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

Lactate to albumin ratio as a prognosis predictor in gastrointestinal bleeding in the emergency department

Gastrointestinal bleeding (GIB) is a common cause of emergency department (ED) visits, and has various prognoses. This study aimed to verify the prognostic ability of the lactate/albumin (L/A) ratio in patients with GIB compared with the AIMS65 score and blood urea nitrogen/albumin (B/A) ratio. This retrospective study included patients with GIB symptoms who visited the ED in 2019. Baseline characteristics and laboratory data were obtained to calculate the L/A and B/A ratios and AIMS65 score. Each score was evaluated as a predictor of intensive care unit (ICU) admission and in-hospital mortality by using the area under the receiver operating characteristic (AUROC) curve. The multivariate logistic regression analysis revealed that the L/A ratio significantly predicted ICU admission and in-hospital mortality. The AUROC curve for predicting ICU admission were 0.788, 0.695, and 0.586 for the L/A, B/A, and AIMS65 scores, respectively, while the AUROC curve for predicting in-hospital mortality were 0.807, 0.799, and 0.683 for the L/A, B/A, and AIMS65 scores, respectively. The L/A ratio, which consists of the serum lactate and albumin levels, showed superior performance relative to the B/A ratio and AIMS65 score in predicting the prognosis of patients with GIB.

Emergency medicine updates: Upper gastrointestinal bleeding

INTRODUCTION

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSIONS

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

Admission Hypocalcemia and the Need for Endoscopic and Clinical Interventions among Patients with Upper Gastrointestinal Bleeding

INTRODUCTION

Calcium is an essential co-factor in the coagulation cascade, and hypocalcemia is associated with adverse outcomes in bleeding patients, including trauma patients, women with postpartum hemorrhage, and patients with intracranial hemorrhage. In this retrospective, single-center, cohort study, we aimed to determine whether admission-ionized calcium (Ca++) is associated with higher rates of therapeutic interventions among patients presenting with acute nonvariceal upper gastrointestinal bleeding (NV-UGIB).

METHODS

Adult patients admitted due to NV-UGIB between January 2009 and April 2020 were identified. The primary outcome was defined as a need for clinical intervention (two or more packed cell transfusions, need for endoscopic, surgical, or angiographic intervention). Univariate and multivariable logistic regression analyses were performed to determine whether Ca++ was an independent predictor of the need for therapeutic interventions. Propensity score matching was performed to adjust the imbalances of covariates between the groups.

RESULTS

A total of 434 patients were included, of whom 148 (34.1%) had hypocalcemia (Ca++ <1.15 mmol/L). Patients with hypocalcemia were more likely to require therapeutic interventions than those without hypocalcemia (48.0% vs. 18.5%, p < 0.001). Specifically, patients with hypocalcemia were more likely to require endoscopic intervention for control of bleeding (25.0% vs. 15.7%, p = 0.03) and multiple packed cell transfusions (6.8% vs. 0.3%, p < 0.001). Additionally, they had significantly longer hospital stay (5.0 days [IQR 3.0-8.0] vs. 4.0 days [IQR 3.0-6.0], p = 0.01). After adjusting for multiple covariates, Ca++ was an independent predictor of the need for therapeutic intervention (aOR 1.62, 95% confidence interval [CI] 1.22-2.14, p < 0.001). The addition of Ca++ to the Modified Glasgow Blatchford score improved its accuracy in the prediction of therapeutic intervention from AUC of 0.68 (95% CI 0.63-0.72) to 0.72 (95% CI 0.67-0.76), p = 0.02. After incorporation of the propensity score, the results did not change significantly.

CONCLUSION

These findings suggest that hypocalcemia is common and is associated with an adverse clinical course in patients with NV-UGIB. Measurement of Ca++ on admission may facilitate risk stratification in these patients. Trials are needed to assess whether the correction of hypocalcemia will lead to improved outcomes.

Treatment of Factor-Xa Inhibitor-associated Bleeding with Andexanet Alfa or 4 Factor PCC: A Multicenter Feasibility Retrospective Study

Background: There are no randomized trials comparing andexanet alfa and 4 factor prothrombin complex concentrate (4F-PCC) for the treatment of factor Xa inhibitor (FXa-I)-associated bleeds, and observational studies lack important patient characteristics. We pursued this study to demonstrate the feasibility of acquiring relevant patient characteristics from electronic health records. Secondarily, we explored outcomes in patients with life-threatening FXa-I associated bleeds after adjusting for these variables. Methods: We conducted a multicenter, chart review of 100 consecutive adult patients with FXa-I associated intracerebral hemorrhage (50) or gastrointestinal bleeding (50) treated with andexanet alfa or 4F-PCC. We collected demographic, clinical, laboratory, and imaging data including time from last factor FXa-I dose and bleed onset. Results: Mean (SD) age was 75 (12) years; 34% were female. Estimated time from last FXa-I dose to bleed onset was present in most cases (76%), and patients treated with andexanet alfa and 4F-PCC were similar in baseline characteristics. Hemostatic efficacy was excellent/good in 88% and 76% of patients treated with andexanet alfa and 4F-PCC, respectively (P = 0.29). Rates of thrombotic events within 90 days were 14% and 16% in andexanet alfa and 4F-PCC patients, respectively (P = 0.80). Survival to hospital discharge was 92% and 76% in andexanet alfa and 4F-PCC patients, respectively (P = 0.25). Inclusion of an exploratory propensity score and treatment in a logistic regression model resulted in an odds ratio in favor of andexanet alfa of 2.01 (95% confidence interval 0.67-6.06) for excellent/good hemostatic efficacy, although the difference was not statistically significant. Conclusion: Important patient characteristics are often documented supporting the feasibility of a large observational study comparing real-life outcomes in patients with FXa-I-associated bleeds treated with andexanet alfa or 4F-PCC. The small sample size in the current study precluded definitive conclusions regarding the safety and efficacy of andexanet alfa or 4F-PCC in FXa-I-associated bleeds.

