Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention

Mortality Risk Scoring System in Patients after Bleeding from Cancers in the Upper Gastrointestinal Tract

Background/Aims

: Risk scoring systems for upper gastrointestinal (UGI) bleeding have not been well validated for tumor bleeding. This study aimed to identify risk factors for mortality in patients with UGI cancer bleeding and to develop a predictive model.

Methods

: Consecutive patients with UGI cancers who underwent esophagogastroduodenoscopy for suspected bleeding were retrospectively included. Patient characteristics, endoscopic findings and 30-day mortality were assessed. A predictive model was made based on risk factors for mortality using logistic regression, and the area under the curve (AUC) of this model was calculated. It was then compared with other risk scoring systems.

Results

: In a total of 264 patients, 193 had tumor bleeding. Among them, 108 (56.0%), 76 (39.4%), and nine (4.7%) patients received conservative treatment, endoscopic therapy, and non-endoscopic hemostasis, respectively. Rebleeding occurred in 23 (21.3%), 26 (34.2%), and one (11.1%) patient(s), respectively. Our new model is composed of altered mental status, renal failure, rebleeding, age older than 65 years, and low serum albumin (all p<0.05). This model predicted 30-day mortality with an AUC of 0.79 (95% confidence interval, 0.72 to 0.86), which was significantly higher than AUCs of the Glasgow-Blatchford score, Rockall, and AIMS65 score (AUC=0.61, 0.64, and 0.69, respectively, all p<0.05).

Conclusions

: Our new scoring system provides a better prediction of 30-day mortality than existing scoring systems in patients with UGI cancer bleeding. This new scoring system can be used to predict and prepare these patients who are known to have high mortality.

Three Simple Parameters on Admission to the Emergency Department are Predictors for Endoscopic Intervention in Patients with Suspected Nonvariceal Upper Gastrointestinal Bleeding

BACKGROUND

A considerable number of patients with nonvariceal upper gastrointestinal bleeding (UGIB) need endoscopic intervention.

OBJECTIVE

The aim of this study was to determine factors that predict the need for endoscopic intervention at the time of admission to the emergency department.

METHODS

Consecutive patients with International Classification of Diseases, Tenth Revision diagnosis code K92.2 (gastrointestinal hemorrhage) who underwent upper endoscopy between February 2019 and February 2022, including patients diagnosed with nonvariceal UGIB in the emergency department in the study were reviewed retrospectively. The patients were divided into two groups: those treated endoscopically and those not treated endoscopically. These two groups were compared according to clinical and laboratory findings at admission and independent predictors for endoscopic intervention were determined using multivariate regression analysis.

RESULTS

Although 123 patients (30.3%) were treated endoscopically, endoscopic treatment was not required in 283 (69.7%) patients. Syncope, mean arterial pressure (MAP), and blood urea nitrogen (BUN) at admission were independent predictors for endoscopic intervention in the multivariate analysis, after adjusting for endoscopy time. The area under the curve of the syncope+MAP+BUN combination for endoscopic intervention was 0.648 (95% CI 0.588-0.708). Although the syncope+MAP+BUN combination predicted the need for intervention significantly better than pre-endoscopy Rockall and AIMS65 scores (p = 0.010 and p < 0.001, respectively), there was no significant difference in its comparison with the Glasgow-Blatchford score (p = 0.103).

CONCLUSIONS

Syncope, MAP, and BUN at admission were independent predictors for endoscopic therapy in patients with nonvariceal UGIB. Rather than using complicated scores, it would be more practical and easier to predict the need for endoscopic intervention with these three simple parameters, which are included in the Glasgow-Blatchford score.

Preclinical study of a novel ingestible bleeding sensor for upper gastrointestinal bleeding

BACKGROUND/AIMS

Upper gastrointestinal bleeding (UGIB) is a life-threatening condition that necessitates early identification and intervention and is associated with substantial morbidity, mortality, and socioeconomic burden. However, several diagnostic challenges remain regarding risk stratification and the optimal timing of endoscopy. The PillSense System is a noninvasive device developed to detect blood in patients with UGIB in real time. This study aimed to assess the safety and performance characteristics of PillSense using a simulated bleeding model.

METHODS

A preclinical study was performed using an in vivo porcine model (14 animals). Fourteen PillSense capsules were endoscopically placed in the stomach and blood was injected into the stomach to simulate bleeding. The safety and sensitivity of blood detection and pill excretion were also investigated.

RESULTS

All the sensors successfully detected the presence or absence of blood. The minimum threshold was 9% blood concentration, with additional detection of increasing concentrations of up to 22.5% blood. All the sensors passed naturally through the gastrointestinal tract.

CONCLUSION

This study demonstrated the ability of the PillSense System sensor to detect UGIB across a wide range of blood concentrations. This ingestible device detects UGIB in real time and has the potential to be an effective tool to supplement the current standard of care. These favorable results will be further investigated in future clinical studies.

Derivation and validation of a novel risk score to predict need for haemostatic intervention in acute upper gastrointestinal bleeding (London Haemostat Score)

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency, which takes up considerable healthcare resources. However, only approximately 20%-30% of bleeds require urgent haemostatic intervention. Current standard of care is for all patients admitted to hospital to undergo endoscopy within 24 hours for risk stratification, but this is difficult to achieve in practice, invasive and costly.

AIM

To develop a novel non-endoscopic risk stratification tool for AUGIB to predict the need for haemostatic intervention by endoscopic, radiological or surgical treatments. We compared this with the Glasgow-Blatchford Score (GBS).

DESIGN

Model development was carried out using a derivation (n=466) and prospectively collected validation cohort (n=404) of patients who were admitted with AUGIB to three large hospitals in London, UK (2015-2020). Univariable and multivariable logistic regression analysis was used to identify variables that were associated with increased or decreased chances of requiring haemostatic intervention. This model was converted into a risk scoring system, the London Haemostat Score (LHS).

RESULTS

The LHS was more accurate at predicting need for haemostatic intervention than the GBS, in the derivation cohort (area under the receiver operating curve (AUROC) 0.82; 95% CI 0.78 to 0.86 vs 0.72; 95% CI 0.67 to 0.77; p<0.001) and validation cohort (AUROC 0.80; 95% CI 0.75 to 0.85 vs 0.72; 95% CI 0.67 to 0.78; p<0.001). At cut-off scores at which LHS and GBS identified patients who required haemostatic intervention with 98% sensitivity, the specificity of the LHS was 41% vs 18% with the GBS (p<0.001). This could translate to 32% of inpatient endoscopies for AUGIB being avoided at a cost of only a 0.5% false negative rate.

