.69 (0.62, 0.75), respectively. GBS (cutoffs 0, ≤1 and ≤2), CRS (cutoffs 0, ≤1 and ≤2), AIMS65 (cutoffs 0 and ≤1) and ABC (cutoffs ≤1 and ≤3) scores all were associated with few patients (0.01-0.04) dying. The proportion of patients suffering other secondary outcomes varied between scoring systems but, in general, was lowest for the GBS. GBS (using cutoffs 0, ≤1 and ≤2) showed excellent discriminative ability in predicting the need for hospital-based interventions (OR 0.02, (0.00, 0.16), 0.00 (0.00, 0.02) and 0.01 (0.00, 0.01), respectively). A CRS cutoff of 0 was less discriminative. For the other secondary outcomes, discriminative abilities varied between scores but, in general, the GBS (using cutoffs up to 2) was clinically useful for most outcomes.

CONCLUSIONS

A GBS cut-off of one or less prognosticated low-risk patients the best. Expanding the GBS cut-off to 2 maintains prognostic accuracy while allowing more patients to be managed safely as outpatients. The evidence is limited by the number, homogeneity, quality, and generalizability of available data and subjectivity of deciding on clinical impact. Additional, comparative and, ideally, interventional studies are needed.

A Glasgow-Blatchford Bleeding Score of >2 Is a Poor Predictor of Endoscopic Intervention in Nonvariceal Upper GI Bleeding

OBJECTIVES

Recent data show that a Glasgow-Blatchford Bleeding Score (GBS) >2 does not identify patients with upper gastrointestinal (GI) bleeding who benefit from inpatient esophagogastroduodenoscopy (EGD). This study aimed to determine the rate of endoscopic hemostatic interventions (HI) in patients with nonvariceal acute GI bleeding (NVAUGIB) admitted with a GBS >2. Secondary aims included comparison of clinical outcomes in patients with and without HI and cost of nontherapeutic EGDs.

METHODS

We conducted a retrospective review of medical records of patients admitted to a referral hospital for NVAUGIB from January 2015 to December 2017. Mortality, blood transfusion rates, length of stay, length of intensive care unit stay, and cost of a nontherapeutic EGD were outcomes of interest. Patients 18 years of age and older of both sexes were included. The accuracy of the GBS >2 cutoff was determined using receiver operating characteristic curve analysis.

RESULTS

A total of 357 patients were included and only 58 (16.2%) required HI. The area under the curve for GBS >2 as a predictor of HI was 0.57. The performance of HI did not influence mortality (P = 0.33), blood transfusion rates (P = 0.51), length of stay (P = 0.2), or length of intensive care unit stay (P = 0.36). The estimated cost of performing nontherapeutic EGD was approximately $855,000 for the 299 patients who did not need HI.

CONCLUSIONS

A GBS cutoff of >2 is not an accurate criterion to triage patients with NVAUGIB for inpatient emergent EGD. More clinically meaningful and cost-effective methods to triage these patients are necessary.

Risk stratifying patients with non-varicosic upper gastrointestinal hemorrhage using the Glasgow-Blatchford score: A case series of 91 patients

Introduction

Non-variceal upper gastrointestinal hemorrhage (NVUGIH) often leads to systematic hospitalization and emergency endoscopy. However, in most cases, it does not constitute an immediate life threat. This study aimed to evaluate the Glasgow-Blatchford Score (GBS) in predicting the need for transfusions, and/or endoscopic or surgical treatments.

Materials and methods

We conducted a retrospective monocentric study including 91 patients admitted in the general surgery department of the Hospital La Rabta Tunis for a NVUGIH.

Univariate analysis was performed with the Student t-test for continuous variables and with the Chi-square test for categorical variables. For a cut-off point of 9, we calculated the sensibility and the sensitivity of the GBS to predict the need for transfusions and/or hemostatic procedure.

Results

During the study period, 91 patients were admitted for NVUGIH. Sixty-one patients (67%) were transfused. Seven patients (7.7%) underwent emergency surgery and two patients had endoscopic hemostasis.

The predictive factors for the use of transfusion and/or hemostasic treatments were: Age >50 years, ASA score, HR ≥ 90 bpm, pallor, Hb ≤ 9,5 g/dl, Urea ≥9,7 mmol/L.

For a cut-off of 9 points of the GBS, sensitivity was 85.71% and specificity 92.86%. The positive predictive value was 96%. The negative predictive value was 74%.

Conclusion

The main interest of the GBS lies in dispatching the patients between intensive care units for therapeutic intervention (if GBS> = 9) and ordinary hospitalization for surveillance (if GBS <9). It then makes it possible to rationalize the management of patients with digestive hemorrhage to identify those requiring hospital treatments (transfusion, endoscopic treatment, or surgery).

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Non variceal upper gastrointestinal bleeding often leads to systematic emergency endoscopy.

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In most cases, bleeding does not constitute an immediate life threat.

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The Glasgow-Blatschford score can be reliable to predict the need for therapeutic intervention.

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For a score inferior to nine, patients can be admitted into an ordinary unit.

Comparison of risk scoring systems for critical care patients with upper gastrointestinal bleeding: predicting mortality and length of stay

INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is a common reason for intensive care admission. While there exist a number of UGIB scoring systems which are used to predict mortality, there are limited studies assessing the discriminative value of these scores in intensive care unit (ICU) patients. The purpose of this study was to analyse five different UGIB scoring systems in predicting ICU mortality and length of stay and compare them to two commonly used ICU mortality scoring systems.

MATERIAL AND METHODS

We retrospectively identified all patients requiring ICU admission for UGIB to St James's Hospital over an 18-month period. We calculated their AIM65, Glasgow- Blatchford score, pre- and post-Rockall score, ABC, APACHE II and SOFA scores. We used area under the receiver operating characteristic curve (AUROC) to compare the predictive values of these six scoring systems for ICU and hospital mortality as well as ICU length of stay greater than seven days.

RESULTS

APACHE II showed excellent discriminative value in predicting mortality in ICU patients (AUROC: 0.87; CI: 0.75-0.99) while the SOFA score showed good discriminative value (AUROC: 0.71; CI: 0.50-0.93). None of the UGIB scoring systems predicted mortality in these patients. All scoring systems showed poor discriminative value in predicting ICU length of stay.

CONCLUSIONS

We were not able to validate any of these UGIB scoring systems for mortality or length of stay prediction in ICU patients. This study supports the validity of APACHE II as a clinical tool for predicting mortality in ICU patients with UGIB.

Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy

For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes. The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.

AIMS65 predicts prognosis of patients with duodenal ulcer bleeding; a comparison with other risk-scoring systems

BACKGROUND AND AIM

Duodenal ulcer bleeding has a higher risk of mortality than bleeding from other portions of the gastrointestinal tract. AIMS65 is an effective risk-scoring system to predict prognosis of upper gastrointestinal bleeding and can be easily calculated without endoscopic findings. In this study, we investigate the usefulness of AIMS65 to predict prognosis of patients with duodenal ulcer bleeding.