A Nomogram Model for Prediction of Mortality Risk of Patients with Dangerous Upper Gastrointestinal Bleeding: A Two-center Retrospective Study

OBJECTIVE

This study aimed to establish a nomogram model to predict the mortality risk of patients with dangerous upper gastrointestinal bleeding (DUGIB), and identify high-risk patients who require emergent therapy.

METHODS

From January 2020 to April 2022, the clinical data of 256 DUGIB patients who received treatments in the intensive care unit (ICU) were retrospectively collected from Renmin Hospital of Wuhan University (n=179) and the Eastern Campus of Renmin Hospital of Wuhan University (n=77). The 179 patients were treated as the training cohort, and 77 patients as the validation cohort. Logistic regression analysis was used to calculate the independent risk factors, and R packages were used to construct the nomogram model. The prediction accuracy and identification ability were evaluated by the receiver operating characteristic (ROC) curve, C index and calibration curve. The nomogram model was also simultaneously externally validated. Decision curve analysis (DCA) was then used to demonstrate the clinical value of the model.

RESULTS

Logistic regression analysis showed that hematemesis, urea nitrogen level, emergency endoscopy, AIMS65, Glasgow Blatchford score and Rockall score were all independent risk factors for DUGIB. The ROC curve analysis indicated the area under curve (AUC) of the training cohort was 0.980 (95%CI: 0.962-0.997), while the AUC of the validation cohort was 0.790 (95%CI:0.685-0.895). The calibration curves were tested for Hosmer-Lemeshow goodness of fit for both training and validation cohorts (P=0.778, P=0.516).

CONCLUSION

The developed nomogram is an effective tool for risk stratification, early identification and intervention for DUGIB patients.

Age, blood tests and comorbidities and AIMS65 risk scores outperform Glasgow-Blatchford and pre-endoscopic Rockall score in patients with upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal (GI) bleeding is a life-threatening condition with high mortality rates.

AIM

To compare the performance of pre-endoscopic risk scores in predicting the following primary outcomes: In-hospital mortality, intervention (endoscopic or surgical) and length of admission (≥ 7 d).

METHODS

We performed a retrospective analysis of 363 patients presenting with upper GI bleeding from December 2020 to January 2021. We calculated and compared the area under the receiver operating characteristics curves (AUROCs) of Glasgow-Blatchford score (GBS), pre-endoscopic Rockall score (PERS), albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 (AIMS65) and age, blood tests and comorbidities (ABC), including their optimal cut-off in variceal and non-variceal upper GI bleeding cohorts. We subsequently analyzed through a logistic binary regression model, if addition of lactate increased the score performance.

RESULTS

All scores had discriminative ability in predicting in-hospital mortality irrespective of study group. AIMS65 score had the best performance in the variceal bleeding group (AUROC = 0.772; P < 0.001), and ABC score (AUROC = 0.775; P < 0.001) in the non-variceal bleeding group. However, ABC score, at a cut-off value of 5.5, was the best predictor (AUROC = 0.770, P = 0.001) of in-hospital mortality in both populations. PERS score was a good predictor for endoscopic treatment (AUC = 0.604; P = 0.046) in the variceal population, while GBS score, (AUROC = 0.722; P = 0.024), outperformed the other scores in predicting surgical intervention. Addition of lactate to AIMS65 score, increases by 5-fold the probability of in-hospital mortality (P < 0.05) and by 12-fold if added to GBS score (P < 0.003). No score proved to be a good predictor for length of admission.

CONCLUSION

ABC score is the most accurate in predicting in-hospital mortality in both mixed and non-variceal bleeding population. PERS and GBS should be used to determine need for endoscopic and surgical intervention, respectively. Lactate can be used as an additional tool to risk scores for predicting in-hospital mortality.

Strengths and limitations of risk stratification tools for patients with upper gastrointestinal bleeding: a narrative review

INTRODUCTION

Despite advances in the management of patients with upper gastrointestinal bleeding (UGIB), associated morbidity and mortality remain significant. Most patients, however, will experience favorable outcomes without a need for hospital-based interventions. Risk assessment scores may assist in such early risk-stratification. These scales may optimize identification of low-risk patients, resulting in better resource utilization, including a reduced need for early endoscopy and fewer hospital admissions. The aim of this article is to provide an updated detailed review of risk assessment scores in UGIB.

AREA COVERED

A literature review identified past and currently available pre-endoscopic risk assessment scores for UGIB, with a focus on low-risk prediction. Strengths and weaknesses of the different scales are discussed as well as their impact on clinical decision-making.

EXPERT OPINION

The current evidence supports using the Glasgow Blatchford Score as it is the most accurate tool available when attempting to identify low-risk patients who can be safely managed on an outpatient basis. Currently, no risk assessment tool appears accurate enough in confidently classifying patients as high risk. Future research should utilize more standardized methodologies, while favoring interventional trial designs to better characterize the clinical impact attributable to the use of such risk stratification schemes.

Embolization for acute nonvariceal bleeding of upper and lower gastrointestinal tract: a systematic review

BACKGROUND

Acute non-variceal gastrointestinal bleedings (GIBs) are pathological conditions associated with significant morbidity and mortality. Embolization without angiographic evidence of contrast media extravasation is proposed as an effective procedure in patients with clinical and/or laboratory signs of bleeding. The purpose of this systematic review is to define common clinical practice and clinical and technical outcomes of blind and preventive embolization for upper and lower gastrointestinal bleeding.