CONCLUSIONS

The LHS is accurate at predicting the need for haemostatic intervention in AUGIB and could be used to identify a proportion of low-risk patients who can undergo delayed or outpatient endoscopy. Validation in other geographical settings is required before routine clinical use.

[Endovascular embolization for prevention of recurrent bleeding from the upper gastrointestinal tract]

OBJECTIVE

To evaluate the results of preventive endovascular hemostasis in patients with high risk of recurrent bleeding from the upper gastrointestinal tract.

MATERIAL AND METHODS

We analyzed treatment outcomes in 158 patients with ulcerative gastroduodenal bleeding and high risk of recurrence (≥17 scores), Forrest 1-2 A/B and mortality (SAPS II score ≥30). Endovascular embolization of the left gastric or gastroduodenal artery was performed to prevent recurrent bleeding.

RESULTS

Endovascular hemostasis was technically successful in 94.4% of cases (153 patients). Embolization could not be performed due to technical reasons in 5 patients. One patient developed retroperitoneal hematoma as a complication after transcatheter angiography and embolization that required surgical intervention. Recurrent bleeding after technically successful embolization occurred in 11 (7%) patients. The PVA microemboli and spirals were used for embolization of the left gastric and gastroduodenal arteries, respectively. Additional PVA microemboli were also used in gastroduodenal artery in some cases. Twenty-six (16.5%) patients died.

CONCLUSION

Endovascular hemostasis in patients with severe comorbidities (SAPS II score ≥30) and high risk of recurrent bleeding (≥17 scores) reduced the incidence of recurrent bleeding to 6.96% and mortality to 17%.

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.

Scoring systems for predicting clinical outcomes in peptic ulcer bleeding

Few studies have focused on assessing the usefulness of scoring systems such as the Rockall score (RS), Glasgow-Blatchford score (GBS), and AIMS65 score for risk stratification and prognosis prediction in peptic ulcer bleeding patients. This study aimed to assess scoring systems in predicting clinical outcomes of patients with peptic ulcer bleeding. A total of 682 peptic ulcer bleeding patients who underwent esophagogastroduodenoscopy between January 2013 and December 2017 were found eligible for this study. The area under the receiver-operating characteristic curve (AUROC) of each score was calculated for predicting rebleeding, hospitalization, blood transfusion, and mortality. The median age of patients was 64 (interquartile range, 56-75) years. Of the patients, 74.9% were men, and 373 underwent endoscopic intervention. The median RS, GBS, and AIMS65 scores were significantly higher in patients who underwent endoscopic intervention than in those who did not. The AUROC of RS for predicting rebleeding was significantly higher than that of GBS (P = .022) or AIMS65 (P < .001). GBS best predicted the need for blood transfusion than either pre-RS (P = .013) or AIMS65 (P = .001). AIMS65 score showed the highest AUROC for mortality (0.652 vs. 0.622 vs. 0.691). RS was significantly associated with rebleeding (odds ratio, 1.430; P < .001) and overall survival (hazard ratio, 1.217; P < .001). The RS, GBS, and AIMS65 scoring systems are acceptable tools for predicting clinical outcomes in peptic ulcer bleeding. RS is an independent prognostic factor of rebleeding and overall survival.

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).

•

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.

A novel scoring system to predict therapeutic intervention for non-variceal upper gastrointestinal bleeding

Various scoring systems have been developed to predict the need for endoscopic treatment in patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, they have rarely been applied in clinical practice because the processes are complicated. The aim of this study was to establish a simple scoring system that predicts the need for endoscopic intervention in patients with NVUGIB. We retrospectively enrolled 509 consecutive patients with suspected NVUGIB who underwent emergency endoscopy. In the development cohort (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from 349 patients' data by multivariate logistic regression analysis. This led to the development of a novel scoring system named the Nagoya University score (N score). In the validation cohort (from January 2019 to September 2020), we evaluated the diagnostic value of the N score, the Hirosaki score, and the Glasgow-Blatchford scores (GBS) by receiver operating characteristic (ROC) curves using another 160 patients' data. Multivariate logistic regression analysis revealed syncope, hematemesis, blood urea nitrogen (BUN), and BUN/Cr as significant predictive factors for endoscopic intervention. In the validation study, the N score was superior to the GBS and equal to the Hirosaki score in predicting the endoscopic intervention (AUC, N score 0.776 [95% CI 0.702-0.851] vs. GBS 0.615 [0.523-0.708], Hirosaki 0.719 [0.636-0.803]). The N score revealed a sensitivity of 84.5% and a specificity of 61.8%. Our N score, which is consisted of only four factors, would select patients who require endoscopic intervention with high probability.

Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases

OBJECTS

Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB.

METHODS

Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents.

RESULTS

Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti-thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non-users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%).

CONCLUSIONS

Although the usage of anti-thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti-thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti-thrombotic agents.

Timing of Emergency Endoscopy for Acute Upper Gastrointestinal Bleeding: A Literature Review

Upper gastrointestinal (GI) bleeding is a common cause for Emergency Department and hospital admissions and has significant mortality and morbidity if it remains untreated. Upper endoscopy is the key procedure for both diagnosis and treatment of acute upper GI bleeding. The aim of this article is to review the optimal timing of endoscopy in patients with acute upper GI bleeding. The cost-effectiveness and the influence of urgent or emergent endoscopy on patients' outcomes are discussed. Also, we compare and contrast the available evidence and guidelines regarding the recommended time points for performing endoscopy in different clinical settings.

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.

Clinical Outcomes of Patients with Non-ulcer and Non-variceal Upper Gastrointestinal Bleeding: A Prospective Multicenter Study of Risk Prediction Using a Scoring System

BACKGROUND AND AIMS

Compared with ulcer bleeding (UB) in non-variceal upper gastrointestinal bleeding (NVUGIB), non-ulcer bleeding (NUB) is often considered to have a low risk of poor outcomes and is treated less intensively without any risk stratification. We conducted this study to assess the predictability of scoring systems for NUB and compare the outcomes of NUB and UB.

METHODS

A total of 1831 UGIB patients were registered in the database during the period from February 2011 to December 2013. Among them, 1424 patients with NVUGIB were divided into two groups: Group UB (1101 patients with peptic ulcer bleeding) and Group NUB (323 patients with non-peptic ulcer-related bleeding).

