Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding

AIMS

In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB).

METHODS

We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding.

RESULTS

A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings (n=50, 20%; n=29, 11.7%; and n=28, 11.3%, respectively). Of the participants, 93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180).

CONCLUSIONS

We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Helicobacter bizzozeronii infection in a girl with severe gastric disorders in México: case report

BACKGROUND

Gastric non-Helicobacter pylori helicobacters (NHPH) naturally colonize the stomach of animals. In humans, infection with these bacteria is associated with chronic active gastritis, peptic ulceration and MALT-lymphoma. H. bizzozeronii belongs to these NHPH and its prevalence in children is unknown.

CASE PRESENTATION

This case report describes for the first time a NHPH infection in a 20-month-old girl with severe gastric disorders in Mexico. The patient suffered from melena, epigastric pain, and bloating. Gastroscopy showed presence of a Hiatus Hill grade I, a hemorrhagic gastropathy in the fundus and gastric body, and a Forrest class III ulcer in the fundus. Histopathologic examination revealed a chronic active gastritis with presence of long, spiral-shaped bacilli in the glandular lumen. Biopsies from antrum, body and incisure were negative for presence of H. pylori by culture and PCR, while all biopsies were positive for presence of H. bizzozeronii by PCR. Most likely, infection occurred through intense contact with the family dog. The patient received a triple therapy consisting of a proton pump inhibitor, clarithromycin, and amoxicillin for 14 days, completed with sucralfate for 6 weeks, resulting in the disappearance of her complaints.

CONCLUSION

The eradication could not be confirmed, although it was suggested by clear improvement of symptoms. This case report further emphasizes the zoonotic importance of NHPH. It can be advised to routinely check for presence of both H. pylori and NHPH in human patients with gastric complains.

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.

Upper Gastrointestinal Bleeding Due to a Left Gastric Artery Pseudoaneurysm: A Case Series

BACKGROUND

Left gastric artery (LGA) pseudoaneurysm presenting with upper gastrointestinal (UGI) bleeding is rare but fatal, unless treated.

AIMS

We aimed to describe the clinical and endoscopic features of patients with UGI bleeding due to LGA pseudoaneurysms.

METHODS

We performed a computerized search of our hospital's de-identified clinical data warehouse to identify patients with UGI bleeding due to an LGA pseudoaneurysm between 2000 and 2020. Patients' electronic medical records and data on esophagogastroduodenoscopy and digital subtraction angiography were reviewed retrospectively.

RESULTS

Of 26 patients with an LGA pseudoaneurysm, six patients had UGI bleeding related to an LGA pseudoaneurysm. No patients had previous vascular diseases or pancreatitis. One patient had liver cirrhosis and a history of radiofrequency ablation for hepatocellular carcinoma, one had colon cancer, two had undergone abdominal surgeries, one had received chemoradiotherapy for renal cell carcinoma, and one had no intraabdominal diseases. Symptoms were hematemesis in two, hematochezia in the other two, and melena in the remaining two patients. Esophagogastroduodenoscopy showed a pulsating bulge in the ulcer in two and a large Dieulafoy's lesion-like structure in four patients. All patients achieved hemostasis by angioembolization.

CONCLUSION

LGA pseudoaneurysm should be suspected in UGI bleeding if a large Dieulafoy's lesion-like structure or a pulsating bulge in the ulcer is found at the lesser curvature of the gastric body on endoscopy and if the patient has any intra-abdominal inflammatory disease.

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.

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Clinical Decision Rules in the Evaluation and Management of Adult Gastrointestinal Emergencies

Although abdominal pain is a common chief complaint in the emergency department, only 1 in 6 patients with abdominal pain are diagnosed with a gastrointestinal (GI) emergency. These patients often undergo extensive testing as well as hospitalizations to rule out an acute GI emergency and there is evidence that not all patients benefit from such management. Several clinical decision rules (CDRs) have been developed for the diagnosis and management of patients with suspected acute appendicitis and upper GI bleeding to identify those patients who may safely forgo further testing or hospital admission. Further validation studies demonstrating the superiority of these CDRs over contemporary practice are needed.