MAIN BODY

Through the PubMed, Embase and Google Scholar database, an extensive search was performed in the fields of empiric and preventive embolization for the treatment of upper and lower gastrointestinal bleedings (UGIB and LGIB). Inclusion criteria were: articles in English for which it has been possible to access the entire content; adults patients treated with empiric or blind transcatheter arterial embolization (TAE) for UGIB and/or LGIB. Only studies that analysed clinical and technical success rate of blind and empiric TAE for UGIB and/or LGIB were considered for our research. Exclusion criteria were: recurrent articles from the same authors, articles written in other languages, those in which the entire content could not be accessed and that articles were not consistent to the purposes of our research. We collected pooled data on 1019 patients from 32 separate articles selected according to the inclusion and exclusion criteria. 22 studies focused on UGIB (total 773 patients), one articles focused on LGIB (total 6 patients) and 9 studies enrolled patients with both UGIB and LGIB (total 240 patients). Technical success rate varied from 62% to 100%, with a mean value of 97.7%; clinical success rate varied from 51% to 100% with a mean value of 80%. The total number of complications was 57 events out of 1019 procedures analysed.

CONCLUSION

TAE is an effective procedure in the treatment of UGIB patients in which angiography does not demonstrate direct sign of ongoing bleeding. The attitude in the treatment of LGIBs must be more prudent in relation to poor vascular anastomoses and the high risk of intestinal ischemia. Blind and preventive procedures cumulatively present a relatively low risk of complications, compared to a relatively high technical and clinical success.

External validation and comparison of the Glasgow-Blatchford score, modified Glasgow-Blatchford score, Rockall score and AIMS65 score in patients with upper gastrointestinal bleeding: a cross-sectional observational study in Western Switzerland

Upper gastrointestinal bleeding (UGIB) presents a high incidence in an emergency department (ED) and requires careful evaluation of the patient's risk level to ensure optimal management. The primary aim of this study was to externally validate and compare the performance of the Rockall score, Glasgow-Blatchford score (GBS), modified GBS and AIMS65 score to predict death and the need for an intervention among patients with UGIB. This was a cross-sectional observational study of patients consulting the ED of a Swiss tertiary care hospital with UGIB. Primary outcomes were the inhospital need for an intervention, including transfusion, or an endoscopic procedure or surgery or inhospital death. The secondary outcome was inhospital death. We included 1521 patients with UGIB, median age, 68 (52-81) years; 940 (62%) were men. Melena or hematemesis were the most common complaints in 1020 (73%) patients. Among 422 (28%) patients who needed an intervention or died, 76 (5%) died in the hospital. Accuracy of the scoring systems assessed by receiver operating characteristic curves showed that the Glasgow-Blatchford bleeding and modified GBSs had the highest discriminatory capacity to determine inhospital death or the need of an intervention [AUC, 0.77 (95% CI, 0.75-0.80) and 0.78 (95% CI, 0.76-0.81), respectively]. AIMS65 and the pre-endoscopic Rockall score showed a lower discrimination [AUC, 0.68 (95% CI, 0.66-0.71) and 0.65 (95% CI, 0.62-0.68), respectively]. For a GBS of 0, only one patient (0.8%) needed an endoscopic intervention. The modified Glasgow-Blatchford and Glasgow-Blatchford bleeding scores appear to be the most accurate scores to predict the need for intervention or inhospital death.

CHAMPS score in predicting mortality of patients with acute nonvariceal upper gastrointestinal bleeding

OBJECTIVE

The aim of this study was to evaluate the performance of the Charlson Comorbidity Index ≥2, in-hospital onset, albumin <2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥2, steroid use score in predicting mortality in patients with nonvariceal upper gastrointestinal bleeding and compare it with the Glasgow-Blatchford score; the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score; the age, blood tests, and comorbidities score; and Complete Rockall score.

METHODS

The data of patients with acute upper gastrointestinal bleeding who visited the emergency department during the study period were obtained from the hospital automation system by using the classification of disease codes and analyzed in this retrospective study. Adult patients with endoscopically confirmed nonvariceal upper gastrointestinal bleeding were included in the study. Patients with bleeding from the tumor, bleeding after endoscopic resection, or missing data were excluded. The prediction accuracy of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score was calculated using the area under the receiver operating characteristic curve and compared with that of Glasgow-Blatchford score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, the age, blood tests, and comorbidities score, and Complete Rockall score.

RESULTS

A total of 805 patients were included in the study, and the in-hospital mortality rate was 6.6%. The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score (area under the receiver operating characteristic curve 0.812, 95%CI 0.783-0.839) was better than Glasgow-Blatchford score (area under the receiver operating characteristic curve 0.683, 95%CI 0.650-0.713, p=0.008), and similar to the the age, blood tests, and comorbidities score (area under the receiver operating characteristic curve 0.829, 95%CI 0.801-0.854, p=0.563), the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score (area under the receiver operating characteristic curve 0.794, 95%CI 0.764-0.821, p=0.672), and Complete Rockall score (area under the receiver operating characteristic curve 0.761, 95%CI 0.730-0.790, p=0.106).

CONCLUSION

The performance of the Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroid use score in predicting in-hospital mortality for our study population is better than Glasgow-Blatchford score and similar to the the age, blood tests, and comorbidities score, the albumin, international normalized ratio; alteration in mental status, systolic blood pressure, and age 65 score, and Complete Rockall score.