METHODS

Two hundred and fifty-five patients with endoscopically diagnosed duodenal ulcer bleeding at Kurashiki Central hospital from July 2007 to June 2017 were studied. We compared AIMS65, Glasgow Blatchford score (GBS), admission Rockall, and full Rockall scoring systems for predicting in-hospital mortality by calculating area under the receiver operating characteristic curve (AUROC).

RESULTS

In-hospital mortality due to duodenal ulcer bleeding occurred in 17 (6.7%). Scores of all scoring systems were significantly higher in patients with in-hospital mortality than in patients without it. AUROC values for predicting in-hospital mortality was 0.83 in AIMS65, 0.74 in GBS, 0.76 in admission Rockall score, and 0.82 in full Rockall score, a statistically insignificant difference among the systems. In AIMS65, score more than or equal to 2 was an optimal value to predict in-hospital mortality, with sensitivities of 88.2% and specificities of 59.7%, respectively.

CONCLUSIONS

AIMS65 predicted in-hospital mortality of patients with duodenal ulcer bleeding as accurately as did other scoring systems. Given its simplicity of calculation, AIMS65 may be a more clinically practical system in the management of bleeding duodenal ulcer patients.

Comparison of Glasgow-Blatchford Score and Rockall Score in Patients with Upper Gastrointestinal Bleeding

Introduction:

Upper gastrointestinal bleeding can be a life-threatening condition and requires careful evaluation from the very first episode in order to reduce the risk of rebleeding, hemorrhagic shock and death. The outcome of a patient with upper gastrointestinal bleeding depends on resuscitation measures taken during admission to the hospital and an adequate assessment of the patient’s risk level.

Aim:

The aim of the study is to compare Glasgow Blatchford score and Rockall score and to identify the most accurate score used in predicting unfavorable outcomes and the need for intervention.

Methods:

This study involves 237 patients with upper gastrointestinal bleeding. The accuracy of the scoring systems was assessed by plotting receiver-operating characteristic curves (ROC curves) and was calculated for GBS and RS with 95% confidence interval (CI).

Results:

As for mortality prediction, RS was superior to GBS (AUC 0.806 vs. 0.750). The GBS had a higher accuracy in detecting patients who needed transfusion units and was superior to the RS (AUC 0.810 vs.0.675). In predicting the need for intervention, RS was superior to GBS (AUC 0.707 vs. 0.636.

Conclusion:

GBS and RS are developed to help clinicians to triage patients appropriately in order to assess endoscopic therapy within a suitable time frame, as well as identify low risk patients for possible outpatient management. High accuracy of the GBS in predicting a need for transfusion represents an important endpoint to assess. RS was superior to GBS in predicting a need for intervention as well as mortality. Currently, a combination of these scoring systems is the best way for proper assessment.

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.

Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure

Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.

Outcomes in patients with acute upper gastrointestinal bleeding following changes to management protocols at an Australian hospital

Background and Aim

Upper gastrointestinal bleeding (UGIB) has a high mortality rate and requires efficient and directed acute management. This project aimed to assess patient outcomes following changes to UGIB management protocols at Northern Hospital, Victoria, Australia. Changes involved streamlining management under a single inpatient unit, earlier endoscopy, blood transfusion thresholds, and risk stratification.

Methods

This was a cohort study of 400 patients aged ≥18 years admitted to Northern Hospital who underwent endoscopy for acute UGIB. Data of preprotocol changes (Group 1) and prospectively postprotocol changes (Group 2) were collected retrospectively. Primary outcomes were inpatient mortality, rebleeding, radiologic or surgical intervention, and endoscopic reintervention. Secondary outcomes included length of stay (LOS) ≥4 days and blood units transfused. Univariate analyses were conducted comparing groups and associations between variables and outcomes, followed by multivariate analyses for each outcome.

Results

There was no difference in mortality on multivariate analysis (P = 0.95). Rebleeding reduced by 4% (adjusted odds ratio [AOR] 0.48; P = 0.03), LOS ≥4 days reduced by 15.1% (AOR 0.46; P < 0.00) and median blood units transfused decreased with adjusted incidence rate ratio of 0.81 (P = 0.00). Early endoscopy (i.e. ≤12 h) for all patients increased by 15% (P < 0.00) and there were 12% more high‐risk patients (i.e. Glasgow–Blatchford score ≥ 12) in Group 2 (P = 0.01).

Conclusion

Following changes to UGIB protocols at this Australian hospital, endoscopic times decreased with reductions in rebleeding, LOS ≥4 days, and blood transfusion rates. These findings demonstrate improved outcomes after the implementation of new treatment targets focusing on streamlined care of patients presenting with UGIB.

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.

Predictors of endoscopic intervention in upper gastrointestinal bleeding patients hospitalized for another illness: a multi-center retrospective study

BACKGROUND

To characterize variables that may predict the need for endoscopic intervention in inpatients admitted for several causes who during the hospitalization developed acute non-variceal upper gastrointestinal bleeding (NVUGIB).

METHODS

A retrospective analysis of inpatients who underwent upper gastro-intestinal endoscopy for acute NVUGIB while hospitalized for other causes from 1 January 2016 to 1 December 2017, was performed. In the primary outcome analysis, patients (N.=14) who underwent endoscopic intervention (group A) were compared to those (N.=87) who did not need for endoscopic intervention (group B). Secondary outcome analysis included patients who had significant endoscopic findings compared to those who did not have them.

RESULTS

Multivariate regression analysis showed that in the primary outcome analysis, two parameters were significant: the number of packed red blood cells (PRBC) units transfused (odds ratio [OR]: 1.5, P=0.01) and Rockall Score (RS) (OR: 1.4, P=0.06) with receiver operator characteristic (ROC) curve of 0.7844. In the secondary outcome analysis, only the use of proton pump inhibitor drugs at admission was associated with protective effect for the development of significant endoscopic findings (odds ratio [OR]: 0.42, P=0.05) with ROC curve of 0.7342.

CONCLUSIONS

In hospitalized patients, in case of de novo NVUGIB, the number of PRBC units transfused and RS are predictive of significant endoscopic findings.

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

BACKGROUND

It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined.

METHODS

To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.

RESULTS

A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.