Uptake of Clinical Prognostic Tools in COPD Exacerbations Requiring Hospitalisation

Clinical prognostic tools are used to objectively predict outcomes in many fields of medicine. Whilst over 400 have been developed for use in chronic obstructive pulmonary disease (COPD), only a minority have undergone full external validation and just one, the DECAF score, has undergone an implementation study supporting use in clinical practice. Little is known about how such tools are used in the UK. We distributed surveys at two time points, in 2017 and 2019, to hospitals included in the Royal College of Physicians of London national COPD secondary care audit program. The survey assessed the use of prognostic tools in routine care of hospitalized COPD patients. Hospital response rates were 71/196 in 2017 and 72/196 in 2019. The use of the DECAF and PEARL scores more than doubled in decisions about unsupported discharge (7%-15.3%), admission avoidance (8.1%-17%) and readmission avoidance (4.8%-13.1%); it more than tripled (8.8%-27.8%) in decisions around hospital-at-home or early supported discharge schemes. In other areas, routine use of clinical prognostic tools was uncommon. In palliative care decisions, the use of the Gold Standards Framework Prognostic Indicator Guidance fell (5.6%-1.4%). In 2017, 43.7% of hospitals used at least one clinical prognostic tool in routine COPD care, increasing to 52.1% in 2019. Such tools can help challenge prognostic pessimism and improve care. To integrate these further into routine clinical care, future research should explore current barriers to their use and focus on implementation studies.Supplemental data for this article is available online at https://dx.doi.org/10.1080/15412555.2021.1959540.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Semiautomated Glasgow-Blatchford Bleeding Score helps direct bed placement for patients with upper gastrointestinal bleeding

OBJECTIVE

The Glasgow-Blatchford Bleeding Score (GBS) was designed to identify patients with upper gastrointestinal bleeding (UGIB) who do not require hospitalisation. It may also help stratify patients unlikely to benefit from intensive care.

DESIGN

We reviewed patients assigned a GBS in the emergency room (ER) via a semiautomated calculator. Patients with a score ≤7 (low risk) were directed to an unmonitored bed (UMB), while those with a score of ≥8 (high risk) were considered for MB placement. Conformity with guidelines and subsequent transfers to MB were reviewed, along with transfusion requirement, rebleeding, length of stay, need for intervention and death.

RESULTS

Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients had a GBS ≤7. 29 (12%) low-risk patients were admitted to MBs. Four low-risk patients admitted to UMB required transfer to MB within the first 48 hours. Low-risk patients admitted to UMBs were no more likely to die, rebleed, need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low-risk patient died from GIB. Patients with GBS ≥8 were more likely to rebleed, require transfusion and interventions to control bleeding but not to die.

CONCLUSION

A semiautomated GBS calculator can be incorporated into an ER workflow. Patients with a GBS ≤7 are unlikely to need MB care for UGIB. Further studies are warranted to determine an ideal scoring system for MB admission.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

Rebleeding in Variceal and Nonvariceal Gastrointestinal Bleeds in Cirrhotic Patients Using Vitamin K1: The LIVER-K Study

BACKGROUND

Gastroesophageal varices are the most common cause of upper gastrointestinal bleeding (UGIB) in patients with cirrhosis. Vitamin K₁ is commonly administered to patients presenting with UGIB and elevated international normalized ratio, despite limited evidence to support this practice.

OBJECTIVES

The primary objective was to describe the incidence of rebleeding within 30 days after vitamin K₁ administration in patients with cirrhosis and UGIB. The secondary objective was to describe prescribing patterns for vitamin K₁.

METHODS

This retrospective, descriptive multicentre study involved patients with cirrhosis and UGIB who were admitted to any of the 4 adult acute care hospitals in Calgary, Alberta, from January 1, 2014, to December 31, 2016. Patients were divided into 2 groups: those who received vitamin K₁ and those who did not.