A multicenter prospective study of the treatment and outcome of patients with gastroduodenal peptic ulcer bleeding in Japan

Gastroduodenal peptic ulcers are the main cause of nonvariceal upper gastrointestinal bleeding (UGIB). We believe that recent advances in endoscopic techniques and devices for diagnosing upper gastrointestinal tract tumors have advanced hemostasis for UGIB. However, few prospective multicenter studies have examined how these changes affect the prognosis. This prospective study included 246 patients with gastroduodenal peptic ulcers treated at 14 participating facilities. The primary endpoint was in-hospital mortality within 4 weeks, and the secondary endpoints required intervention and refractory bleeding. Subsequently, risk factors affecting these outcomes were examined using various clinical items. Furthermore, the usefulness of the risk stratification using the Glasgow-Blatchford score, rockall score and AIMS65 based on data from the day of the first urgent endoscopy were examined in 205 cases in which all items were complete there are two periods. Thirteen (5%) patients died within 4 weeks; and only 2 died from bleeding. Significant risk factors for poor outcomes were older age and severe comorbidities. Hemostasis was required in 177 (72%) cases, with 20 cases of refractory bleeding (2 due to unsuccessful endoscopic treatment and 18 due to rebleeding). Soft coagulation was the first choice for endoscopic hemostasis in 57% of the cases and was selected in more than 70% of the cases where combined use was required. Rockall score and AIMS65 predicted mortality equally, and Glasgow-Blatchford score was the most useful in predicting the requirement for intervention. All scores predicted refractory bleeding similarly. Although endoscopic hemostasis for UGIB due to peptic ulcer had a favorable outcome, old age and severe comorbidities were risk factors for poor prognosis. We recommend that patients with UGIB should undergo early risk stratification using a risk scoring system.

Identification of risk factors for upper gastrointestinal bleeding in intensive care unit patients (GIBICU study)

BACKGROUND AND GOALS

Risk stratification for the need for therapeutic endoscopy and prediction of mortality in patients with upper gastrointestinal bleeding (UGIB) can be assessed by several scores. However, current scores are not validated for variceal bleeding and Intensive Care Unit (ICU) patients. The aim of this study was to evaluate potential parameters for the prediction of UGIB and patient outcomes.

PATIENTS AND STUDY METHODS

In this monocenter retrospective observational study, data from all esophagogastroduodenoscopies (EGD) between November 2014 and February 2020 with suspected hemorrhage in our ICU were evaluated.

RESULTS

Out of 345 included EGD, 42.3% of UGIB was diagnosed. 51.9% needed endoscopic intervention. Overall, 52.3% of included patients with UGIB died. Logistic regression showed that preceding variceal or non-variceal UGIB (p < .001), serum lactate (p = .001), heart rate (HR) (p = .005), and blood transfusions (p = .001) were significant predictors of UGIB. Previous UGIB (p < .001), male sex (p = .015), known varices (p < .001), serum albumin (p = .19) and use of catecholamines (p = .040) were significant predictors for the need of endoscopic intervention. Higher mortality was significantly associated with the usage of steroids (p < .001), malignant preconditions (p = .021), serum albumin (p = .020) and prolonged PTT (partial thromboplastin time) (p = .001).

CONCLUSIONS

We were able to identify additional parameters that had previously not been included in existing scores to predict the risk of UGIB, the need for therapeutic endoscopy and mortality in ICU patients. Therefore, an extension of these scores is necessary. Further validation of identified parameters in multicenter trials is needed to improve risk scores for ICU patients.

Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding

Objective

To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB).

Methods

A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed.

Results

In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively.

Conclusion

The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.

Risk factors for major gastrointestinal bleeding in the general population in Finland

BACKGROUND

Data on non-drug related risk-factors for gastrointestinal bleeding (GIB) in the general population are limited, especially for life-style factors, clinical measurements and laboratory parameters.

AIM

To identify and investigate non-drug risk factors for major GIB in the general population of Finland.

METHODS

We performed a retrospective cohort study using data from the FINRISK health examination surveys, which have been conducted every 5 years across Finland from 1987 to 2007. Participants were adults aged 25 years to 74 years, excluding those with a previous hospitalization for GIB. Follow-up from enrollment was performed through linkage to national electronic health registers and ended at an event of GIB that led to hospitalization/death, death due to any other cause, or after 10 years. Covariates included demographics, socioeconomic and lifestyle factors, clinical measurements, laboratory parameters and comorbidities. Variable selection was undertaken using Least Absolute Shrinkage and Selection Operator (LASSO) and factors associated with GIB were identified using Cox regression.

RESULTS

Among 33,508 participants, 403 (1.2%) experienced GIB [256 men (63.5%); mean age, 56.0 years (standard deviation (SD) ± 12.1)] and 33105 who did not experience GIB [15768 men (47.6%); mean age, 46.8 (SD ± 13) years], within 10 years of follow-up. Factors associated with a significantly increased risk of GIB were baseline age [per 10-year increase; hazard ratio (HR) 1.62, 95% confidence interval (CI): 1.42-1.86], unemployment (HR: 1.70, 95%CI: 1.11-2.59), body mass index (BMI) (HR: 1.15, 95%CI: 1.01-1.32), gamma-glutamyl transferase (GGT) (HR: 1.05, 95%CI: 1.02-1.09), precursors of GIB (HR: 1.90, 95%CI: 1.37-2.63), cancer (HR: 1.47, 95%CI: 1.10-1.97), psychiatric disorders (HR: 1.32, 95%CI: 1.01-1.71), heart failure (HR: 1.46, 95%CI: 1.04-2.05), and liver disorders (HR: 3.20, 95%CI: 2.06-4.97). Factors associated with a significantly decreased risk of GIB were systolic blood pressure (SBP) (HR: 0.78, 95%CI: 0.64-0.96), 6-10 cups of coffee a day (HR: 0.67, 95%CI: 0.46-0.99), or > 10 cups (HR: 0.43, 95%CI: 0.23-0.81).

