Original Article

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

Authors: Kanchana Myneedu, MD, Mahesh Gajendran, MD, Alberto Contreras, MD, Alejandro Robles, MD, Antonio Mendoza Ladd, MD

Abstract

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.
Posted in: Gastroenterology49

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Gleeson F, Clarke E, Lennon J, et al. Outcome of accident and emergency room triaged patients with low risk non-variceal upper gastrointestinal haemorrhage. Ir Med J 2006;99:114–117.
 
2. Viviane A, Alan BN. Estimates of costs of hospital stay for variceal and nonvariceal upper gastrointestinal bleeding in the United States. Value Health 2008;11:1–3.
 
3. Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis. Dig Dis Sci 2018;63: 1286–1293.
 
4. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018. Gastroenterology 2019; 156:254–272.e11.
 
5. Lim CH, Heatley RV. Prospective study of acute gastrointestinal bleeding attributable to anti-inflammatory drug ingestion in the Yorkshire region of the United Kingdom. Postgrad Med J 2005;81:252–254. .
 
6. Nable JV, Graham AC. Gastrointestinal bleeding. Emerg Med Clin 2016;34: 309–325.
 
7. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356:1318–1321.
 
8. Masaoka T, Suzuki H, Hori S, et al. Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention. J Gastroenterol Hepatol 2007;22:1404–1408.
 
9. Schiefer M, Aquarius M, Leffers P, et al. Predictive validity of the Glasgow Blatchford Bleeding Score in an unselected emergency department population in continental Europe. Eur J Gastroenterol Hepatol 2012;24:382–387.
 
10. Srirajaskanthan R, Conn R, Bulwer C, et al. The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage. Int J Clin Pract 2010;64:868–874.
 
11. Stephens JR, Hare NC, Warshow U, et al. Management of minor upper gastrointestinal haemorrhage in the community using the Glasgow Blatchford Score. Eur J Gastroenterol Hepatol 2009;21:1340–1346.
 
12. Bryant RV, Kuo P, Williamson K, et al. Performance of the Glasgow-Blatchford score in predicting clinical outcomes and intervention in hospitalized patients with upper GI bleeding. Gastrointest Endosc 2013;78:576–583.
 
13. Pang SH, Ching JYL, Lau JYW, et al. Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc 2010;71:1134–1140.
 
14. Pioppo L, Bhurwal A, Reja D, et al. Incidence of non-variceal upper gastrointestinal bleeding worsens outcomes with acute coronary syndrome: result of a national cohort. Dig Dis Sci 2021;66:999–1008.
 
15. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National audit of acute upper gastrointestinal haemorrhage. Lancet 1996; 347:1138–1140.
 
16. Chen I-C, Hung M-S, Chiu T-F, et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am J Emerg Med 2007;25:774–779.
 
17. Sanders DS, Carter MJ, Goodchap RJ, et al. Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am J Gastroenterol 2002;97:630–635.
 
18. Vreeburg EM, Terwee CB, Snel P, et al. Validation of the Rockall risk scoring system in upper gastrointestinal bleeding. Gut 1999;44:331–335.
 
19. Saltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 2011;74:1215–1224.
 
20. Hyett BH, Abougergi MS, Charpentier JP, et al. The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding. Gastrointest Endosc 2013;77:551–557.
 
21. Ramaekers R, Mukarram M, Smith CA, et al. The predictive value of preendoscopic risk scores to predict adverse outcomes in emergency department patients with upper gastrointestinal bleeding: a systematic review. Acad Emerg Med 2016;23:1218–1227.
 
22. Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2012;10:1130–1135.e1.
 
23. Tham J, Stanley A. Clinical utility of pre-endoscopy risk scores in upper gastrointestinal bleeding. Exp Rev Gastroenterol Hepatol 2019;13:1161–1167.
 
24. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med 2019;171:805–822.
 
25. Hwang JH, Fisher DA, Ben-Menachem T, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc 2012;75:1132–1138.
 
26. Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - update 2021. Endoscopy 2021;53:300–332.
 
27. Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017;356:i6432.