CONCLUSIONS

In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed to develop a multisociety care bundle centred on the early management of AUGIB. Commissioned by the British Society of Gastroenterology (BSG), a UK multisociety task force was assembled to produce an evidence-based and consensus-based care bundle detailing key interventions to be performed within 24 hours of presentation with AUGIB. A modified Delphi process was conducted with stakeholder representation from BSG, Association of Upper Gastrointestinal Surgeons, Society for Acute Medicine and the National Blood Transfusion Service of the UK. A formal literature search was conducted and international AUGIB guidelines reviewed. Evidence was appraised using the Grading of Recommendations, Assessment, Development and Evaluation tool and statements were formulated and subjected to anonymous electronic voting to achieve consensus. Accepted statements were eligible for incorporation into the final bundle after a separate round of voting. The final version of the care bundle was reviewed by the BSG Clinical Services and Standards Committee and approved by all stakeholder groups. Consensus was reached on 19 statements; these culminated in 14 corresponding care bundle items, contained within 6 management domains: Recognition, Resuscitation, Risk assessment, Rx (Treatment), Refer and Review. A multisociety care bundle for AUGIB has been developed to facilitate timely delivery of evidence-based interventions and drive quality improvement and patient outcomes in AUGIB.

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.

Determinants of empiric transfusion in gastrointestinal bleeding in the emergency department

INTRODUCTION

Current guidelines for the management of GI bleeding (GIB) recommend restrictive transfusion triggers unless patients have shock or specific comorbidities. However, these studies may not be applicable to Emergency Department (ED) patients. Factors determining transfusion decisions in the ED are poorly understood. We compared baseline characteristics and outcomes between ED patients with GI bleeding transfused at lower or higher empiric hemoglobin levels.

METHODS

Single center, retrospective analysis of hospital records from a large tertiary care center of ED patients diagnosed with GIB who underwent red blood cell transfusion in the ED. A pre-transfusion hemoglobin cutoff of 7 g/dl was used to divide patients into restrictive and empirically transfused groups. Demographics, mortality, hospital length-of-stay, and mortality risk estimates were compared between groups.

RESULTS

175 patients met inclusion criteria, with 120 restrictive patients (68.5%) and 55 liberal patients (31.4%). The sample was 49.7% male, with mean age 67.2 years, similar between groups. Patients in the empiric transfusion group had more acute emergency severity index scores (2.09 vs. 2.3). No difference was found between groups in triage vital signs, pre-endoscopy Rockall scores or mortality estimates, or length of stay. Most common reasons for empiric transfusion from chart review were hypotension and witnessed large hemorrhage.

CONCLUSIONS

Patients that were empirically transfused had similar presentations to patients meeting restrictive guidelines, based on review of triage data. Transfusions above restrictive thresholds occurred frequently in our population. Additional studies are required to clarify appropriate criteria to guide transfusions for GIB in the ED.

Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding

Introduction: Acute upper-gastrointestinal bleeding (AUGIB) is a common medical emergency, with an incidence of 103-172 per 100,000 in the United Kingdom (UK) and mortality of 2% to 10%. Early and accurate prediction of the severity of an AUGIB episode may help guide management, including in or outpatient management, level of care required, and timing of endoscopy. This article aims to address the clinical utility of the various pre-endoscopic risk assessment tools used in AUGIB.Areas covered: The authors undertook a literature review of the current evidence on the pre-endoscopic risk assessment scores. Additional the authors discuss the recently published novel risk assessment scores.Expert opinion: The evidence shows that GBS is the most clinically useful risk assessment score in correctly identifying very low-risk patients suitable for outpatient management. At present, research is ongoing to assess machine learning in the assessment of patients presenting with AUGIB. More research is needed but it shows promise for the future.

Predictors of rebleeding and in-hospital mortality in patients with nonvariceal upper digestive bleeding

BACKGROUND

Nonvariceal upper digestive bleeding (NVUDB) represents a severe emergency condition and is associated with significant morbidity and mortality. Despite a decrease in the incidence due to the widespread use of potent therapy with proton pump inhibitors as well as the implementation of modern endoscopic techniques, the mortality rate associated with NVUDB is still high.

AIM

To identify the clinical, biological, and endoscopic parameters associated with a poor outcome in patients with NVUDB to allow the stratification of risk, which will lead to the implementation of the most accurate management.

METHODS

We performed a retrospective study including patients who were admitted to the Gastroenterology Department of Clinical Emergency County Hospital Timisoara, Romania, with a diagnosis of NVUDB between 1 January 2008 and 31 December 2016. All the data were collected from the patient’s records, including demographic data, medication history, hemodynamic status, paraclinical tests, and endoscopic features as well as the methods of hemostasis, rate of rebleeding, need for surgery and death; we also assessed the Rockall score of the patients, length of hospitalization and associated comorbidities. All these parameters were evaluated as potential risk factors associated with rebleeding and death in patients with NVUDB.

RESULTS

We included a batch of 1581 patients with NVUDB, including 523 (33%) females and 1058 (67%) males with a median age of 66 years. The main cause of NVUDB was peptic ulcer (73% of patients). More than one-third of the patients needed endoscopic treatment. Rebleeding rate was 7.72%; surgery due to failure of endoscopic hemostasis was needed in 3.22% of cases; the in-hospital mortality rate was 8.09%, and the bleeding-episode-related mortality rate was 2.97%. Although our predictive models for rebleeding and death had a low sensitivity, the specificity was very high, suggesting a better discriminative capacity for identifying patients with better outcomes. Our results showed that the Rockall score was associated with both rebleeding and death; comorbidities such as respiratory conditions, liver cirrhosis and sepsis increased significantly the risk of in-hospital mortality (OR of 3.29, 2.91 and 8.03).

CONCLUSION

Our study revealed that the Rockall score, need for endoscopic therapy, necessity of transfusion and sepsis were risk factors for rebleeding. Moreover, an increased Rockall score and the presence of comorbidities were predictive factors for in-hospital mortality.

AIMS65 scoring system is comparable to Glasgow-Blatchford score or Rockall score for prediction of clinical outcomes for non-variceal upper gastrointestinal bleeding

Background

Risk stratification for patients with nonvariceal upper gastrointestinal (NVUGI) bleeding is crucial for successful prognosis and treatment. Recently, the AIMS65 score has been used to predict mortality risk and rebleeding. The purpose of this study was to compare the performance of the AIMS65 score with the Glasgow-Blatchford score (GBS), Rockall score, and pre-endoscopic Rockall score in Korea.

Methods

We retrospectively studied 512 patients with NVUGI bleeding who were treated at a university hospital between 2013 and 2016. The AIMS65, GBS, Rockall score, and pre-endoscopic Rockall score were used to stratify patients based on their bleeding risk. The primary outcome was in-hospital mortality. The secondary outcomes were composite clinical outcomes of mortality, rebleeding, and intensive care unit (ICU) admission. Each scoring system was compared using the receiver-operating curve (ROC).