CONCLUSION

Our study confirms established risk-factors for GIB and identifies potential risk-factors not previously reported such as unemployment, BMI, GGT, SBP and coffee consumption.

Comparisons of six endoscopy independent scoring systems for the prediction of clinical outcomes for elderly and younger patients with upper gastrointestinal bleeding

OBJECTIVES

To compare the predictive ability of six pre-endoscopic scoring systems (ABC, AIMS65, GBS, MAP(ASH), pRS, and T-score) for outcomes of upper gastrointestinal bleeding (UGIB) in elderly and younger patients.

METHODS

A retrospective study of 1260 patients, including 530 elderly patients (age [Formula: see text] 65) and 730 younger patients (age < 65) presenting with UGIB, was performed at Zhongda Hospital Southeast University, from January 2015 to December 2020. Six scoring systems were used.

RESULTS

ABC had the largest areas under the curve (AUCs) of 0.827 (0.792-0.858), and 0.958 (0.929-0.987) for elderly and younger groups for predicting mortality respectively. The differences of the AUCs for predicting the outcome of mortality and rebleeding between the two groups were significant for ABC and pRS (p < 0.01). For intervention prediction, significant differences were observed only for pRS [AUC 0.623 (0.578-0.669) vs. 0.699 (0.646-0.752)] (p < 0.05) between the two groups. For intensive care unit (ICU) admission, the AUC for MAP (ASH) [0.791 (0.718-0.865) vs. 0.891 (0.831-0.950)] and pRS [0.610 (0.514-0.706) vs. 0.891 (0.699-0.865)] were more effective for the younger group (p < 0.05 and p < 0.01, respectively). For comparison of scoring systems in the same cohort, ABC was significantly higher than pRS: AUC 0.710 (0.699-0.853, p < 0.05) and T-score 0.670 (0.628-0.710, p < 0.01) for predicting mortality in the elderly group. In the younger group, ABC was significantly higher than GBS and T-score (p < 0.01). MAP(ASH) performs the best in predicting intervention in both groups.

CONCLUSIONS

ABC and pRS are more accurate for predicting mortality and rebleeding in the younger cohort, and pRS may not be suitable for elderly patients. There was no difference between the two study populations for GBS, AIMS65, and T-score. Except for ICU admission, MAP(ASH) showed fair accuracy for both cohorts.

Development and validation of a model to predict rebleeding within three days after endoscopic hemostasis for high-risk peptic ulcer bleeding

Background

Peptic ulcer bleeding remains a typical medical emergency with significant morbidity and mortality. Peptic ulcer rebleeding often occurs within three days after emergent endoscopic hemostasis. Our study aims to develop a nomogram to predict rebleeding within three days after emergent endoscopic hemostasis for high-risk peptic ulcer bleeding.

Methods

We retrospectively reviewed the data of 386 patients with bleeding ulcers and high-risk stigmata who underwent emergent endoscopic hemostasis between March 2014 and October 2018. The least absolute shrinkage and selection operator method was used to identify predictors. The model was displayed as a nomogram. Internal validation was carried out using bootstrapping. The model was evaluated using the calibration plot, decision-curve analyses, and clinical impact curve.

Results

Overall, 386 patients meeting the inclusion criteria were enrolled, with 48 patients developed rebleeding within three days after initial endoscopic hemostasis. Predictors contained in the nomogram included albumin, prothrombin time, shock, haematemesis/melena and Forrest classification. The model showed good discrimination and good calibration with a C-index of 0.854 (C-index: 0.830 via bootstrapping validation). Decision-curve analyses and clinical impact curve also demonstrated that it was clinically valuable.

Conclusion

This study presents a nomogram that incorporates clinical, laboratory, and endoscopic features, effectively predicting rebleeding within three days after emergent endoscopic hemostasis and identifying high-risk rebleeding patients with peptic ulcer bleeding.

Trial registration This clinical trial has been registered in the ClinicalTrials.gov (ID: NCT04895904) approved by the International Committee of Medical Journal Editors (ICMJE).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02145-9.

Evaluation of Six Preendoscopy Scoring Systems to Predict Outcomes for Older Adults with Upper Gastrointestinal Bleeding

Objectives

To compare the ability of six preendoscopic scoring systems (ABC, AIMS65, Glasgow Blatchford score (GBS), MAP(ASH), pRS, and T-score) to predict outcomes of upper gastrointestinal bleeding (UGIB) in older adults.

Methods

This was a retrospective study of 602 older adults (age ≥ 65) presenting with UGIB at Zhongda Hospital Southeast University from January 2015 to June 2021. Six scoring systems were used to analyze all patients.

Results

ABC had the largest area under the curve (AUC) (0.833; 95% confidence interval (CI): 0.801–0.862) and was significantly higher than pRS 0.696 (95% CI: 0.658–0.733, p < 0.01) and T-score 0.667 (95% CI: 0.628–0.704, p < 0.01) in predicting mortality. MAP(ASH) (0.783; 95% CI: 0.748–0.815) performs the best in predicting intervention and was similar to GBS, T-score, ABC, and AIMS65. The AUCs for MAP(ASH) (0.732; 95% CI: 0.698–0.770), AIMS65 (0.711; 95% CI: 0.672–0.746), and ABC (0.718; 95% CI: 0.680–0.754) were fair for rebleeding, while those of GBS (0.662; 95% CI: 0.617–0.694), T-score (0.641; 95% CI: 0.606–0.684), and pRS (0.609; 95% CI: 0.569–0.648) were performed poorly. MAP(ASH) performs the best in predicting ICU admission (0.784; 95% CI: 0.749–0.816). All the five scores were significantly higher than pRS (p < 0.05 for ABC, AIMS65 and T-score, p < 0.01 for GBS and MAP).