RESULTS

A total of 370 patients met the inclusion criteria, of whom 243 received vitamin K₁ and 127 did not. Baseline characteristics were similar between the groups. Greater proportions of patients in the vitamin K₁ group received transfusions of packed red blood cells, fresh frozen plasma, platelets, cryoprecipitate, or prothrombin concentrate during their admissions. There was no significant difference in the duration of octreotide and pantoprazole infusions. Among patients in the vitamin K₁ group, there were more admissions to the intensive care unit and longer lengths of stay. More patients in the no vitamin K₁ group had esophageal varices evident on endoscopy that required endoscopic treatment. Forty of the patients (16.5%) in the vitamin K₁ group and 7 (5.5%) in the no vitamin K₁ group had rebleeding within 30 days of the initial bleed. The median total vitamin K₁ dose administered was 25 mg.

CONCLUSIONS

The study results suggest that vitamin K₁ does not reduce the incidence of rebleeding within 30 days of the initial bleed in patients with cirrhosis and UGIB.

Risk Stratification of Older Adults Who Present to the Emergency Department With Syncope: The FAINT Score

STUDY OBJECTIVE

Older adults with syncope are commonly treated in the emergency department (ED). We seek to derive a novel risk-stratification tool to predict 30-day serious cardiac outcomes.

METHODS

We performed a prospective, observational study of older adults (≥60 years) with unexplained syncope or near syncope who presented to 11 EDs in the United States. Patients with a serious diagnosis identified in the ED were excluded. We collected clinical and laboratory data on all patients. Our primary outcome was 30-day all-cause mortality or serious cardiac outcome.

RESULTS

We enrolled 3,177 older adults with unexplained syncope or near syncope between April 2013 and September 2016. Mean age was 73 years (SD 9.0 years). The incidence of the primary outcome was 5.7% (95% confidence interval [CI] 4.9% to 6.5%). Using Bayesian logistic regression, we derived the FAINT score: history of heart failure, history of cardiac arrhythmia, initial abnormal ECG result, elevated pro B-type natriuretic peptide, and elevated high-sensitivity troponin T. A FAINT score of 0 versus greater than or equal to 1 had sensitivity of 96.7% (95% CI 92.9% to 98.8%) and specificity 22.2% (95% CI 20.7% to 23.8%), respectively. The FAINT score tended to be more accurate than unstructured physician judgment: area under the curve 0.704 (95% CI 0.669 to 0.739) versus 0.630 (95% CI 0.589 to 0.670).

CONCLUSION

Among older adults with syncope or near syncope of potential cardiac cause, a FAINT score of zero had a reasonably high sensitivity for excluding death and serious cardiac outcomes at 30 days. If externally validated, this tool could improve resource use for this common condition.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of various prognostic scores in variceal and non-variceal upper gastrointestinal bleeding: A prospective cohort study

BACKGROUND AND AIMS

Various prognostic scores like Glasgow-Blatchford bleeding score (GBS), modified Glasgow-Blatchford bleeding score (mGBS), full Rockall score (FRS) including endoscopic findings, clinical Rockall score (CRS), and albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 (AIMS65) are used for risk stratification in patients with upper gastrointestinal bleeding (UGIB). The utility of these scores in variceal UGIB (VUGIB) is not well defined. In this prospective study, we aimed to assess the performance of these scores in patients with non-variceal (NVUGIB) and VUGIB.

METHODS

We included 1011 patients (during March 2017 and August 2018) including 439 with NVUGIB and 572 VUGIB. Performance of GBS, mGBS, FRS, CRS, and AIMS65 for various outcome measures was analyzed using the area under receiver operator characteristic curve (AUROC).