Results

A total of 17 patients (3.3%) died and rebleeding developed in 65 patients (12.7%). Eighty-six patients (16.8%) required ICU admission. The AIMS65 (area under the curve (AUC) 0.84, 95% confidence interval, 0.81–0.88)) seemed to be superior to the GBS (AUC 0.72, 0.68–0.76), the Rockall score (AUC 0.75, 0.71–0.79), or the pre-endoscopic Rockall score (AUC 0.74, 0.70–0.78) in predicting in-hospital mortality, but there was not a statistically significant difference between the groups (P = 0.07). The AUC value of the AIMS65 was not significantly different from the other scoring systems in prediction of rebleeding, endoscopic intervention, or ICU admission.

Conclusions

The AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting the mortality, rebleeding, or ICU admission. Because AIMS65 is a much easier, readily calculated scoring system compared to the others, we would recommend using the AIMS65 in daily practice.

Comparison of computed tomography findings with clinical risks factors for endoscopic therapy in upper gastrointestinal bleeding cases

Several risk scoring systems exist for acute upper gastrointestinal bleeding (UGIB). The clinical Rockall score (clinical RS) and the Glasgow-Blatchford score (GBS) are major risk scores that consider only clinical data. Computed tomography (CT) findings are equivocal in non-variceal UGIB. We compared CT findings with clinical data to predict mortality, rebleeding and need for endoscopic therapy in non-variceal UGIB patients. This retrospective, single-center study included 386 patients admitted to our emergency department with diagnosis of non-variceal UGIB by urgent endoscopy between January 2009 and March 2015. Multivariable logistic regression analysis was used to investigate CT findings and risk factors derived from clinical data. CT findings could not significantly predict mortality and rebleeding in non-variceal UGIB patients. However, upper gastrointestinal hemorrhage in CT findings better predicted the need for endoscopic therapy than clinical data. The adjusted odds ratios were 10.10 (95% CI 5.01-20.40) for clinical RS and 10.70 (95% CI 5.08-22.70) for the GBS. UGI hemorrhage in CT findings could predict the need for endoscopic therapy in non-variceal UGIB patients in our emergency department. CT findings as well as risk score systems may be useful for predicting the need for endoscopic therapy.

Comparison of the Glasgow-Blatchford and Rockall Scores for prediction of nonvariceal upper gastrointestinal bleeding outcomes in Chinese patients

The Glasgow-Blatchford scores (GBS) and Rockall scores (RS) are commonly used for stratifying patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Although predictive value of these scoring methods has been extensively validated, their clinical effectiveness remains unclear. The following study evaluated the GBS and RS scoring system with reference to bleeding, needs for further surgery, endoscopic intervention and death, in order to verify their effectiveness and accuracy in clinical application.Patients who presented with NVUGIH, or who were consequently diagnosed with the disease (by endoscopy examination) between January 1, 2008, and December 31, 2012 were enrolled in the study. GBS and RS scores were compared to predict bleeding, the needs for further surgery, endoscopic intervention, death by ROC curves and AUC value.Among 2977 patients, the pre-endoscopic RS and complete RS score (CRS) were superior to the GBS score (AUC: 0.842 vs 0.804 vs 0.622, respectively) for predicting the mortality risk in patients. The pre-endoscopic RS score predicting re-bleeding was significantly higher than the CRS and the GBS score (AUC: 0.658 vs 0.548 vs 0.528, respectively). In addition, the 3 scoring systems revealed to be poor predictors of surgical operation effectiveness (AUC: 0.589 vs 0.547 vs 0.504, respectively).Our data demonstrated that the GBS and RS scoring systems could be used to predict outcomes in patients with nonvariceal upper gastrointestinal bleeding.

Machine learning model to predict recurrent ulcer bleeding in patients with history of idiopathic gastroduodenal ulcer bleeding

BACKGROUND

Patients with a history of Helicobacter pylori-negative idiopathic bleeding ulcers have an increased risk of recurring ulcer complications.

AIM

To build a machine learning model to identify patients at high risk for recurrent ulcer bleeding.

METHODS

Data from a retrospective cohort of 22 854 patients (training cohort) diagnosed with peptic ulcer disease in 2007-2016 were analysed to build a model (IPU-ML) to predict recurrent ulcer bleeding. We tested the IPU-ML in all patients with a diagnosis of gastrointestinal bleeding (n = 1265) in 2008-2015 from a different catchment population (independent validation cohort). Any co-morbid conditions which had occurred in >1% of study population were eligible as predictors.

RESULTS

Recurrent ulcer bleeding developed in 4772 patients (19.5%) in the training cohort, during a median follow-up period of 2.7 years. IPU-ML model built on six parameters (age, baseline haemoglobin, and presence of gastric ulcer, gastrointestinal diseases, malignancies, and infections) identified patients with bleeding recurrence within 1 year with an area under the receiver operating characteristic curve (AUROC) of 0.648. When we set the IPU-ML cutoff value at 0.20, 27.5% of patients were classified as high risk for rebleeding with a sensitivity of 41.4%, specificity of 74.6%, and a negative predictive value of 91.1%. In the validation cohort, the IPU-ML identified patients with a recurrence ulcer bleeding within 1 year with an AUROC of 0.775, and 84.3% of overall accuracy.

CONCLUSION

We developed a machine-learning model to identify those patients with a history of idiopathic gastroduodenal ulcer bleeding who are not at high risk for recurrent ulcer bleeding.

Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal bleeding

BACKGROUND/AIMS

Selecting patients with an urgent need for endoscopic hemostasis is difficult based only on simple parameters of presumed acute upper gastrointestinal bleeding. This study assessed easily applicable factors to predict cases in need of urgent endoscopic hemostasis due to acute upper gastrointestinal bleeding.

METHODS

The consecutively included patients were divided into the endoscopic hemostasis and nonendoscopic hemostasis groups. We reviewed the enrolled patients' medical records and analyzed various variables and parameters for acute upper gastrointestinal bleeding outcomes such as demographic factors, comorbidities, symptoms, signs, laboratory findings, rebleeding rate, and mortality to evaluate simple predictive factors for endoscopic treatment.

RESULTS

A total of 613 patients were analyzed, including 329 patients in the endoscopic hemostasis and 284 patients in the non-endoscopic hemostasis groups. In the multivariate analysis, a bloody nasogastric lavage (adjusted odds ratio [AOR], 6.786; 95% confidence interval [CI], 3.990 to 11.543; p < 0.0001) and a hemoglobin level less than 8.6 g/dL (AOR, 1.768; 95% CI, 1.028 to 3.039; p = 0.039) were independent predictors for endoscopic hemostasis. Significant differences in the morbidity rates of endoscopic hemostasis were detected between the group with no predictive factors and the group with one or more predictive factors (OR, 2.677; 95% CI, 1.920 to 3.733; p < 0.0001).

CONCLUSION

A bloody nasogastric lavage and hemoglobin < 8.6 g/dL were independent predictors of endoscopic hemostasis in patients with acute upper gastrointestinal bleeding.