RESULTS

The most common cause of bleeding in Group NUB was Mallory-Weiss tears (51.1%), followed by Dieulafoy lesions (18.9%). A receiver operating characteristic (ROC) analysis revealed that the pre-Rockall score [area under the ROC (AUROC) = 0.798; 95% CI 0.707-0.890] and full Rockall score (AUROC = 0.794; 95% CI 0.693-0.895) were relatively good at predicting overall mortality in NUB. Glasgow-Blatchford score (AUROC = 0.783; 95% CI 0.730-0.836) was the most closely correlated with the need for clinical intervention in NUB. Those who had Glasgow-Blatchford score of 0 did not require any interventions, including blood transfusions. There were no statistical differences in overall mortality (p = 0.387), bleeding-related mortality (p = 0.447), or the incidence of re-bleeding (p = 0.117) between the two groups.

CONCLUSIONS

Scoring systems are useful to predict mortality and the need for clinical intervention in patients with NUB.

Comparison of AIMS65, Glasgow-Blatchford and Rockall scoring approaches in predicting the risk of in-hospital death among emergency hospitalized patients with upper gastrointestinal bleeding: a retrospective observational study in Nanjing, China

BACKGROUND

This study aims to compare the performance of AIMS65, Glasgow-Blatchford (GBS) and Rockall scores (RS) in predicting the death risk among emergency-hospitalized patients with upper gastrointestinal bleeding (UGIB) in regional China.

METHODS

A retrospective study was implemented between January 2014 and December 2015. Eligible participants were those who were hospitalized with UGIB. The outcome variable was in-hospital death, while explanatory variables were AIMS65, GBS and RS scores. Odds ratios (OR) and 95% confidence interval (CI) were estimated to assess the association of AIMS65, GBS and RS with death risk using multivariate logistic regression models. The areas under the receiver operating characteristics curve (AUC) of three scoring systems were computed to compare their predictive power.

RESULTS

Among 799 UGIB participants, 674 were non-variceal bleeding (NVUGIB) and 125 variceal bleeding (VUGIB) patients. AIMS65 (OR = 14.72, 95% CI = 6.48, 33.43) and RS (OR = 1.60, 95% CI = 1.20, 2.13) were positively associated with the risk of in-hospital death. Moreover, AIMS65 (AUC = 0.91, 95% CI = 0.84, 0.98) performed the best in predicting in-hospital death, followed by RS (AUC = 0.79, 95% CI = 0.72, 0.86) and GBS (AUC = 0.71, 95% CI = 0.59, 0.83) among overall UGIB participants. AIMS65 was also the best indicator to predict in-hospital death among either NVUGIB participants (AUC = 0.89, 95% CI = 0.80, 0.98) or VUGIB participants (AUC = 0.94, 95% CI = 0.89, 1.00).

CONCLUSIONS

AIMS65, GBS and RS scoring approaches were all acceptable for predicting in-hospital death among UGIB patients irrespective of the subtype of UGIB in China. The AIMS65 might be the most powerful predictor.

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.

Scoring systems for peptic ulcer bleeding: Which one to use?

AIM

To compare the Glasgow-Blatchford score (GBS), Rockall score (RS) and Baylor bleeding score (BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers.

METHODS

Between January 2008 and December 2013, 1012 consecutive patients admitted with peptic ulcer bleeding (PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores (RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics (AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.

RESULTS

PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome (AUROC 0.82 vs 0.67 vs 0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality (AUROC 0.84 vs 0.57 vs 0.64), rebleeding (AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion (AUROC 0.83 vs 0.63 vs 0.58) and surgical intervention (0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome (AUROC 0.82 vs 0.69, respectively).

CONCLUSION

The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.

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.

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.

Glasgow Blatchford, pre-endoscopic Rockall and AIMS65 scores show no difference in predicting rebleeding rate and mortality in variceal bleeding

OBJECTIVE

To compare the performance of the Glasgow Blatchford score (GBS), pre-endoscopic Rockall score (PRS) and AIMS65 score in predicting specific clinical endpoints following variceal upper gastrointestinal hemorrhage (UGIH).

MATERIAL AND METHODS

Between January 2008 and December 2013, we retrospectively analyzed 225 consecutive hospitalized patients managed for endoscopically confirmed UGIH.

RESULTS

A total of 225 patients (mean age 61.3 years), mostly diagnosed with alcoholic cirrhosis (195/86.7%), presented with variceal UGIH during the study period. Rebleeding occurred in 22 (9.8%) patients and 30-day mortality was 39 (17.3%). Initial hemostasis was achieved with N-butyl cyanoacrylate (151/79.1%) and endoscopic variceal ligation (40/20.9%), while secondary rebleeding prophylaxis in 110 (48.9%) patients was accomplished using endoscopic variceal ligation (92%). The majority of patients died from the underlying disease, while 12 (30.8%) died from bleeding. Median hospital stay was 6 (1-35) days. There was no statistically significant difference among AIMS65, GBS and PRS in predicting mortality (AUROC 0.70 vs. 0.64 vs. 0.66) or rebleeding rates (AUROC 0.74 vs. 0.60 vs. 0.67). The GBS was superior in predicting the need for blood transfusion compared to AIMS65 score (AUROC 0.75 vs. 0.61, p = 0.01) and PRS (AUROC 0.75 vs. 0.58, p = 0.009).

CONCLUSIONS

The AIMS65, GBS and PRS scores are comparable but not useful for predicting outcome in patients with variceal UGIH because of poor discriminative ability. The GBS is superior in predicting the need for transfusion compared to AIMS65 score and PRS.

The Predictive Value of Preendoscopic Risk Scores to Predict Adverse Outcomes in Emergency Department Patients With Upper Gastrointestinal Bleeding: A Systematic Review

OBJECTIVES

Risk stratification of emergency department (ED) patients with upper gastrointestinal bleeding (UGIB) using preendoscopic risk scores can aid ED physicians in disposition decision-making. We conducted a systematic review to assess the predictive value of preendoscopic risk scores for 30-day serious adverse events.

METHODS

We searched MEDLINE, PubMed, Embase, and the Cochrane Database of Systematic Reviews from inception to March 2015. We included studies involving adult ED UGIB patients evaluating preendoscopic risk scores and excluded reviews, case reports, and animal studies. The composite outcome included 30-day mortality, recurrent bleeding, and need for intervention. In two phases (screening and full review), two reviewers independently screened articles for inclusion and extracted patient-level data. The consensus data were used for analysis. We reported sensitivity, specificity, positive and negative predictive value, and positive and negative likelihood ratios with 95% confidence intervals.

