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

Evaluation and treatment of gastrointestinal bleeding in patients taking anticoagulants presenting to the emergency department

This manuscript is a consensus document of an expert panel on the Evaluation and Treatment of Gastrointestinal Bleeding in Patients Taking Anticoagulants Presenting to the Emergency Department, sponsored by the American College of Emergency Physicians.

Review article: Upper gastrointestinal bleeding - review of current evidence and implications for management

BACKGROUND

Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital-based care. Advances in care across pre-endoscopic, endoscopic and post-endoscopic phases have led to improvements in clinical outcomes.

AIMS

To provide a detailed, evidence-based update on major aspects of care across pre-endoscopic, endoscopic and post-endoscopic phases.

METHODS

We performed a structured bibliographic database search for each topic. If a recent high-quality meta-analysis was not available, we performed a meta-analysis with random effects methods and odds ratios with 95% confidence intervals.

RESULTS

Pre-endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high-risk stigmata, endoscopic therapy, including over-the-scope clips (OTSCs) and TC-325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post-endoscopic management includes early enteral feeding for all UGIB patients. For high-risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high-risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered.

CONCLUSIONS

Management of acute UGIB should include treatment plans for pre-endoscopic, endoscopic and post-endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding.

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.

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.

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.

The Predictive Value of Glasgow-Blatchford Score: The Experience of an Emergency Department

INTRODUCTION

Upper gastrointestinal bleeding (UGB) is a common emergency and a major cause of morbidity and mortality worldwide. An early and accurate assessment at admission is essential to estimate the severity of each case, assisting in the management of patients. The Glasgow-Blatchford score (GBS) is currently recommended for risk stratification of UGB in the emergency department (ED), helping triage patients to in-hospital vs. ambulatory management. The aim of this study was to test the validity of the GBS in an ED.

METHODS

Patients who presented to the ED with a diagnosis of UGB between 2017 and 2018 were retrospectively analyzed.

RESULTS

The mean GBS value of the 149 patients included in the study was 10.3. Of the patients, 4.3% had values ≤1 and 8.7% had values ≤3. The sensitivity and negative predictive value for intervention needs (98.9% and 91.7%) and complications in 30 days (100% and 100%) remained high with a threshold ≤3. In the receiver operating characteristic curves, GBS presented an area under the curve of 0.883 and 0.625, regarding the need for intervention and complications in 30 days, respectively.

CONCLUSIONS

In our population, the threshold ≤2, and eventually ≤3, allows the identification of twice as many low-risk patients, manageable as outpatients, without significant increases in intervention needs or complications in 30 days.

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.

Advancing care for acute gastrointestinal bleeding using artificial intelligence

The future of gastrointestinal bleeding will include the integration of machine learning algorithms to enhance clinician risk assessment and decision making. Machine learning algorithms have shown promise in outperforming existing clinical risk scores for both upper and lower gastrointestinal bleeding but have not been validated in any prospective clinical trials. The adoption of electronic health records provides an exciting opportunity to deploy risk prediction tools in real time and also to expand the data available to train predictive models. Machine learning algorithms can be used to identify patients with acute gastrointestinal bleeding using data extracted from the electronic health record. This can lead to an automated process to find patients with symptoms of acute gastrointestinal bleeding so that risk prediction tools can be then triggered to consistently provide decision support to the physician. Neural network models can be used to provide continuous risk predictions for patients who are at higher risk, which can be used to guide triage of patients to appropriate levels of care. Finally, the future will likely include neural network-based analysis of endoscopic stigmata of bleeding to help guide best practices for hemostasis during the endoscopic procedure. Machine learning will enhance the delivery of care at every level for patients with acute gastrointestinal bleeding through identifying very low risk patients for outpatient management, triaging high risk patients for higher levels of care, and guiding optimal intervention during endoscopy.

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.

Comparison of three risk scores to predict outcomes in upper gastrointestinal bleeding; modifying Glasgow-Blatchford with albumin

INTRODUCTION

Management of upper gastrointestinal bleeding (UGIB) is of great importance. In this way, we aimed to evaluate the performance of three well known scoring systems of AIMS65, Glasgow-Blatchford Score (GBS) and Full Rockall Score (FRS) in predicting adverse outcomes in patients with UGIB as well as their ability in identifying low risk patients for outpatient management. We also aimed to assess whether changing albumin cutoff in AIMS65 and addition of albumin to GBS add predictive value to these scores.

METHODS

This was a retrospective study on adult patients who were admitted to Razi hospital (Rasht, Iran) with diagnosis of upper gastrointestinal bleeding between March 21, 2013 and March 21, 2017. Patients who didn't undergo endoscopy or had incomplete medical data were excluded. Initially, we calculated three score systems of AIMS65, GBS and FRS for each patient by using initial Vital signs and lab data. Secondary, we modified AIMS65 and GBS by changing albumin threshold from <3.5 to <3.0 in AIMS65 and addition of albumin to GBS, respectively. Primary outcomes were defined as in hospital mortality, 30-day rebleeding, need for blood transfusion and endoscopic therapy. Secondary outcome was defined as composition of primary outcomes excluding need for blood transfusion. We used AUROC to assess predictive accuracy of risk scores in primary and secondary outcomes. For albumin-GBS model, the AUROC was only calculated for predicting mortality and secondary outcome. The negative predictive value for AIMS65, GBS and modified AIMS65 was then calculated.

RESULT

Of 563 patients, 3% died in hospital, 69.4% needed blood transfusion, 13.1% needed endoscopic therapy and 3% had 30-day rebleeding. The leading cause of UGIB was erosive disease. In predicting composite of adverse outcomes all scores had statistically significant accuracy with highest AUROC for albumin-GBS. However, in predicting in hospital mortality, only albumin-GBS, modified AIMS65 and AIMS65 had acceptable accuracy. Interestingly, albumin, alone, had higher predictive accuracy than other original risk scores. None of the four scores could predict 30-day rebleeding accurately; on the contrary, their accuracy in predicting need for blood transfusion was high enough. The negative predictive value for GBS was 96.6% in score of ≤2 and 85.7% and 90.2% in score of zero in AIMS65 and modified AIMS65, respectively.

CONCLUSION

Neither of risk scores was highly accurate as a prognostic factor in our population; however, modified AIMS65 and albumin-GBS may be optimal choice in evaluating risk of mortality and general assessment. In identifying patient for safe discharge, GBS ≤ 2 seemed to be advisable choice.

Risk stratification in upper and upper and lower GI bleeding: Which scores should we use?

Risk assessment is widely used in upper gastrointestinal bleeding (UGIB) however no score accurately predicts all important clinical outcomes. This review discusses the performance of the Rockall score, pre-endsocopy Rockall score, Glasgow-Blatchford score, AIMS-65 and newer scores such as Progetto Nazionale Emorragia Digestiva and CANUKA scores. The quality of external validation varies considerably for each score. There is a relative lack of risk scores available for use in lower GI bleeding (LGIB) but recent developments have focussed on the identification of low risk patients. The BLEED, NOBLADS, Strate and Sengupta scores have been developed to predict severe bleeding or death, each with varying performance. The Oakland score has been developed to identify patients at low risk of adverse outcomes who may be suitable for outpatient management. The comparative performance of the LGIB scores and Rockall, Glasgow-Blatchford and AIMS-65 in the prediction of outcomes in LGIB is also discussed.