Comparison of four scoring systems for risk stratification of upper gastrointestinal bleeding

Objective:

This study aimed to compare the performances of the Glasgow–Blatchford Bleeding Score (GBS), pre-endoscopic Rockall score (PRS), complete Rockall score (CRS), and Cedars–Sinai Medical Center Predictive Index (CSMCPI) in predicting clinical outcomes in patients with upper gastrointestinal bleeding (UGIB).

Methods:

Patients who were admitted to the emergency department because of UGIB and underwent endoscopy within the first 24 hour were included in this study. The GBS, PRS, CRS, and CSMCPI were propectively calculated. The performances of these scores were assessed using a receiver operating characteristic curve.

Results:

A total of 153 patients were included in this study. For the prediction of high-risk patients, area under the curve (AUC) was obtained for GBS (0.912), PRS (0.968), CRS (0.991), and CSMCPI (0.918). For the prediction of rebleeding, AUC was obtained for GBS (0.656), PRS (0.625), CRS (0.701), and CSMCPI (0.612). For the prediction of 30-day mortality, AUC was obtained for GBS (0.658), PRS (0.757), CRS (0.823), and CSMCPI (0.745).

Conclusion:

These results suggest that effectiveness of CRS is higher than that of other scores in predicting high-risk patients, rebleeding and 30-day mortality in patients with UGIB.

Validity of the Pre-endoscopic Scoring Systems for the Prediction of the Failure of Endoscopic Hemostasis in Bleeding Gastroduodenal Peptic Ulcers

Objective Although several pre-endoscopic scoring systems have been used to predict the mortality or the need for intervention for upper gastrointestinal bleeding, their usefulness to predict the failure of endoscopic hemostasis in bleeding gastroduodenal peptic ulcers has not yet been fully investigated. In this study, we evaluated the usefulness of the Glasgow-Blatchford score (GBS), the clinical Rockall score (CRS), and the AIMS65 score in predicting the failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. Methods We retrospectively evaluated 226 consecutive emergency endoscopic cases with bleeding gastroduodenal peptic ulcers between April 2010 and September 2016. The study outcome was the failure of first endoscopic hemostasis. The GBS, CRS, and AIMS65 scores were assessed for their ability to predict the failure of endoscopic hemostasis using a receiver-operating characteristic curve. Results Eight cases (3.5%) failed to achieve first endoscopic hemostasis. Surgery was required in six cases, and interventional radiology was required in two cases. The GBS was superior to both the CRS and the AIMS65 score in predicting the failure of endoscopic hemostasis [area under the curve, 0.77 (95% confidence interval, 0.64-0.90), 0.65 (0.56-0.74) and 0.75 (0.56-0.95), respectively]. No failure of endoscopic hemostasis was noted in cases in which the patient scored less than GBS 10 and CRS 2. Conclusion The GBS was the most useful scoring system for the prediction of failure of endoscopic hemostasis in patients with bleeding gastroduodenal peptic ulcers. The GBS was also useful in identifying the patients who did not require surgery or interventional radiology.

Glasgow Blatchford Score and risk stratifications in acute upper gastrointestinal bleed: can we extend this to 2 for urgent outpatient management?

Upper gastrointestinal (GI) bleeds are a common presentation to emergency departments in the UK. The Glasgow Blatchford score (GBS) predicts the outcome of patients at presentation. Current UK and European guidelines recommend outpatient management for a GBS of 0. In the current study, our aim was to assess whether extending the GBS allows for early discharge while maintaining patient safety. We also analysed whether pathologies could be missed by discharging patients too early. Data were retrospectively collected on patients admitted with symptoms of an upper GI bleed between 1 October 2013 and 10 June 2016. The GBS was calculated and gastroscopy reports were obtained for each patient. In total, 399 patients were identified, 63 of whom required therapy. The negative predictive value (NPV) for excluding the need for endoscopic intervention with a GBS score up to 1 was 100%. Extending the score to 2 and 3 reduced the NPV to 98.53% and 98.77%, respectively. The NPV of GBS in excluding any diagnosis at 0 was 43.55%. Two patients died as a result of GI bleeding, with a GBS score of 3. Therefore, we can conclude that, for non-variceal bleeds, the GBS can be extended to 2 for safe outpatient management, thereby reducing the number of bed days and pressure for urgent endoscopies.

The Role of History of Gastro-Duodenal Ulcer in Patients with Upper Gastrointestinal Bleeding

BACKGROUND

Some scoring systems have been introduced to predict the need for performing urgent endoscopy in patients with upper gastrointestinal bleeding (UGIB). However, in an emergency situation, this intervention is insufficient and cannot easily provide the required treatment.

AIM

To identify new risk factors that can predict the need for endoscopic intervention (EI) in UGIB patients.

METHODS

This is a retrospective cross-sectional study. Patients with UGIB admitted from April 2011 to August 2014 were included. The proportion of cases requiring EI and clinical factors (age, gender, antiplatelet/anticoagulant therapy, history of gastro-duodenal ulcer (GDU), systolic blood pressure, heart rate, hemoglobin, mean corpuscular volume, blood urea nitrogen-creatinine ratio (BUN/Cr ratio), prothrombin time-international normalized ratio, and Glasgow-Blatchford Score (GBS) were analyzed using logistic regression models.

RESULT

Of 378 patients who were included in this study, 180 were found to be with GDU. The proportion of cases requiring EI was significantly higher in those with GDU than in other causes except variceal bleeding (53.5 vs. 37.0%, p < 0.01). Multivariate analysis revealed that a history of GDU was an independent risk factor (OR 1.78, 95% CI 1.06-3.00) in addition to BUN/Cr ratio (OR 1.02, 95% CI 1.00-1.03) and GBS (OR 1.19, 95% CI 1.08-1.33).

CONCLUSION

A history of GDU was an independent risk factor for predicting the need for EI in UGIB in addition to BUN/Cr ratio and GBS.

Validation of a Modified Glasgow-Blatchford Score for Risk Stratification of Patients with Suspected Upper Gastrointestinal Bleeding in an Accident and Emergency Department in Hong Kong

Objectives

To validate the use of a modified Glasgow-Blatchford Score (mGBS) for risk stratification of patients with suspected upper gastrointestinal bleeding (UGIB) in an accident and emergency department in Hong Kong.

Methods

This was a retrospective cohort study of patients who attended the emergency department of the study centre from January 2014 to June 2014 who were subsequently admitted to surgical wards with suspected UGIB. High risk patients were considered to be those who required in-patient clinical interventions (blood transfusion, therapeutic endoscopy, angiographic embolisation, or surgery). The mGBS was calculated for each patient. The sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the score were calculated.