RESULTS

We identified 3,173 articles, of which 16 were included: three studied Glasgow Blatchford score (GBS); one studied clinical Rockall score (cRockall); two studied AIMS65; six compared GBS and cRockall; three compared GBS, a modification of the GBS, and cRockall; and one compared the GBS and AIMS65. Overall, the sensitivity and specificity of the GBS were 0.98 and 0.16, respectively; for the cRockall they were 0.93 and 0.24, respectively; and for the AIMS65 they were 0.79 and 0.61, respectively. The GBS with a cutoff point of 0 had a sensitivity of 0.99 and a specificity of 0.08.

CONCLUSION

The GBS with a cutoff point of 0 was superior over other cutoff points and risk scores for identifying low-risk patients but had a very low specificity. None of the risk scores identified by our systematic review were robust and, hence, cannot be recommended for use in clinical practice. Future prospective studies are needed to develop robust new scores for use in ED patients with UGIB.

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.

A simple scoring system to assess the need for an endoscopic intervention in suspected upper gastrointestinal bleeding: A prospective cohort study

BACKGROUND

Assessment of the emergent endoscopy for upper gastrointestinal bleeding (UGIB) patients has important clinical implications. There is no validated criterion to triage.

AIMS

To develop a simple score predicting an endoscopic intervention.

METHODS

A prospective cohort study was conducted at a tertiary care centre. Primary outcome was the high-risk stigmata which were well-established endoscopic findings to determine the need for an endoscopic intervention. We created a simple score by multivariable logistic regression and compared with the Glasgow Blatchford Score (GBS). External validation was performed in a second cohort.

RESULTS

284 of consecutive 568 patients with suspected UGIB had the high-risk stigmata. Three variables were selected: "no daily use of proton pump inhibitors during one week before examination (+1 point)", "shock index (heart rate/systolic blood pressure)≥1 (+1 point)" and "urea/creatinine≥140 (blood urea nitrogen/creatinine≥30) (+1 point)". The accumulating score (range 0-3) achieved an area under the receiver-operating characteristic curve (AUC) of 0.74 (95% confidence interval [CI], 0.70-0.78), which was superior to the GBS (AUC, 0.63; 95% CI, 0.59-0.68; p<0.001). Validation in an external cohort demonstrated superiority to the GBS (AUC, 0.78 vs. 0.59; p<0.001).

CONCLUSIONS

The simple score has greater accuracy than the GBS for assessing the need for an endoscopic intervention in cases of suspected UGIB. Further external validation should be performed to verify generalizability.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding

BACKGROUND AND AIM

Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB.

METHODS

During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis.

RESULTS

A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization.

CONCLUSION

In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB.

Upper gastrointestinal bleeding risk scores: Who, when and why?

Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.

Comparison of scoring systems for nonvariceal upper gastrointestinal bleeding: a multicenter prospective cohort study

BACKGROUND AND AIM

The Glasgow-Blatchford score (GBS) and Rockall score (RS) are widely used to assess risk in patients with upper gastrointestinal bleeding (UGIB). We compared both scoring systems and evaluated their clinical usefulness.

METHODS

Between February 2011 and December 2013, 1584 patients with nonvariceal UGIB were included in the study. A prospective study was conducted to compare the performance of the GBS, pre-RS, and full RS. We compared the performance of these scores using receiver operating characteristic curves.

RESULTS

For prediction of the need for hospital-based intervention, the GBS was similar to the full RS (area under the receiver operating characteristic curves [AUROC] 0.705 vs 0.727; P = 0.282) and superior to the pre-RS (AUROC 0.705 vs 0.601; P < 0.0001). In predicting death, the full RS was superior to the GBS (AUROC 0.758 vs 0.644; P = 0.0006) and similar to the pre-RS (AUROC 0.758 vs 0.754; P = 0.869). In predicting rebleeding, the full RS was superior to both GBS (AUROC 0.642 vs 0.585; P = 0.031) and pre-RS (AUROC 0.642 vs 0.593; P = 0.0003). Of 1584 patients, 13 (0.8%) scored 0 on the GBS. Therapeutic intervention was not performed in any of these patients.

CONCLUSIONS

The GBS is more useful than the pre-RS for predicting the need for hospital-based intervention. A cutoff value of 0 for low-risk patients who might be suitable for outpatient management is useful. The full RS is helpful in predicting death. None of the systems accurately predict rebleeding with a low AUROC. (

CLINICAL TRIAL

cris.nih.go.kr/KCT0000514).

Validity of modified early warning, Glasgow Blatchford, and pre-endoscopic Rockall scores in predicting prognosis of patients presenting to emergency department with upper gastrointestinal bleeding

Background

GBS, MEWS, and PER scoring systems are not commonly used for patients presenting to emergency department with GIS bleeding. This study aimed to determine the value of MEWS, GBS, and PER scores in predicting bleeding at follow-up, endoscopic therapy and blood transfusion need, mortality, and rebleeding within a 1-month period.

Methods

A total of 202 consecutive patients with upper GIS bleeding between July 2013 and November 2014 were prospectively enrolled in the study. The relationship between MEWS, GBS, and PER scores and hospital outcome, bleeding at follow-up, endoscopic therapy, transfusion need, rebleeding, and death were examined.

Results

The study included a total of 202 subjects, with 84 (41.6 %) females and 118 (58.4 %) males. There was a significant correlation between GBS, MEWS, and PER scores and hospital outcomes (p <0.004, p <0.001, p <0.001, respectively). A GBS score greater than 11 succesfully predicted bleeding at follow-up (p = 0.0237). GBS score's sensitivity for predicting endoscopic therapy was greater than those of other scoring systems. The discriminatory power of each scoring system was significant for predicting transfusion (p <0.0001, p = 0.0470, and p = 0.0014, respectively). A GBS score greater than 13, a MEWS score greater than 2, and a PER score greater than 3 predicted death. A PER score greater than 3 predicted rebleeding (p <0.0001).

Conclusion

The scoring systems in question can be easily calculated in patients presenting to ED with upper GIS bleeding and may be beneficial for risk stratification, determination of transfusion need, prediction of rebleeding, and decisions of hospitalization or discharge.