RESULTS

The accuracy of prognostic scores in predicting the composite outcome including the need of hospital-based intervention and 42-day mortality was higher in NVUGIB as compared with VUGIB, AUROC: CRS: 0.641 vs. 0.537; FRS: 0.669 vs. 0.625; GBS: 0.719 vs. 0.587; mGBS: 0.711 vs. 0.594; AIMS65: 0.567 vs. 0.548. GBS and mGBS at a cut-off score of 1 had the highest negative predictive value, 91.7% and 91.3%, respectively, for predicting composite outcome in NVUGIB. Similarly, these scores had better accuracy for predicting 42-day rebleeding in NVUGIB as compared to VUGIB, AUROC: CRS: 0.680 vs. 0.537; FRS: 0.698 vs. 0.565; GBS: 0.661 vs. 0.543; mGBS: 0.627 vs. 0.540; AIMS65: 0.695 vs. 0.606.

CONCLUSION

The prognostic scores such as CRS, FRS, GBS, mGBS, and AIMS65 predict the need for hospital-based management, rebleeding, and mortality better among patients with NVUGIB than VUGIB.

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.

Dataset for evaluation of threescoring systems for forecasting the clinical outcomes of patients with upper gastrointestinal bleeding (UGIB) - Ahvaz, Iran

Upper gastrointestinal bleeding (UGIB) which occurs proximal to the Treitz ligament is one of the most common cases is emergency medical conditions. The aim of this data article is to evaluation of Rockall and Blatchford scoring systems for predicting the clinical outcomes of patients with upper gastrointestinal bleeding in Imam-Khomeini Hospital, Ahvaz, Iran. This dataset was collected by retrospective descriptive epidemiologic survey which 350 non-cirrhotic patients with UGIB who referred to Ahwaz Imam-Khomeini Hospital for six months. According to the obtained data, in both clinical Rockall and complete Rockall systems, the need for re-endoscopy and the risk of re-bleeding in patients with high scores was more compared to patients with low scores. While, the obtained data about Blatchford score for re-endoscopy and re-bleeding risk was showed which no significant difference. Based on to present dataset, the Rockall systems was superior to Blatchford systems in predicting the re-bleeding as well as the need for re-endoscopy while, none of the systems were efficient in terms of predicting the need for urgent endoscopy and surgery.

[The role of in-hospital protocols in diagnosis and treatment of ulcerative gastroduodenal bleeding]

AIM

To improve immediate results in patients with acute ulcerative gastroduodenal bleeding.

MATERIAL AND METHODS

The study enrolled 91 patients with ulcerative gastroduodenal bleeding.

RESULTS

Diagnostic and curative procedures should be related to hospital's equipment, specialists' qualification and comprehensive development and application of accepted tactical approaches. 20-year development of this protocol which includes original low-temperature irrigator of stomach and duodenal mucous membranes, objective choice of endoscopic hemostasis technique depending on bleeding source in gastroduodenal wall, early administration of proton pump inhibitors significantly increases efficacy and reliability of endoscopic hemostasis. It was followed by improved early outcomes: recurrent bleeding incidence was 4.2%, surgical activity decreased by 68% up to 13.2%, overall and postoperative mortality was 2.2% and 8.3% respectively.

Predictive factors of therapeutic intervention in on-call endoscopy for suspected gastrointestinal bleeding

BACKGROUND AND AIMS

Performing an endoscopy out of hours confer significant burdens on limited health-care resources. However, not all on-call endoscopies lead to therapeutic interventions. The purpose of the present study was to analyze predictive factors for performing therapeutic intervention in patients with suspected gastrointestinal bleeding.

METHODS

We reviewed and analyzed electronic medical records regarding on-call endoscopy that were prospectively collected for quality control. The subjects were patients with suspected gastrointestinal bleeding who underwent on-call endoscopies at night, on weekends and on holidays between April 2013 and January 2017 in Seoul National University Bundang Hospital. To determine predictive factors for performing therapeutic intervention, the following variables were analyzed: symptoms, patient status, coexisting disease, laboratory findings and medications. To clarify the association between the likelihood of therapeutic intervention in on-call endoscopy and AIMS65 score, the included variables were divided by cutoffs.