Results

A total of 372 patients were included in the study. With an mGBS of 0 (low risk) for detecting the primary outcome, the sensitivity was 99.2% (95% CI, 95.6100%), and the specificity was 25.91 (95% CI 20.6-31.8%). The negative likelihood ratio was 0.031 (95% CI 0.004-0.2). The AUC was 0.90 (95% CI 0.87 to 0.93).

Conclusion

The modified Glasgow-Blatchford Score is a clinically useful tool for emergency physician to identify UGIB patients at low-risk of requiring in-hospital clinical interventions. (Hong Kong j.emerg.med. 2016;23:3-11)

Comparison of Risk Stratification Scores for Patients Presenting with Symptoms of Upper Gastrointestinal Bleeding in the Emergency Department

Objective

To compare four scoring systems to predict outcomes in patients with symptoms of upper gastrointestinal bleeding presenting to the emergency department.

Method

A single centered prospective cohort study. All adult patients presenting to the emergency department of the studying centre with haematemsis or tarry stool or coffee ground vomiting or coffee ground aspirate from nasogastric tube were included from February 2012 to April 2012. The outcome variables include mortality, length of stay in hospital, blood product transfusion and interventions for bleeding control. The AIMS65 score, pre-endoscopic Rockall score, Glasgow Blatchford Score (GBS) and the modified Glasgow Blatchford Score (mGBS) were evaluated. Diagnostic characteristics were presented and areas under the receiver-operating-characteristic (AUROC) curve were compared.

Results

A total of 129 patients were included in the study. 81 of them (62.8%) had upper endoscopy performed. The mortality rate was 3.1%. Initial haemoglobin level of <10 was an important factor in risk stratification. Validation of the 4 scoring systems showed GBS had highest sensitivities (98.3-100%) and negative predictive values (90-100%) for all outcome variables but could not achieve a good specificity and positive predictive values against the outcomes. Both GBS and modified GBS outperformed the other two scoring systems in the AUROC curves in predicting composite high-risk outcome, length of stay in hospital and blood transfusion.

Conclusion

GBS appeared the best scoring system in the emergency department for screening purpose and to stratify those high risk patients for admission and low risk patients for out-patient management. (Hong Kong j.emerg.med. 2016;23:199-209)

Glasgow Blatchford Score of limited benefit for low-risk urban patients: a mixed methods study

BACKGROUND AND STUDY AIMS

 Most patients with upper gastrointestinal bleeding (UGIB) are hospitalized. Risk-stratifying UGIB with scoring tools may decrease avoidable admissions, thereby reducing the cost of care. We sought to describe how frequently low-risk UGIB patients present to urban emergency departments (ED) and the proportion who are admitted to examine how incorporating risk scores into decision support might diminish healthcare utilization in this population.

PATIENTS AND METHODS

 This is a retrospective cohort study of ED patients presenting from 2009 - 2013 to three urban hospitals that do not use electronic UGIB decision support. We used ED disposition diagnosis codes (ICD-9) to identify patients followed by manual chart review for verification and additional data collection. Patients with a Glasgow Blatchford Score (GBS) of 0 were classified as low risk. We also surveyed ED physicians at these hospitals to assess their beliefs about UGIB decision support.

RESULTS

 Over the study period, 66 patients (13.2 per year) presented to the ED with low-risk UGIB. Of these, 10 patients (15.2 %) were admitted and none required endoscopic hemostasis. Most survey respondents (55.6 %, n = 20) were aware of UGIB risk scores but a minority (19.4 %, n = 7) used one.

CONCLUSIONS

 Low-risk UGIB patients infrequently present to the ED and only a minority are admitted. Despite advocacy to incorporate decision support into routine clinical care, ED physicians independently identified low risk patients. There is insufficient evidence to suggest the magnitude of this problem is large enough to warrant implementation of decision support for low risk UGIB.

Comparison of AIMS65 Score and Other Scoring Systems for Predicting Clinical Outcomes in Koreans with Nonvariceal Upper Gastrointestinal Bleeding

Background/Aims

The AIMS65 score has not been sufficiently validated in Korea. The objective of this study was to compare the AIMS65 and other scoring systems for the prediction of various clinical outcomes in Korean patients with acute nonvariceal upper gastrointestinal bleeding (NVUGIB).

Methods

The AIMS65 score, clinical and full Rockall scores (cRS and fRS) and Glasgow-Blatchford (GBS) score were calculated in patients with NVUGIB in a single center retrospectively. The performance of these scores for predicting mortality, rebleeding, transfusion requirement, and endoscopic intervention was assessed by calculating the area under the receiver-operating characteristic curve.

Results

Of the 523 patients, 3.4% died within 30 days, 2.5% experienced rebleeding, 40.0% required endoscopic intervention, and 75.7% needed transfusion. The AIMS65 score was useful for predicting the 30-day mortality, the need for endoscopic intervention and for transfusion. The fRS was superior to the AIMS65, GBS, and cRS for predicting endoscopic intervention and the GBS was superior to the AIMS65, fRS, and cRS for predicting the transfusion requirement.

Conclusions

The AIMS65 score was useful for predicting the 30-day mortality, transfusion requirement, and endoscopic intervention in Korean patients with acute NVUGIB. However, it was inferior to the GBS and fRS for predicting the transfusion requirement and endoscopic intervention, respectively.

Upper Gastrointestinal Bleeding in Patients with End Stage Renal Disease: Causes, Characteristics and Factors Associated with Need for Endoscopic Therapeutic Intervention

BACKGROUND AND OBJECTIVES

The risk of upper gastrointestinal bleeding (UGIB) is increased among the end-stage renal disease (ESRD) patients. The aim of the current study was to describe the causes and characteristics of UGIB in ESRD patients at our center and to assess the need for endoscopic therapeutic intervention (ETI) using Rockall (RS) and Glasgow Blatchford scores (GBS).

MATERIAL AND METHODS

All patients with ESRD and UGIB with age ≥14 years were included. Frequencies and percentages were computed for categorical variables. Chi square test or Fischer's exact test was used for statistical analysis.

RESULTS

A total of 59 subjects had a mean age of 47.25 ± 15 years.The most common endoscopic findings seen were erosions in 33 (55.9%) patients, followed by ulcers in 18 (30.3%) patients. ETI was required in 33 (55.9%) patients, which included adrenaline injection in 19 (32.3%), hemoclip in 9 (15.2%) and argon plasma coagulation in 5 (8.4%) patients. Factors associated with the need of ETI were identified as: a combined presentation of hematemesis and melena (P=0.033), ulcer (P=0.002) and associated chronic liver disease (P=0.015). Six (10.1%) patients died. Death was more common if ETI was not performed (P=0.018).

CONCLUSION

ETI was more commonly required in patients on maintenance hemodialysis with UGIB, who had presence of combined hematemesis and melena, ulcers and associated chronic liver disease. A Glasgow Blatchford score of >14 was helpful in assessing the need for ETI in these patients.