Risk assessment scores for patients with upper gastrointestinal bleeding and their use in clinical practice

Upper gastrointestinal bleeding (UGIB) is a common cause for emergency admission to hospital representing a significant clinical as well as economic burden. UGIB encompasses a wide range of severities from life-threatening exsanguination to minor bleeding that may not require hospital admission. Patients with UGIB are often initially assessed and managed by junior doctors and non-gastroenterologists. Several risk scores have been created for the assessment of these patients, some requiring endoscopic data for calculation and others that are calculable from clinical data alone. A key question in clinical practice is how to accurately identify patients with UGIB at high risk of adverse outcome. Patients considered high risk are more likely to experience adverse outcomes and will require urgent intervention. In contrast, those patients with UGIB who are considered to be low risk could potentially be managed on an outpatient basis. The Glasgow Blatchford Score (GBS) appears best at identifying patients at low risk of requiring intervention or death and therefore may be best for use in clinical practice, allowing outpatient management in low risk cases. There has been some debate as to the optimal GBS cut-off score for safely identifying this low-risk group. Many guidelines suggest that patients with a GBS of zero can be safely managed as outpatients, but more recent studies have suggested that this threshold could potentially be safely increased to ≤1. Most other patients require inpatient endoscopy within 24 h and the full Rockall score remains important for risk assessment following endoscopy, particularly as it includes the endoscopic diagnosis. A minority of patients will require emergency endoscopy following resuscitation, but at present there is no evidence that risk scores can accurately identify this very high-risk group. Studies have shown the latest risk assessment score, the AIMS65, looks promising in the prediction of mortality. However, to date there is no data on the use of the AIMS65 in identifying low risk patients for possible outpatient management.

Comparison of AIMS65, Glasgow-Blatchford score, and Rockall score in a European series of patients with upper gastrointestinal bleeding: performance when predicting in-hospital and delayed mortality

OBJECTIVE

AIMS65 is a score designed to predict in-hospital mortality, length of stay, and costs of gastrointestinal bleeding. Our aims were to revalidate AIMS65 as predictor of inpatient mortality and to compare AIMS65's performance with that of Glasgow-Blatchford (GBS) and Rockall scores (RS) with regard to mortality, and the secondary outcomes of a composite endpoint of severity, transfusion requirements, rebleeding, delayed (6-month) mortality, and length of stay.

METHODS

The study included 309 patients. Clinical and biochemical data, transfusion requirements, endoscopic, surgical, or radiological treatments, and outcomes for 6 months after admission were collected. Clinical outcomes were in-hospital mortality, delayed mortality, rebleeding, composite endpoint, blood transfusions, and length of stay.

RESULTS

In receiver-operating characteristic curve analyses, AIMS65, GBS, and RS were similar when predicting inpatient mortality (0.76 vs. 0.78 vs. 0.78). Regarding endoscopic intervention, AIMS65 and GBS were identical (0.62 vs. 0.62). AIMS65 was useless when predicting rebleeding compared to GBS or RS (0.56 vs. 0.70 vs. 0.71). GBS was better at predicting the need for transfusions. No patient with AIMS65 = 0, GBS ≤ 6, or RS ≤ 4 died. Considering the composite endpoint, an AIMS65 of 0 did not exclude high risk patients, but a GBS ≤ 1 or RS ≤ 2 did. The three scores were similar in predicting prolonged in-hospital stay. Delayed mortality was better predicted by AIMS65.

CONCLUSION

AIMS65 is comparable to GBS and RS in essential endpoints such as inpatient mortality, the need for endoscopic intervention and length of stay. GBS is a better score predicting rebleeding and the need for transfusion, but AIMS65 shows a better performance predicting delayed mortality.

Prospective multicenter validation of the Glasgow Blatchford bleeding score in the management of patients with upper gastrointestinal hemorrhage presenting at an emergency department

BACKGROUND/AIMS

The Glasgow Blatchford Bleeding Score (GBS) has been developed to assess the need for treatment in patients with acute upper gastrointestinal hemorrhage (UGIH) presenting at emergency departments (EDs). We aimed (a) to determine the validity of the GBS and Rockall scoring systems for prediction of need for treatment and (b) to identify the optimal cut-off value of the GBS.

METHODS

We carried out a population-based, prospective multicenter study of 520 consecutive patients presenting with acute UGIH at EDs of three hospitals. The accuracy of GBS and Rockall scores in predicting the need for treatment (i.e. endoscopic, surgical, or radiological intervention and blood transfusion) was analyzed using receiver operating characteristic curves.

RESULTS

Receiver operating characteristic curve analysis showed that the GBS had a good discriminative ability to determine the need for treatment in patients with acute UGIH (area under the curve: 0.88; 95% confidence interval: 0.85-0.91). The GBS was superior to both the clinical Rockall and the full Rockall score in predicting the need for treatment (area under the curve: 0.86 vs. 0.70 vs. 0.77). At a cut-off value of up to 2, the GBS had the optimal combination of sensitivity (99.4%) and specificity (42.4%).

CONCLUSION

The GBS is superior compared with both Rockall scores in predicting the need for treatment in patients with suspected acute UGIH presenting at EDs in the Netherlands. Patients with a GBS of 2 or less form a subgroup of low-risk patients. These low-risk patients are eligible for outpatient management, which might reduce hospital admissions and healthcare costs.

Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding

Acute nonvariceal upper gastrointestinal bleeding remains an important cause of hospital admission with an associated mortality of 2-14%. Initial patient evaluation includes rapid hemodynamic assessment, large-bore intravenous catheter insertion and volume resuscitation. A hemoglobin transfusion threshold of 7 g/dL is recommended, and packed red blood cell transfusion may be necessary to restore intravascular volume and improve tissue perfusion. Patients should be risk stratified into low- and high-risk categories, using validated prognostic scoring systems such as the Glasgow-Blatchford, AIMS65 or Rockall scores. Effective early management of acute, nonvariceal upper gastrointestinal hemorrhage is critical for improving patient outcomes.

Does Preendoscopy Rockall Score Safely Identify Low Risk Patients following Upper Gastrointestinal Haemorrhage?

Objective. To determine if preendoscopy Rockall score (PERS) enables safe outpatient management of New Zealanders with upper gastrointestinal haemorrhage (UGIH). Methods. Retrospective analysis of adults with UGIH over 59 consecutive months. PERS, diagnosis, demographics, need for endoscopic therapy, transfusion or surgery and 30-day mortality and 14-day rebleeding rate, and sensitivity and specificity of PERS for enabling safe discharge preendoscopy were calculated. Results. 424 admissions with UGIH. Median age was 74.3 years (range 19–93 years), with 55.1% being males. 30-day mortality was 4.6% and 14-day rebleeding rate was 6.0%. Intervention was required in 181 (46.6%): blood transfusion (147 : 37.9%), endoscopic intervention (75 : 19.3%), and surgery (8 : 2.1%). 42 (10.8%) had PERS = 0 with intervention required in 15 (35.7%). Females more frequently required intervention, OR 1.73 (CI: 1.12–2.69). PERS did not predict intervention but did predict 30-day mortality: each point increase equated to an increase in mortality of OR 1.46 (CI: 1.11–1.92). Taking NSAIDs/aspirin reduced 30-day mortality, OR 0.22 (CI: 0.08–0.60). Conclusion. PERS identifies 10.8% of those with UGIH as low risk but 35.7% required intervention or died. It has a limited role in assessing these patients and should not be used to identify those suitable for outpatient endoscopy.