RESULTS

A total of 270 patients (male: 72.6%, mean age: 62.6 years) with suspected gastrointestinal bleeding had on-call endoscopies and 153 (56.7%) patients had therapeutic intervention. Gastroscopy, colonoscopy and both endoscopic techniques were performed in 215, 42 and 13 patients, respectively. In the multivariate analysis, hematemesis (p < .001, odds ratio [OR], 2.484) and prolonged prothrombin time-international normalized ratio (PT-INR) (p = .033; OR, 1.958) were correlated with performing therapeutic intervention in on-call endoscopy. AIMS65 score with a cutoff of 2 was associated with the likelihood of intervention (p = .043).

CONCLUSIONS

Hematemesis and prolonged PT-INR were predictive factors of therapeutic intervention when on-call endoscopy was performed in patients with suspected gastrointestinal bleeding.

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.

Is the AIMS 65 Score Useful in Prepdicting Clinical Outcomes in Korean Patients with Variceal and Nonvariceal Upper Gastrointestinal Bleeding?

Background/Aims

Various clinical scoring systems, including the Glasgow-Blatchford score (GBS), Rockall risk score (RS), and AIMS65 score (AIMS65), have been validated to predict the clinical outcomes in patients with upper gastrointestinal bleeding (UGIB). We compared the performance of these three scoring systems in predicting clinical outcomes in patients with UGIB in Korea.

Methods

We retrospectively evaluated 286 patients with UGIB who visited emergency department. The primary outcome was the need for clinical intervention (endoscopic, radiologic, or surgical) and blood transfusion.

Results

The causes of UGIB were esophageal/gastric varices in 64 patients, peptic ulcer in 168, Mallory-Weiss tear in 32, malignancy of UGI tract in eight, and unknown in 14. One hundred seventy-four (61%) patients required blood transfusion, 166 (58%) required endoscopic intervention, and 10 (3.5%) required surgical intervention. The GBS outperformed the RS and AIMS65 in predicting the need for endoscopic intervention.

Conclusions

The GBS and RS were more accurate than AIMS65 in predicting the need for clinical interventions and transfusion patients with UGIB, regardless of variceal or nonvariceal bleeding. The AIMS65 may not be optimal for predicting clinical outcomes of UGIB in Korea.

Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding

Background

Risk scoring systems are used to evaluate patients with upper gastrointestinal bleeding (UGIB). We compared Glasgow-Blatchford score (GBS), modified GBS (mGBS), and Pre-endoscopy Rockall score (Pre-E RS) for immediate application without endoscopic findings in predicting the need of interventions and the 30-day mortality in patients with UGIB.

Methods

Patients who visited the emergency room with UGIB from January 2007 to June 2016 were included. GBS, mGBS, and Pre-E RS were obtained for all patients. The area under the receiver-operating characteristic curves (AUC) was used to assess the accuracy of the scoring systems to determine the need for interventions and 30-day mortality. Also, we investigated the potential cutoff scores for predicting 30-day mortality and the need for interventions.

Results

In predicting the need for interventions, GBS (AUC = 0.727) and mGBS (AUC = 0.733) outperformed Pre-E RS (AUC = 0.564, P < 0.0001). In predicting 30-day mortality, Pre-E RS (AUC = 0.929) outperformed GBS (AUC = 0.664, P < 0.0001) and mGBS (AUC = 0.652, P < 0.0001). Based on AUC analyses of sensitivities and specificities, the optimal cutoff mGBS and GBS for the need for interventions was 9 (70.71% sensitivity, 89.35% specificity) and 9 (73.57% sensitivity, 82.90% specificity) respectively, and optimal cutoff Pre-E RS for 30-day mortality was 4 (88.0% sensitivity, 97.52% specificity).