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

OBJECTIVE

Acute upper gastrointestinal bleeding (UGIB) is a potentially life-threatening condition that requires rapid assessment in the emergency department (ED). We aimed to compare the performance of the AIMS65, Glasgow-Blatchford (Blatchford), preendoscopic Rockall (pre-Rockall), and preendoscopic Baylor bleeding (pre-Baylor) scores in predicting 30-day mortality in patients with acute UGIB in the ED setting.

METHODS

Consecutive patients with acute UGIB who were admitted to the ED ward during 2012-2016 were retrospectively recruited. Data were retrieved from the admission list of the ED using international classification of disease codes via computer registration. The predictive accuracy of these four scores was compared using the area under the receiver operating characteristic curve (AUC) method.

RESULTS

Among the 395 patients included during the study period, the total 30-day mortality rate was 10.4% (41/395). The AIMS65 and Glasgow-Blatchford scores performed better with an AUC of 0.907 (95% confidence interval (CI), 0.852-0.963; P<0.001) and 0.870 (95% confidence interval, 0.833-0.902; P<0.001) compared with other scoring systems (preendoscopic Rockall score: AUC, 0.709; 95% CI, 0.635-0.784; P<0.001; preendoscopic Baylor score: AUC, 0.523; 95% CI, 0.472-0.573; P>0.05).

CONCLUSION

In patients with acute UGIB in the ED, the AIMS65 and Glasgow-Blatchford scores are clinically more useful for predicting 30-day mortality than the preendoscopic Rockall and preendoscopic Baylor scores. The AIMS65 score might be more ideal for risk stratification in the ED setting.

The Performance of a Modified Glasgow Blatchford Score in Predicting Clinical Interventions in Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding: A Vietnamese Prospective Multicenter Cohort Study

BACKGROUND/AIMS

To compare the performance of a modified Glasgow Blatchford score (mGBS) to the Glasgow Blatchford score (GBS) and the pre-endoscopic Rockall score (RS) in predicting clinical interventions in Vietnamese patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB).

METHODS

A prospective multicenter cohort study was conducted in five tertiary hospitals from May 2013 to February 2014. The mGBS, GBS, and pre-endoscopic RS scores were prospectively calculated for all patients. The accuracy of mGBS was compared with that of GBS and preendoscopic RS using area under the receiver operating characteristic curve (AUC). Clinical interventions were defined as blood transfusions, endoscopic or radiological intervention, or surgery.

RESULTS

There were 395 patients including 128 (32.4%) needing endoscopic treatment, 117 (29.6%) requiring blood transfusion and two (0.5%) needing surgery. In predicting the need for clinical intervention, the mGBS (AUC, 0.707) performed as well as the GBS (AUC, 0.708; p=0.87) and outperformed the pre-endoscopic RS (AUC, 0.594; p<0.001). However, none of these scores effectively excluded the need for endoscopic intervention at a threshold of 0.

CONCLUSIONS

mGBS performed as well as GBS and better than pre-endoscopic RS for predicting clinical interventions in Vietnamese patients with ANVUGIB. (Gut Liver 2016;10375- 381).

Clinical Performance of Prediction Rules and Nasogastric Lavage for the Evaluation of Upper Gastrointestinal Bleeding: A Retrospective Observational Study

Introduction. The majority of patients with acute upper gastrointestinal bleeding (UGIB) are admitted for urgent endoscopy as it can be difficult to determine who can be safely managed as an outpatient. Our objective was to compare four clinical prediction scoring systems: Glasgow Blatchford Score (GBS) and Clinical Rockall, Adamopoulos, and Tammaro scores in a sample of patients presenting to the emergency department of a large US academic center. Methods. We performed a retrospective cohort study of patients during 2008–2010. Our outcome was significant UGIB defined as high-risk stigmata on endoscopy, or receipt of blood transfusion or surgery, or death. Results. A total of 393 patients met inclusion criteria. The GBS was the most sensitive for detecting significant UGIB at 98.30% and had the highest negative predictive value (90.00%). Adding nasogastric lavage data to the GBS increased the sensitivity to 99.57%. Conclusions. Of all four scoring systems compared, the GBS demonstrated the highest sensitivity and negative predictive value for identifying a patient with a significant UGIB. Therefore, patients with a 0 score can be safely managed as an outpatient. Our results also suggest that performing a nasogastric lavage adds little to the diagnosis UGIB.

Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study

OBJECTIVE

 To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.

DESIGN

 International multicentre prospective study.

SETTING

 Six large hospitals in Europe, North America, Asia, and Oceania.

PARTICIPANTS

 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.

MAIN OUTCOME MEASURES

 Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.

RESULTS

 The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.

CONCLUSIONS

 The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.

Use of capsule endoscopy in the emergency department as a triage of patients with GI bleeding

BACKGROUND AND AIMS

Upper GI bleeding (UGIB) still constitutes one of the major hospital admissions through emergency departments (EDs). This feasibility study aims to test whether capsule endoscopy (CE) can reduce unnecessary hospital admissions in patients with suspected UGIB.

METHODS

This was a prospective randomized controlled trial in which patients who presented with symptoms or signs suggestive of UGIB were randomized to receive either the standard treatment (ST) of hospital management or receive CE, after which hospital admission was determined by the findings of CE. Patients were also graded by Glasgow Blatchford score (GBS) at the ED for assessment of need of hospital admission.

RESULTS

Seventy-one patients fulfilled the recruitment criteria, with 37 subjects enrolled into the CE group and 34 subjects into the ST group. Seven CE patients with active bleeding or significant endoscopic findings were admitted to the hospital compared with the ST group in which all 34 patients were admitted. There was no difference in the clinical outcome in terms of recurrent bleeding and 30-day mortality. Hospital admission was also greatly reduced if CE instead of GBS was used to triage patients in the ED.

CONCLUSIONS

This feasibility study shows that CE offers a safe and effective method in triaging patients presenting with symptoms of UGIB that do not require hospital admission. (Clinical trial registration number: NCT02446678.).

Comparison of three scoring systems in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding: a prospective observational study

OBJECTIVE

To compare the performances of the Glasgow-Blatchford score (GBS), modified GBS (mGBS) and AIMS65 in predicting clinical outcomes in patients with acute upper gastrointestinal bleeding (AUGIB).

METHODS

This study enrolled 320 consecutive patients with AUGIB. Patients at high and low risks of developing adverse clinical outcomes (rebleeding, the need of clinical intervention and death) were categorized according to the GBS, mGBS and AIMS65 scoring systems. The outcome of the patients were the occurrences of adverse clinical outcomes. The areas under the receiver operating characteristics curve (AUROC) of three scoring systems were compared.