Outpatient management of low-risk patients with upper gastrointestinal bleeding: can we safely extend the Glasgow Blatchford Score in clinical practice?

BACKGROUND AND AIM

The Glasgow Blatchford Score (GBS) is a validated prognostic score for patients presenting with upper gastrointestinal (GI) bleeding (UGIB). The score predicts the need for therapeutic intervention or death, and studies have suggested that outpatient management is safe for patients with a GBS of zero. Our aim was to assess whether we could safely extend the threshold for outpatient management to patients with GBS≤1.

METHODS

Following assessment of our historical data, our UGIB protocol was changed to recommend outpatient management for patients with a GBS≤1, unless required for other reasons. Data on all patients presenting with UGIB over the following 12 months were prospectively recorded, including GBS and clinical Rockall scores. Adverse outcomes were defined by a 30-day combined endpoint of death, endotherapy, interventional radiology, surgery or transfusion. Negative predictive value (NPV) of GBS≤1 for adverse outcomes in UGIB was calculated.

RESULTS

A total of 514 patients presented with UGIB in the 12 month study period. Of the patients, 183 (35.6%) had GBS≤1 (111, GBS=0; 72, GBS=1). Of these, 88 (48.1%) were managed as outpatients, and none had an adverse outcome. Of the 95 (51.9%) patients with GBS≤1 managed as inpatients, 80 (84.2%) had comorbidities requiring inpatient care. Within this admitted group with GBS≤1, one patient required transfusion and one died from a nongastrointestinal malignancy. GBS≤1 had an NPV of 99.45% (95% confidence interval 95.53-99.97%) in predicting adverse outcomes within 30 days.

CONCLUSION

GBS≤1 has a high NPV for adverse outcomes in UGIB. This suggests outpatient management of patients with UGIB and that GBS≤1 is safe in our population.

Gastrointestinal Hemorrhage Severity Triage: Locally Derived Score May Outperform Existing Scoring Systems

Background

Scoring tools to predict need for intervention, re-bleeding and mortality of upper gastrointestinal hemorrhage (UGIH) have been developed. It is inconclusive whether these tools are also appropriate for UGIH severity and/or urgency triage. The objective of the study was to compare the performances of the Blatchford score, the Rockall score, and the UGIH score on UGIH severity triage.

Methods

Retrospective 3-year data of UGIH patients (2009 - 2011) were collected. Patients were assigned to each of the three scoring systems based on their clinical characteristics required for the scoring systems. The score ranges of each scoring system were transformed into the same scale from 0 to 100. The score performances were compared by diagnostic indices, graphically presented with area under receiver operating curve (AuROC), discrimination curves, and statistically tested with Chi-squared tests.

Results

When focusing on the diagnostic indices, the local UGIH had similar sensitivity to, but better specificity than the Blatchford score in detecting mild UGIH. The sensitivity was better than and the specificity was less than the Blatchford score in detecting severe UGIH. The local UGIH score was better than the pre-endoscopic Rockall in almost all diagnostic indices. Focusing overall performances, the local UGIH score classified patients non-significantly better than the Blatchford: 89.3% vs. 87.9% for mild (P = 0.243), 87.2% vs. 85.0% for severe (P = 0.092), but significantly classified better than the pre-endoscopic Rockall score: 89.3% vs. 76.4% for mild (P < 0.001), and 87.2% vs. 81.2% for severe (P < 0.001). When exploring the discrimination curves, the Blatchford score classified more patients into the mild categories, and less into the severe categories than the local UGIH score. In contrast, the pre-endoscopic Rockall score classified less patients into the mild, but more into the severe than the local UGIH score.

Conclusion

Triaging UGIH patients into three severity levels in order to decide or set for endoscopy should apply the scoring system specifically developed for that purpose. Adopting other scores developed for other purposes may result in under- and/or over-estimations. The local UGIH score classified patients into three severity levels to help indicate endoscopy more efficiently than the Blatchford score and the pre-endoscopic Rockall score which was developed for different purposes.

Comparison of the Glasgow-Blatchford and AIMS65 scoring systems for risk stratification in upper gastrointestinal bleeding in the emergency department

OBJECTIVES

The aim of this study was to compare the performance of the Glasgow-Blatchford and the AIMS65 scoring systems as early risk assessment tools for accurately identifying patients with upper gastrointestinal (GI) bleeding who are at a low risk of requiring clinical interventions, including emergency endoscopy. The secondary objective was to compare their performance regarding relevant clinical outcomes.

METHODS

Data were collected prospectively over a 2-year period in the emergency department of a university hospital. Adult patients with upper GI bleeding from either variceal or nonvariceal sources were included. Composite clinical outcomes consisted of a need for surgical or endoscopic intervention, rebleeding, intensive care unit admission, or in-hospital mortality. Patients who required blood transfusions or suffered composite clinical outcomes were considered high-risk patients. Glasgow-Blatchford score (GBS) and AIMS65 score were calculated for each patient. The sensitivity and specificity of the scoring systems were calculated. The areas under the receiver-operating characteristic curve (AUC) of the scores were compared.