Conclusions

Mortality, intervention, rebleeding, and ICU admission in UGIB for older adults can be predicted well using MAP(ASH). ABC is the most accurate for predicting mortality. Except for rebleeding, GBS has an acceptable performance in predicting ICU admission, mortality, and intervention. AIMS65 and T-score performed moderately, and pRS may not be suitable for the target cohort.

Prediction of adverse outcomes using non-endoscopic scoring systems in patients over 80 years of age who present with the upper gastrointestinal bleeding in the emergency department

BACKGROUND

The emergency department (ED) admission rate for elderly patients with non-variceal upper gastrointestinal bleeding (UGIB) is increasing. The AIMS65 and Glasgow-Blatchford score (GBS) are two distinct scoring systems proposed to predict in-hospital and post-discharge mortality, length of stay (LOS), and health-related costs in these patients. The objective of the present study is to evaluate the accuracy of these scoring systems, in conjunction with the Charlson comorbidity index (CCI), to predict 30-day mortality and LOS in UGIB patients who are 80 years of age or older METHODS: A retrospective analysis was undertaken of 182 patients with non-variceal UGIB who were admitted to the ED of Canakkale Onsekiz Mart University Hospital. The AIMS65, GBS, and CCI scores were calculated and adverse patient outcomes were assessed.

RESULTS

The mean age of patients was 85.59±4.33 years, and 90 (49.5%) of the patients were males. The AIMS65 was superior to the GBS (area under the receiver operating characteristic curve [AUROC] 0.877 vs. 0.695, respectively) and CCI (AUROC 0.877 vs. 0.526, respectively) in predicting the 30-day mortality. All three scores performed poorly in predicting the LOS in hospital. The cutoff threshold that maximized sensitivity and specificity for mortality was three for the AIMS65 score (sensitivity, 0.87; specificity, 0.80; negative predictive values [NPV], 0.977; positive predictive values [PPV], 0.392), 14 for GBS (sensitivity, 0.83; specificity, 0.51; NPV, 0.923; PPV, 0.367), and 5 for CCI (sensitivity, 0.91; specificity, 0.22; NPV, 0.946; PPV, 0.145).

CONCLUSION

The AIMS65 is a simple, accurate, and non-endoscopic scoring system that can be performed easily in ED settings. It is superior to GBS and CCI in predicting 30-day mortality in elderly patients with UGIB.

Association of ABO Blood Type with Bleeding Severity in Patients with Acute Gastroesophageal Variceal Bleeding

Background and Objectives: ABO blood types have been implicated as potential risk factors for various hemorrhagic diseases. No study has investigated the association between gastroesophageal variceal bleeding and ABO blood types. We aimed to evaluate the impact of ABO blood types on mortality and bleeding risk in acute gastroesophageal variceal bleeding. Materials and Methods: This is a retrospective observational study. Patients presenting with acute gastroesophageal varices bleeding diagnosed by endoscopy were enrolled, and were divided by blood type into a type O group and non-type O group. The outcomes were death within 30 days and the proportion of further bleeding. We used generalized linear mixed-effects models to analyze the outcomes. Results: A total of 327 patients and 648 records of emergency room visits were included. The 30-day mortality was 14.8% (21 of 142 patients) in the type O group, and 16.2% (30 of 185 patients) in the non-type O group (p = 0.532). Further bleeding within 30 days occurred in 34 cases (12.6%) in the type O group, and in 26 cases (6.9%) in the non-type O group (p = 0.539). Conclusions: There was no significant difference in blood transfusion volume in 24 h, recurrent bleeding rates, or mortality between patients with blood type O and those with non-type O.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hypocalcemia is associated with adverse clinical course in patients with upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding (NV-UGIB) is associated with significant morbidity and mortality. Early and efficient risk stratification can facilitate management and improve outcomes. We aimed to determine whether the level of ionized calcium (Ca⁺⁺), an essential co-factor in the coagulation cascade, is associated with the severity of bleeding and the need for advanced interventions among these patients. This was a retrospective single-center cohort study of all patients admitted due to NV-UGIB. The primary outcome was transfusion of ≥ 2 packed red blood cells, arterial embolization, or emergency surgery. Secondary outcomes included (1) transfusion of ≥ 2 packed red blood cells, (2) arterial embolization, or emergency surgery, and (3) all-cause in-hospital mortality. Multivariable logistic regression was performed to determine whether Ca⁺⁺ was an independent predictor of these adverse outcomes. 1345 patients were included. Hypocalcemia was recorded in 604 (44.9%) patients. The rates of primary adverse outcome were significantly higher in the hypocalcemic group, 14.4% vs. 5.1%, p < 0.001. Secondary outcomes-multiple transfusions, need for angiography or surgery, and mortality were also increased (9.9% vs. 2.3%, p < 0.001, 5.3% vs. 2.8%, p = 0.03, and 33.3% vs. 24.7%, p < 0.001, respectively). Hypocalcemia was an independent predictor of primary and all the secondary outcomes, except mortality. Hypocalcemia in high-risk hospitalized patients with NV-UGIB is common and independently associated with adverse outcomes. Ca⁺⁺ monitoring in this population may facilitate the rapid identification of high-risk patients. Trials are needed to assess whether correction of hypocalcemia will lead to improved outcomes.