RESULTS

Irrespective of the systems used, the high-risk groups showed higher rates of rebleeding, intervention and death compared with the low-risk groups (P < 0.05). For the prediction of rebleeding, AIMS65 (AUROC 0.735, 95% CI 0.667-0.802) performed significantly better than GBS (AUROC 0.672, 95% CI 0.597-0.747; P < 0.01) and mGBS (AUROC 0.677, 95% CI 0.602-0.753; P < 0.01). For the prediction of interventions, there was no significant difference among the three systems (GBS: AUROC 0.769, 95% CI 0.668-0.870; mGBS: AUROC 0.745, 95% CI 0.643-0.847; AIMS65: AUROC 0.746, 95% CI 0.640-0.851). For the prediction of in-hospital mortality, there was no significant difference among the three systems (GBS: AUROC 0.796, 95% CI 0.694-0.898; mGBS: AUROC 0.803, 95% CI 0.703-0.904; AIMS65: AUROC 0.786, 95% CI 0.670-0.903).

CONCLUSIONS

The three scoring systems are reliable and accurate in predicting the rates of rebleeding, surgery and mortality in AUGIB. However, AIMS65 outperforms GBS and mGBS in predicting rebleeding.

Evaluation of scoring models for identifying the need for therapeutic intervention of upper gastrointestinal bleeding: A new prediction score model for Japanese patients

BACKGROUND AND AIM

Multiple scoring systems have been developed to predict outcomes in patients with upper gastrointestinal bleeding. We determined how well these and a newly established scoring model predict the need for therapeutic intervention, excluding transfusion, in Japanese patients with upper gastrointestinal bleeding.

METHODS

We reviewed data from 212 consecutive patients with upper gastrointestinal bleeding. Patients requiring endoscopic intervention, operation, or interventional radiology were allocated to the therapeutic intervention group. Firstly, we compared areas under the curve for the Glasgow-Blatchford, Clinical Rockall, and AIMS65 scores. Secondly, the scores and factors likely associated with upper gastrointestinal bleeding were analyzed with a logistic regression analysis to form a new scoring model. Thirdly, the new model and the existing model were investigated to evaluate their usefulness.

RESULTS

Therapeutic intervention was required in 109 patients (51.4%). The Glasgow-Blatchford score was superior to both the Clinical Rockall and AIMS65 scores for predicting therapeutic intervention need (area under the curve, 0.75 [95% confidence interval, 0.69-0.81] vs 0.53 [0.46-0.61] and 0.52 [0.44-0.60], respectively). Multivariate logistic regression analysis retained seven significant predictors in the model: systolic blood pressure <100 mmHg, syncope, hematemesis, hemoglobin <10 g/dL, blood urea nitrogen ≥22.4 mg/dL, estimated glomerular filtration rate ≤ 60 mL/min per 1.73 m² , and antiplatelet medication. Based on these variables, we established a new scoring model with superior discrimination to those of existing scoring systems (area under the curve, 0.85 [0.80-0.90]).

CONCLUSION

We developed a superior scoring model for identifying therapeutic intervention need in Japanese patients with upper gastrointestinal bleeding.

Comparison of Glasgow-Blatchford score and full Rockall score systems to predict clinical outcomes in patients with upper gastrointestinal bleeding

Background

Various risk scoring systems have been recently developed to predict clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). The two commonly used scoring systems include full Rockall score (RS) and the Glasgow-Blatchford score (GBS). Bleeding scores were assessed in terms of prediction of clinical outcomes in patients with UGIB.

Patients and methods

Two hundred patients (age >18 years) with obvious symptoms of UGIB in the emergency department of Rasoul Akram Hospital were enrolled. Full RS and GBS were calculated. We followed the patients for records of rebleeding and 1-month mortality. A receiver operating characteristic curve by using areas under the curve (AUCs) was used to statistically identify the best cutoff point.

Results

Eighteen patients were excluded from the study due to failure to follow-up. Rebleeding and mortality rate were 9.34% (n=17) and 11.53% (n=21), respectively. Regarding 1-month mortality, full RS was better than GBS (AUC, 0.648 versus 0.582; P=0.021). GBS was more accurate in terms of detecting transfusion need (AUC, 0.757 versus 0.528; P=0.001), rebleeding rate (AUC, 0.722 versus 0.520; P=0.002), intensive care unit admission rate (AUC, 0.648 versus 0.582; P=0.021), and endoscopic intervention rate (AUC, 0.771 versus 0.650; P<0.001).

Conclusion

We found the full RS system is better for 1-month mortality prediction while GBS system is better for prediction of other outcomes.

Risks of Bleeding Recurrence and Cardiovascular Events With Continued Aspirin Use After Lower Gastrointestinal Hemorrhage

BACKGROUND & AIMS

It is not clear whether use of low-dose aspirin should be resumed after an episode of lower gastrointestinal (GI) bleeding. We assessed the long-term risks of recurrent lower GI bleeding and serious cardiovascular outcomes after aspirin-associated lower GI bleeding.

METHODS

We performed a retrospective study of patients diagnosed with lower GI bleeding (documented melena or hematochezia and absence of upper GI bleeding) from January 1, 2000 through December 31, 2007 at the Prince of Wales Hospital in Hong Kong. Using the hospital registry, we analyzed data from 295 patients on aspirin and determined their outcomes during a 5-year period. Outcomes included recurrent lower GI bleeding, serious cardiovascular events, and death from other causes, as determined by an independent, blinded adjudication committee. Outcomes were compared between patients assigned to the following groups based on cumulative duration of aspirin use: <20% of the follow-up period (121 nonusers) vs ≥50% of the observation period (174 aspirin users).

RESULTS

Within 5 years, lower GI bleeding recurred in 18.9% of aspirin users (95% confidence interval [CI], 13.3%-25.3%) vs 6.9% of nonusers (95% CI, 3.2%-12.5%; P = .007). However, serious cardiovascular events occurred in 22.8% of aspirin users (95% CI, 16.6%-29.6%) vs 36.5% of nonusers (95% CI, 27.4%-45.6%; P = .017), and 8.2% of aspirin users died from other causes (95% CI, 4.6%-13.2%) vs 26.7% of nonusers (95% CI, 18.7%-35.4%; P = .001). Multivariable analysis showed that aspirin use was an independent predictor of rebleeding, but protected against cardiovascular events and death.

CONCLUSIONS

Among aspirin users with a history of lower GI bleeding, continuation of aspirin is associated with an increased risk of recurrent lower GI bleeding, but reduced risk of serious cardiovascular events and death.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

BACKGROUND

Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs.

OBJECTIVE

The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital.

METHODS

It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources.

RESULTS

The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding.

CONCLUSION

The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems

BACKGROUND AND AIMS

The American College of Gastroenterology recommends early risk stratification in patients presenting with upper GI bleeding (UGIB). The AIMS65 score is a risk stratification score previously validated 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 = .001) and equivalent to the full Rockall score (0.78, P = .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.