RESULTS

There were 254 patients in the study, of whom 163 (64.2%) were men. The median age was 61 years (interquartile range = 45 to 72 years). Among the patients, 211 (83.1%) underwent endoscopy, of whom 49 (19.3%) required endoscopic intervention to achieve hemostasis. Five (2%) patients required surgical intervention. Rebleeding was observed in 33 (13%) patients. A total of 143 (56.3%) patients received blood transfusions. A total of 152 (59.8%) were defined as high risk. Eighty-one (31.9%) experienced at least one component of the composite clinical outcomes, 18 (7.1%) of whom suffered in-hospital mortality. A GBS of 0 was observed in 16 patients (6.3%) in the study group. Two of these were high-risk patients. A total of 101 (39.8%) patients had AIMS65 scores of 0. Thirty-four of these were high-risk patients. A GBS of 0 had higher sensitivity than an AIMS65 score of 0 (98.68% vs. 77.6%). The negative predictive values of the GBS and AIMS65 of 0 were 87.5 and 66.3%, respectively. The GBS and AIMS65 were similar with regard to the composite outcome prediction, with AUCs of 0.795 (95% confidence interval [CI] = 0.74 to 0.843) and 0.746 (95% CI = 0.688 to 0.798), respectively (p = 0.137). The scores were also similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; p = 0.342). The GBS was superior to the AIMS65 in identifying high-risk patients, with AUCs of 0.896 (95% CI = 0.85 to 0.93) and 0.771 (95% CI = 0.714 to 0.821; p < 0.001), respectively. The GBS was also more accurate than the AIM65 in predicting the need for blood transfusions (AUCs of 0.904 vs. 0.796; p < 0.001) and interventions (AUCs of 0.727 vs. 0.647; p = 0.05).

CONCLUSIONS

These results suggest that the GBS has superior sensitivity relative to the AIMS65 in identifying patients who were not likely to require interventions, including emergency endoscopy. Additional work to determine the use in real-time decision making may be warranted and helpful in providing guidance to clinicians.

Performance of new thresholds of the Glasgow Blatchford score in managing patients with upper gastrointestinal bleeding

BACKGROUND & AIMS

Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification.

METHODS

We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk.

RESULTS

There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = .0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%).

CONCLUSIONS

A GBS cut-off value of ≤1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.

Initial assessment and management of patients with nonvariceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB.

Can the presence of endoscopic high-risk stigmata be predicted before endoscopy? A multivariable analysis using the RUGBE database

BACKGROUND

Many aspects in the management of acute upper gastrointestinal bleeding rely on pre-esophagogastroduodenoscopy (EGD) stratification of patients likely to exhibit high-risk stigmata (HRS); however, data predicting the presence of HRS are lacking.

OBJECTIVE

To determine clinical and laboratory predictors of HRS at the index EGD in patients presenting with acute upper gastrointestinal bleeding using retrospective data from a validated national database - the Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy registry. methods: Relevant clinical and laboratory parameters were evaluated. HRS was defined as spurting, oozing, nonbleeding visible vessel or adherent clot after vigorous irrigation. Multivariable modelling was used to identify predictors of HRS including age, sex, hematemesis, use of antiplatelet agents, American Society of Anesthesiologists (ASA) classification, nasogastric tube aspirate, hemoglobin level and elapsed time from the onset of bleeding to EGD.

RESULTS

Of the 1677 patients (mean [± SD] age 66.2 ± 16.8 years; 38.3% female), 28.7% had hematemesis, 57.8% had an ASA score of 3 to 5, and the mean hemoglobin level was 96.8 ± 27.3 g⁄L. The mean time from presentation to endoscopy was 22.2 ± 37.5 h. The best fitting multivariable model included the following significant predictors: ASA score 3 to 5 (OR 2.16 [95% CI 1.71 to 2.74]), a shorter time to endoscopy (OR 0.99 [95% CI 0.98 to 0.99]) and a lower initial hemoglobin level (OR 0.99 [95% CI 0.99 to 0.99]).

CONCLUSION

A higher ASA score, a shorter time to endoscopy and lower initial hemoglobin level all significantly predicted the presence of endoscopic HRS. These criteria could be used to improve the optimal selection of patients requiring more urgent endoscopy.

Emergency endoscopy for acute gastrointestinal bleeding: prognostic value of endoscopic hemostasis and the AIMS65 score in Japanese patients

BACKGROUND AND AIM

To evaluate the prognostic factors, including risk scores (Glasgow-Blatchford score and AIMS65) in patients with acute upper or lower gastrointestinal bleeding.

METHODS

The medical records of patients who had undergone emergency gastrointestinal endoscopy for suspected gastrointestinal bleeding during the past 5 years were retrospectively analyzed.

RESULTS

A total of 232 endoscopies (130 esophagogastroduodenoscopies, 102 colonoscopies) for 192 patients met the inclusion criteria. Median age was 66 years, and 64% of patients were males. Endoscopy identified causes for bleeding in 173 patients (post-endoscopic interventions for neoplastic lesions in 36 cases, colonic diverticula in 34, gastroduodenal ulcers in 29, gastric erosions in 15, vascular ectasia in 14, post-biopsy bleeding in 13, malignant tumors in 10, inflammatory conditions in nine, esophagogastric varices in five, Mallory-Weiss tears in four, nasalbleeding in three, and injury by swallowed blister pack in one), whereas the source of bleeding remained obscure in 19 patients. Blood transfusion was given in 97 patients (51%), and 97 (51%) underwent endoscopic hemostasis. During the follow-up period, 49 patients (26%) experienced rebleeding, seven of whom were treated by interventional radiology. Thirty-nine patients (20%) died as a result of various diseases. The probabilities of overall survival (OS) after 3 and 5 years were 71% and 67%, respectively. Cox multivariate analysis revealed blood transfusion, co-existing malignancy, absence of endoscopic hemostasis, and high AIMS65 score to be independent prognostic factors for poor OS.

CONCLUSION

The AIMS65 score is useful for predicting the prognosis of patients with acute gastrointestinal bleeding.

"First look" unsedated transnasal esogastroduodenoscopy in patients with upper gastrointestinal bleeding? A prospective evaluation

BACKGROUND AND AIMS

With small diameter endoscopes, transnasal esophagogastroduodenoscopy (t-EGD) is routinely performed. The aim of this prospective observational study was to evaluate the role of t-EGD for upper gastrointestinal bleeding (UGIB).

PATIENTS AND METHODS

One hundred and forty-five consecutive patients (mean age, 66±18.4 years) with suspicion of UGIB were classified a priori into 3 groups according to initial clinical presentation: (1) intensive care unit with EGD under sedation, (2) endoscopy unit with EGD under transient sedation and (3) unsedated t-EGD as "first look". Demographic, clinical and biological parameters, Rockall and Blatchford scores, endoscopic diagnosis and treatment, and outcome were analysed.

RESULTS

Unsedated t-EGD was attempted in 89 patients, performed in 52 (5 failures, 28 contraindications) and the procedure was converted under sedation for 2 patients. Based on ASA classification, clinical (blood pressure, hemodynamical failure) and biological variables (hemoglobin, platelets, creatinine), these patients were less severe than in the other groups. Pre-endoscopic Rockall and Blatchford scores were significantly lower in this group. More patients in this group presented significant cardiovascular co-morbidity (47.2%), taking aspirin, clopidogrel and/or anticoagulant.