Conclusions

GBS and mGBS are considered to be moderately accurate in making an early decision about the need of interventions in patients with UGIB. Pre-E RS is considered to be highly accurate in early detection of patients at high risk for 30-day mortality without endoscopic findings. In addition, we suggested potential cutoff scores to predict the need of interventions for GBS and mGBS, and 30-day mortality for Pre-E RS. Further studies are needed to confirm the clinical applicability of results.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Utility of the Shock Index for Risk Stratification in Patients with Acute Upper Gastrointestinal Bleeding

OBJECTIVES

Patients with upper gastrointestinal bleeding (UGIB) frequently require hospitalization, and a small but significant percentage of these patients have adverse outcomes. Risk-scoring tools can help clinicians organize care and make predictions about outcomes. The shock index (heart rate divided by systolic blood pressure) has been used in multiple acute disorders and has the potential to identify patients with UGIB who are at risk for adverse outcomes.

METHODS

We retrospectively reviewed the electronic medical records of patients admitted with UGIB between January 1, 2012 and December 31, 2015. We collected information about patient demographics, presenting symptoms, underlying clinical disorders, endoscopic results, and outcomes. We calculated risk scores using the Glasgow-Blatchford score, the pre-endoscopy Rockall score, the full Rockall score, the AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age older than 65 years) score, and the shock index.

RESULTS

This study included 214 admissions for acute UGIB. The mean age was 59.0 ± 15.9 years, 64.5% were men, the mean hemoglobin was 9.2 ± 3.1 g/dL, and the mean shock index was 0.78 ± 0.21 bpm/mm Hg. The mean shock index was significantly increased in patients requiring endoscopic therapy, admission to the intensive care unit, blood component transfusion, and red blood cell transfusion. Classification of patients by a shock index >0.7 preferentially selected patients with these adverse short-term outcomes. Among the scoring tools evaluated in this study, the shock index was the best predictor of the need for endoscopic therapy.

CONCLUSIONS

The shock index is a good tool to identify patients with the potential for short-term adverse outcomes when they present with UGIB. It performs as well as other risk-scoring tools for GI bleeding and has the potential for serial use during hospitalization to identify changes in the clinical course.

New clinical paradigms for treating and preventing antiplatelet gastrointestinal bleeding

PURPOSE OF REVIEW

To quantify antiplatelet-related gastrointestinal bleeding (GIB), characterize patients at greatest risk and summarize risk-management strategies emphasizing evolving knowledge in acute management of antiplatelet-related bleeding.

RECENT FINDINGS

New paradigms for acute management of antiplatelet-related GIB exist in the domains of resuscitation and the transfusion of blood products, strategic use of proton pump therapy and identification and eradication of Helicobacter pylori. This review will also highlight the importance of prompt resumption of cardiac aspirin and dual antiplatelet therapy following endoscopic hemostasis to minimize the risk of future cardiac events.

SUMMARY

This review will provide pragmatic strategies for the management of acute antiplatelet-related GIB. Emerging areas of clinical knowledge will be addressed and knowledge gaps requiring further research to inform clinical practice will be highlighted.

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND/AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Gastrointestinal bleeding secondary to the new anticoagulants

PURPOSE OF REVIEW

To quantify direct oral anticoagulants (DOACs) related gastrointestinal bleeding (GIB), characterize patients at greatest risk and provide a pragmatic approach for the management of these drugs. This review will also summarize risk-management strategies and highlight evolving areas of clinical knowledge.

RECENT FINDINGS

DOACs permit anticoagulation with predictable dosing without the need for routine serum monitoring. Since their availability on the market, they have quickly emerged as a popular alternative for patients requiring short-term and lifelong anticoagulation. However, they are associated with an increased risk of GIB when compared with warfarin; thus, gastroenterologists must be prepared to manage DOAC-related GIB and prevent drug-related complications. This review will focus on acute and elective periendoscopic DOAC management, high-risk clinical groups for DOAC-related GIB, quantification of DOAC levels, use of reversal agents and minimization of thromboembolic risk associated with temporary interruption.

SUMMARY

This review will highlight pragmatic strategies for the treatment of DOAC-related bleeding and the prevention of postendoscopic DOAC bleeding. It will address new and evolving areas of periendoscopic management and identify knowledge gaps requiring further research to inform clinical practice.