Current Status and Future Perspective of Artificial Intelligence in the Management of Peptic Ulcer Bleeding: A Review of Recent Literature

With the decreasing incidence of peptic ulcer bleeding (PUB) over the past two decades, the clinician experience of managing patients with PUB has also declined, especially for young endoscopists. A patient with PUB management requires collaborative care involving the emergency department, gastroenterologist, radiologist, and surgeon, from initial assessment to hospital discharge. The application of artificial intelligence (AI) methods has remarkably improved people's lives. In particular, AI systems have shown great potential in many areas of gastroenterology to increase human performance. Colonoscopy polyp detection or diagnosis by an AI system was recently introduced for commercial use to improve endoscopist performance. Although PUB is a longstanding health problem, these newly introduced AI technologies may soon impact endoscopists' clinical practice by improving the quality of care for these patients. To update the current status of AI application in PUB, we reviewed recent relevant literature and provided future perspectives that are required to integrate such AI tools into real-world practice.

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

Introduction:

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

Aim:

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

Methods:

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

Results:

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

Conclusion:

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

Novel and Simple Criteria for Predicting Mortality of Peptic Ulcer Disease

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Biopsy in emergency gastroscopy does not increase the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding combined with suspected malignant gastric ulcer: a multicenter retrospective cohort study

BACKGROUND

Few studies have reported whether a biopsy in emergency gastroscopy (EG) increased the risk of rebleeding in patients with Forrest I acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) combined with suspected malignant gastric ulcer (SMGU). This study aims to conduct a multicenter retrospective cohort study using propensity score matching to verify whether a biopsy in EG increases the risk of rebleeding in patients diagnosed with Forrest I ANVUGIB combined with SMGU.

METHODS

Using the data for propensity-matched patients, logistic regression models were fitted using rebleeding as the dependent variable. Survival time was defined as the length of time the patient experienced from visiting the emergency department to rebleeding. We used the Kaplan-Meier (KM) method to analyze the 30-day survival of the patients with and without a biopsy after matching, and the log-rank test was performed to examine the differences in survival.

RESULTS

With the use of propensity score matching, 308 patients who underwent a biopsy in EG were matched with 308 patients who did not. In the five logistic regression models, there were no significant group differences in the risk of rebleeding in patients with Forrest I ANVUGIB combined with SMGU between the biopsy and no-biopsy groups. The probability of survival was not significantly different between the no-biopsy and biopsy groups.

CONCLUSIONS

In this multicenter, retrospective propensity score matching cohort study, compared with patients without a biopsy, patients with a biopsy during EG had no increased risk of rebleeding, and there was no significant difference in the rate of rebleeding.

Comparison of the quick SOFA score with Glasgow-Blatchford and Rockall scores in predicting severity in patients with upper gastrointestinal bleeding

INTRODUCTION

Upper gastrointestinal bleeding is one of the common causes of mortality and morbidity. The Rockall score (RS) and Glasgow-Blatchford score (GBS) are frequently used in determining the prognosis and predicting in-hospital adverse events, such as mortality, re-bleeding, hospital stay, and blood transfusion requirements. The quick Sepsis Related Organ Failure Assessment (qSOFA) score is easy and swift to calculate. The commonly used scores and the qSOFA score were compared and why and when these scores are most useful was investigated.

METHOD

133 patients admitted to the emergency department with upper gastrointestinal bleeding over the period of a year, were evaluated in this retrospective study. The RS, GBS and qSOFA score were calculated for each patient, and their relationship with in-hospital adverse events, such as length of hospitalization, rebleeding, endoscopic treatment, blood transfusion requirements, and mortality, was investigated.

RESULTS

The mean overall GBS was 9.72 ± 3.72 (0-19), while that of patients who did not survive was 14.0 ± 1.1 (13-16), with an area under the curve (AUC) of 0.901, a cutoff value of 12.5, and specificity (Spe) and sensitivity (Sen) of 1 and 0.82, respectively. The median value of the GBS, in terms of transfusion need, was 7.12 ± 4.01 (0-15). (AUC = 0.752, cut-off = 9.5, Spe = 0.79, Sen = 0.69). The median value of the qSOFA score, in terms of intensive care need, was 1.73 ± 0.7 (0-3) (AUC = 0.921, cut-off = 0.5, Spe = 0.93, Sen = 0.79). The RS median, in terms of re-bleeding, was 8.22 ± 0.97 (6-9).

CONCLUSION

Early use of risk stratification scores in upper gastrointestinal bleeding is important due to the high risk of morbidity and mortality. All scoring systems were effective in predicting mortality, the need for intensive care, and re-bleeding. The GBS had a greater predictive power in terms of mortality and transfusion need, the qSOFA score for intensive care need, and the RS for re-bleeding. The simpler, more efficient, and more easily calculated qSOFA score can be used to estimate the severity of patients with upper gastrointestinal bleeding.

The Clinical Impact of Rockall and Glasgow-Blatchford Scores in Nonvariceal Upper Gastrointestinal Bleeding

Introduction

Risk stratification in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) is crucial for proper management. Rockall score (RS; pre-endoscopic and complete) and Glasgow-Blatchford score (GBS) are some of the most used scoring systems. This study aims to analyze these scores' ability to predict various clinical outcomes and possible cutoff points to identify low- and high-risk patients. Secondarily, this study intents to evaluate the appropriateness of patients' transfers to our facility, which provides a specialized emergency endoscopy service.

Methods

This study was retrospectively conducted at Centro Hospitalar Universitário do Porto and included patients admitted to the Emergency Department with acute manifestations of NVUGIB between January 2016 and December 2018. Receiver operating characteristic (ROC) curves and corresponding areas under the curve (AUC) were calculated. Transferred patients from other institutions and nontransferred (directly admitted to this institution) patients were also compared.