CONCLUSIONS

Our results strongly support that "first look" unsedated t-EGD can avoid unnecessary sedation in selected patients with UGIB, presenting a low probability for endoscopic haemostatic treatment and high sedation risks.

Using an 'action set' for the management of acute upper gastrointestinal bleeding

BACKGROUND

We studied the management of patients with acute upper gastrointestinal (GI) bleeding (AUGIB) at the Royal Free Hospital. The aim was to compare our performance with the national standard and determine ways of improving the delivery of care in accordance with the recently published 'Scope for improvement' report.

METHODS

We randomly selected patients who presented with haematemesis, melaena, or both, and had an oesophageogastroduodenoscopy (OGD) between April and October 2009. We developed local guidelines and presented our findings in various forums. We collaborated with the British Medical Journal's Evidence Centre and Cerner Millennium electronic patient record system to create an electronic 'Action Set' for the management of patients presenting with AUGIB. We re-audited using the same standard and target.

RESULTS

With the action set, documentation of pre-OGD Rockall scores increased significantly (p ≤ 0.0001). The differences in the calculation and documentation of post-OGD full Rockall scores were also significant between the two audit loops (p = 0.007). Patients who inappropriately received proton-pump inhibitors (PPIs) before endoscopy were reduced from 73.8% to 33% (p = 0.02). Patients receiving PPIs after OGD were also reduced from 66% to 50% (p = 0.01). Discharges of patients whose full Rockall score was less than or equal to two increased from 40% to 100% (p = 0.43).

CONCLUSION

The use of the Action Set improved calculation and documentation of risk scores and facilitated earlier hospital discharge for low-risk patients. Significant improvements were also seen in inappropriate use of PPIs. Actions sets can improve guideline adherence and can potentially promote cost-cutting and improve health economics.

Chronic kidney disease, hemodynamic instability, and endoscopic high-risk appearance are associated with 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding

The results of studies that evaluated predictive factors for rebleeding in non-variceal upper gastrointestinal bleeding are inconsistent. The aim of this study was to investigate predictive factors for 30-day rebleeding in these patients. A consecutive 312 patients presenting symptoms and signs of gastrointestinal bleeding were enrolled in this prospective, observational study. Clinical and demographic characteristics and endoscopic findings were evaluated for potential factors associated with 30-day rebleeding using logistic regression analysis. Overall, 176 patients were included (male, 80.1%; mean age, 59.7±16.0 yr). Rebleeding within 7 and 30 days occurred in 21 (11.9%) and 27 (15.3%) patients, respectively. We found that chronic kidney disease (CKD) (OR, 10.29; 95% CI, 2.84-37.33; P<0.001), tachycardia (pulse>100 beats/min) during the admission (OR, 3.79; 95% CI, 1.25-11.49; P=0.019), and Forrest classes I, IIa, and IIb (OR, 6.14; 95% CI, 1.36-27.66; P=0.018) were significant independent predictive factors for 30-day rebleeding. However, neither Rockall nor Blatchford scores showed statistically significant relationships with 30-day rebleeding in a multivariate analysis. CKD, hemodynamic instability during hospitalization, and an endoscopic high-risk appearance are significantly independent predictors of 30-day rebleeding in patients with non-variceal upper gastrointestinal bleeding. These factors may be useful for clinical management of such patients.

Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding

BACKGROUND

Data regarding the utility of the Glasgow-Blatchford bleeding score (GBS) in hospitalized patients with upper GI hemorrhage are limited.

OBJECTIVE

To evaluate the performance of the GBS in predicting clinical outcomes and the need for interventions in patients with upper GI hemorrhage.

DESIGN

Prospective observational study.

SETTING

Single, tertiary-care endoscopic center.

PATIENTS

Between July 2010 and July 2012, 888 consecutive hospitalized patients managed for upper GI hemorrhage were entered into the study.

INTERVENTION

GBS and Rockall scores.

MAIN OUTCOME MEASUREMENTS

GBS and Rockall scores were prospectively calculated. The performance of these scores to predict the need for interventions and outcomes was assessed by using a receiver operating characteristic curve.

RESULTS

Endoscopy was performed in 708 patients (80%). A total of 286 patients (40.3%) required endoscopic therapy, and 29 patients (3.8%) underwent surgery. GBS and post-endoscopy Rockall scores (post-E RS) were superior to pre-endoscopy Rockall scores in predicting the need for endoscopic therapy (area under the curve [AUC] 0.76 vs 0.76 vs 0.66, respectively) and rebleeding (AUC 0.71 vs 0.64 vs 0.57). The GBS was superior to Rockall scores in predicting the need for blood transfusion (AUC 0.81 vs 0.70 vs 0.68) and surgery (AUC 0.71 vs 0.64 vs 0.51). Patients with GBS scores ≤ 3 did not require intervention.

LIMITATIONS

Subjective decision making as to need for endoscopic therapy and blood transfusion.

CONCLUSION

Compared with post-E RS, the GBS was superior in predicting the need for blood transfusion and surgery in hospitalized patients with upper GI hemorrhage and was equivalent in predicting the need for endoscopic therapy, rebleeding, and death. There are potential cutoff GBS scores that allow risk stratification for upper GI hemorrhage, which warrant further evaluation.

Modern management of acute non-variceal upper gastrointestinal bleeding

An acute upper gastrointestinal bleed (AUGIB) often represents a life-threatening event and is recognised universally as a common cause of emergency hospitalisation. Large observational studies have improved our understanding of the disease characteristics and its impact on mortality but despite significant advancement in endoscopic management, mortality remains high, particularly in elderly patients and those with multiple comorbidities. Skilled assessment, risk stratification and prompt resuscitation are essential parts of patient care, with endoscopy playing a key role in the definitive management. A successful outcome partly relies on the clinician's familiarity with current guidelines and recommendations, including the National Institute for Clinical Excellence guidelines published in 2012. Validated risk stratification scores, such as the Blatchford and Rockall score, facilitate early discharge of low-risk patients as well as help in identifying those needing early endoscopic intervention. Major advances in therapeutic endoscopy, including more recently, the development of non-toxic proprietary powders (Hemospray and EndoClot), have resulted in the development of effective treatments of bleeding lesions, reduction in rebleeding rates and the need for emergency surgery. The role of proton-pump inhibitor therapy prior to endoscopy and the level of optimum red cell transfusion in the setting of AUGIB remain fields that require further research.