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

Background

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

Patients and methods

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

Results

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

Conclusion

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

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

BACKGROUND AND AIMS

The American College of Gastroenterology recommends early risk stratification in patients presenting with upper GI bleeding (UGIB). The AIMS65 score is a risk stratification score previously validated to predict inpatient mortality. The aim of this study was to validate the AIMS65 score as a predictor of inpatient mortality in patients with acute UGIB and to compare it with established pre- and postendoscopy risk scores.

METHODS

ICD-10 (International Classification of Diseases, Tenth Revision) codes identified patients presenting with UGIB requiring endoscopy. All patients were risk stratified by using the AIMS65, Glasgow-Blatchford score (GBS), pre-endoscopy Rockall, and full Rockall scores. The primary outcome was inpatient mortality. Secondary outcomes were a composite endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic, or surgical intervention; blood transfusion requirement; intensive care unit (ICU) admission; rebleeding; and hospital length of stay. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.

RESULTS

Of the 424 study patients, 18 (4.2%) died and 69 (16%) achieved the composite endpoint. The AIMS65 score was superior to both the GBS (AUROC, 0.80 vs 0.76, P < .027) and the pre-endoscopy Rockall score (0.74, P = .001) and equivalent to the full Rockall score (0.78, P = .18) in predicting inpatient mortality. The AIMS65 score was superior to all other scores in predicting the need for ICU admission and length of hospital stay. AIMS65, GBS, and full Rockall scores were equivalent (AUROCs, 0.63 vs 0.62 vs 0.63, respectively) and superior to pre-endoscopy Rockall (AUROC, 0.55) in predicting the composite endpoint. GBS was superior to all other scores for predicting blood transfusion.

CONCLUSION

The AIMS65 score is a simple risk stratification score for UGIB with accuracy superior to that of GBS and pre-endoscopy Rockall scores in predicting in-hospital mortality and the need for ICU admission.

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.

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.

Nonvariceal Upper Gastrointestinal Bleeding

In the intensive care unit, vigilance is needed to manage nonvariceal upper gastrointestinal bleeding. A focused history and physical examination must be completed to identify inciting factors and the need for hemodynamic stabilization. Although not universally used, risk stratification tools such as the Blatchford and Rockall scores can facilitate triage and management. Urgent evaluation for nonvariceal upper gastrointestinal bleeds requires prompt respiratory assessment, and identification of hemodynamic instability with fluid resuscitation and blood transfusions if necessary. Future studies are needed to evaluate the indication, safety, and efficacy of emerging endoscopic techniques.

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.

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage

Background/Aims

To evaluate the ability of the recently proposed albumin, international normalized ratio (INR), mental status, systolic blood pressure, age >65 years (AIMS65) score to predict mortality in patients with acute upper gastrointestinal bleeding (UGIB).

Methods

AIMS65 scores were calculated in 251 consecutive patients presenting with acute UGIB by allotting 1 point each for albumin level <30 g/L, INR >1.5, alteration in mental status, systolic blood pressure ≤90 mm Hg, and age ≥65 years. Risk stratification was done during the initial 12 hours of hospital admission.

Results

Intensive care unit (ICU) admission, endoscopic therapy, or surgery were required in 51 patients (20.3%), 64 (25.5%), and 12 (4.8%), respectively. The predictive accuracy of AIMS65 scores ≥2 was high for blood transfusion (area under the receiver operator characteristic curve [AUROC], 0.59), ICU admission (AUROC, 0.61), and mortality (AUROC, 0.74). The overall mortality was 10.3% (n=26), and was 3%, 7.8%, 20%, 36%, and 40% for AIMS65 scores of 0, 1, 2, 3, and 4, respectively; these values were significantly higher in those with scores ≥2 (30.9%) than in those with scores <2 (4.5%, p<0.001).

Conclusions

AIMS65 is a simple, accurate, non-endoscopic risk score that can be applied early (within 12 hours of hospital admission) in patients with acute UGIB. AIMS65 scores ≥2 predict high in-hospital mortality.

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.