Results

Of a total of 420 patients, 23 (5.9%) died, 34 (8.4%) rebled, 217 (51.7%) received blood transfusion, 153 (36.3%) received endoscopic therapy, 22 (5.7%) had surgery, and 171 (42.3%) required hospitalization in the Intermediate or Intensive Care Unit. Regarding mortality prediction, both complete RS (AUC 0.756, p < 0.001) and pre-endoscopic RS (AUC 0.711, p = 0.001) showed good performance. In the prediction of rebleeding, only complete RS (AUC 0.735, p < 0.001) had discriminative ability. GBS had good performance in the prediction of transfusion (AUC 0.785, p < 0.001). No score showed discriminative capability in the prediction of other outcomes. Transferred and nontransferred patients had similar pre-endoscopic RS (3.41 vs. 3.34, p = 0.692) and GBS (13.29 vs. 12.29, p = 0.056). Only patients with GBS ≥6 were transferred to our facility. There were no adverse outcomes recorded in any group when GBS was ≤3.

Discussion/Conclusion

Complete RS and pre-endoscopic RS are effective at predicting mortality, but only complete RS showed good performance at predicting rebleeding. GBS is better at predicting transfusion requirement. Our study suggests that a transfer can possibly be reconsidered if GBS is ≤3, although current recommendations only propose outpatient care when GBS is 0 or 1. Patients' transfers were appropriate, considering the high GBS scores and the outcomes of these patients.

Perfusion index: Could this be a new triage tool for upper gastrointestinal system bleeding in the emergency department? A prospective cohort study

BACKGROUND

Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes.

OBJECTIVE

To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage.

DESIGN AND SETTING

Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019.

METHODS

Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded.

RESULTS

A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001).

CONCLUSION

PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.

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.

Reduced survival after upper gastrointestinal bleed endoscopy in the COVID-19 era is a secondary effect of the response to the global pandemic: a retrospective cohort study

OBJECTIVE

The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support 'COVID-centric' services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds.

DESIGN/METHODS

A retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy.

RESULTS

224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08-0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates.

CONCLUSION

Endoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

The Prognosis Analysis of Liver Cirrhosis with Acute Variceal Bleeding and Validation of Current Prognostic Models: A Large Scale Retrospective Cohort Study

Background

Acute variceal bleeding is a major cause of death in liver cirrhosis. This large scale retrospective cohort study aims to analyze the prognosis of patients with cirrhosis and acute variceal bleeding and to validate the current prognostic models.

Methods

Patients with cirrhosis and acute variceal bleeding were enrolled from Jan 2019 to March 2020. The independent prognostic factors for in-hospital death were identified by logistic regression analyses. Area under curves (AUCs) was compared among Child-Pugh, cirrhosis acute gastrointestinal bleeding (CAGIB) score, and model for end-stage liver disease (MELD) and neutrophil-lymphocyte ratio (NLR) scores.

Results

Overall, 379 patients with liver cirrhosis and acute variceal bleeding were consecutively evaluated. The majority of the patients were males (59.1%) and the mean age of all patients were 53.7 ± 1.3 years (range 14-89). Hepatitis B virus (HBV) was the most common underlying cause of liver cirrhosis (54.1%). 72 (19%) patients had hepatocellular carcinoma. Multivariate logistic regression analyses showed that age, HCC, WBC, total serum bilirubin, serum creatinine, and ALT were independently associated with in-hospital death. And the odds ratios (ORs) for in-hospital death were 1.066 (95% CI 1.017-1.118, P = 0.008), 7.19 (95% CI 2.077-24.893, P = 0.001), 1.123 (95% CI 1.051-1.201, P = 0.001), 1.014 (95% CI 1.005-1.023, P = 0.003), 1.012 (95% CI 1.004-1.021, P = 0.006), and 1.005 (95% CI 1.000-1.009, P = 0.036), respectively. In the whole cohort with HCC patients, the AUCs of Child-Pugh, CAGIB, MELD and NLR scores were 0.842 (95% CI 0.801-0.878), 0.840 (95% CI 0.799-0.876), 0.798 (95% CI 0.754-0.838), and 0.688 (95% CI 0.639-0.735), respectively. The differences were statistically significant between Child-Pugh and NLR scores (P = 0.0118), and between CAGIB and NLR scores (P = 0.0354).

Conclusion

Child-Pugh and CAGIB scores showed better predictive performance for prognosis of patients with cirrhosis and acute variceal bleeding than NLR scores.

Justification of Genetic Factors for Predicting the Risk of Acute Bleeding in Peptic Ulcer Disease

PAI genotyping for the G43A and 4G/5G polymorphisms was performed in 60 patients with peptic ulcer disease: 12 with an uncomplicated ulcer, 5 with perforation, the rest with ongoing bleeding. Fourteen patients had recurrent bleeding. The 5G/5G and G43A genotypes were not detected in patients with uncomplicated ulcers. All patients with ulcer perforation had the G43G genotype, 60% of patients had the 4G/4G genotype, and the rest of them had the 4G/5G and 5G/5G genotypes. The number of carriers of the 5G allele (86.05%) was higher in patients with bleeding than in ones with ulcer perforation (p=0.036) and ulcer without bleeding (p=0.021, χ2=5.32). The number of carriers of the 5G allele was higher in patients with recurrent bleeding (92.86%) than those without any relapses (82.76%) but there were no statistically significant differences (p=0.27, χ2=0.802). The G43G homozygous genotype was found in 94.12% of patients with peptic ulcer without bleeding, which was statistically significantly higher (p=0.02) than the ones with bleeding. The A allele was observed in 27.91% of patients with bleeding and 8.33% patients without any bleeding (p=0.05). The number of carriers of the A allele in patients with recurrent bleeding was statistically significantly higher than in ones without any bleeding (p=0.046). The 5G and A alleles in patients with a peptic ulcer can be used to predict the course of peptic ulcer disease and can be regarded as a predictor of the risk of bleeding relapse.