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Prospective validation of the Glasgow Blatchford scoring system in patients with upper gastrointestinal bleeding in the emergency department
Abstract
Background/aims:
This study aimed to allow decision-making about hospitalization or discharge using the Glasgow Blatchford Scoring system, a risk analysis performed using basic laboratory and clinical variables, in patients presenting to the Emergency Department with upper gastrointestinal system bleeding.
Materials and methods:
This prospective, observational study conducted in the Emergency Department of a university hospital enrolled patients aged ≥18 years, who presented to the Emergency Department with upper gastrointestinal system bleeding between June 2009 and December 2010. For all patients, Glasgow Blatchford Scoring scores were calculated, and the patients were classified into two groups as high-risk and low-risk patients.
Results:
A total of 160 subjects with upper gastrointestinal system bleeding were enrolled in the study. Mean Glasgow Blatchford Scoring scores were 7.1 ± 3.8 for 71 low-risk subjects and 11.7 ± 2.9 for 89 high-risk subjects, and the difference between the two groups was statistically significant (p<0.001). When the performance of the Glasgow Blatchford Scoring system was evaluated in the determination of high risk, the sensitivity and specificity were 100% and 1.41%, respectively, for a cut-off value of Glasgow Blatchford Scoring >0, 100% and 16.9% for a cut-off value of Glasgow Blatchford Scoring >3, 96.63% and 36.62% for a cut-off value of Glasgow Blatchford Scoring >5, and 86.52% and 69.01% for a cut-off value of Glasgow Blatchford Scoring >8. In the receiver operating characteristic curve analysis, for Glasgow Blatchford Scoring in the high-risk estimation, the area under the curve was found to be 0.82 (95% CI: 0.75-0.88), and this value was statistically significant (p=0.0001).
Conclusions:
The Glasgow Blatchford Scoring system, which may be easily calculated based on laboratory and clinical variables, seems to be a useful scoring system for risk analysis of all patients with upper gastrointestinal system bleeding admitted to the Emergency Department.
... Another study used multiple cut-off point was done by Koksal et al., 2012 using cut-off value of >3,>5 and >8. Koksal et al., 2012 showed sensitivity 100% and specificity 16.9% with PPV 60.1% and NPV 100% for cut-off value GBS>3. Sensitivity drops below 100% for value cut-off >5. ...
... As compared to our study sensitivity drop below 100% with cut-off value >2. Our study used similar cutoff point as Koksal et al., 2012. In our study we calculated according to different cut-off value as well to compare and review its value. ...
Introduction: Upper Gastrointestinal Bleeding (UGIB) requiring endoscopic intervention is a common scenario in hospitals. However, not all patients require emergency or urgent endoscopy to be done. This study will validate and associate Glasgow-Blatchford Score (GBS) with Forrest classification. This is to predict the severity of Non-Variceal Upper Gastrointestinal Bleed according to Glasgow Blatchford Score and validate this scoring system in Hospital Universiti Sains Malaysia. This study will also associate between two scoring system of Glasgow Blatchford Score and Forrest Classification between Non-variceal high-risk bleeding with major bleed and non-variceal low risk bleeding with minor bleed. Methodology: Data collected from June 2016 till February 2017, 113 patients with Non-variceal bleed underwent emergency OGDS were retrospectively reviewed and were stratified according to Glasgow Blatchford Score to high and low risk. This stratified risk is associated with Forrest classification to determine its endoscopic findings. Results: Majority are in the high-risk group 107 (94.7%) patients and low risk group 6 (5.3%) patients. Patients in the low risk group was followed up for 30 days and showed no complications or mortality. This study showed patients has a median score of 10.27±3.54. From the data analysis of Glasgow Blatchford Score showed 95.45% sensitivity and 5.49% specificity. Endoscopic findings showed 22 (19.5%) patients had major bleed and 91 (80.5%) patients had minor bleed. Using Fischer Exact Test, there is no significant association between risk and outcome (p-value > 0.950). Conclusion: Based on this study alone, we cannot suggest Glasgow Blatchford Score as a predictor for severity of Upper Gastrointestinal Bleeding. This is because as shown in the results, there were no significant association between GBS and Forrest classification. However, this nonsignificant result maybe compounded by several factors as discussed, namely due to underlying Chronic Kidney Disease with anemia, the timing of endoscopy and initiation of medication. With this bias identified, it can be used as a guide in designing and conducting a better study in the future in order to come to a better conclusion about GBS in our population.
... En España, un estudio observacional, llevado a cabo por Hernández et al., mostró una incidencia anual de 66 casos por cada 100 000 habitantes para el año 2006 (6) . Mientras, otros estudios han mostrado una incidencia de 50-150 casos por cada 100 000 habitantes con una tasa de mortalidad entorno al 11-14% (7,8) . ...
... Siempre debemos individualizar a cada paciente y no generalizar que todo paciente con un valor de GBS ≤ 2 se encuentra exento de riesgo de complicación, y es que se ha visto que existe hasta un 10% de pacientes que pueden presentar complicaciones, específicamente mayores de 70 años, por lo que se recomienda su utilización en pacientes con una edad menor de 70 años (7) . Financiamiento: Los autores no recibieron ningún tipo de financiación para la realización de este estudio. ...
Introduction: The Glasgow-Blatchford (GBS) scale allows us to classify the patient as a high or low risk of presenting complications. In the patients identified as "low risk", the performance of an early endoscopy could reduce the intrahospital days and the overall cost. In our environment, we do not know the usefulness of the GBS scale. Objective: To describe the utility of the Glasgow-Blatchford scale (GBS) in the stratification of risk in patients with non-variceal upper gastrointestinal bleeding (HDA) seen in the emergency department of a tertiary hospital. Materials and methods: 218 patients were prospectively included, and they were performed in the first 24-48 hr an urgent endoscopy. These were stratified, according to the GBS scale, at low risk (GBS ≤ 2), and high risk (GBS ≥ 3). We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the GBS scale in our setting based on the requirement of endoscopic, radiological treatment (arterial embolization), transfusion of blood products and / or surgery, as our gold standar to classify patients as "high risk". Results: A total of 218 patients were included, with a mean age of 56 ± 18 years, of which 121/218 (55%) were male. 156/218 required intervention for what were classified as "high risk" while 62/218 did not specify and classified as "low risk". A cut-off value of GBS ≤ 2 showed a sensitivity of 98% with a NPV of 100%. The utility of the GBS scale showed an area under the ROC curve 0.83 (95% CI 0.75-0.90). Conclusion: The GBS scale used in patients with non-variceal UGB attended in the emergency department has adequate diagnostic validity to predict the need for intervention.
... who found in his study that most they were elderly. The observed meaning was similar to Mildred's study, [7]. as well as in the rego studio [8]. ...
... Usefulness of the Modified Rockall and Baylor Scales in Hemorrhage Upper Digestive Due to Peptic Ulcer elderly. The observed mean was similar to Mildred's study, (7) as well as in the rego studio, (8) where 118 of 161 cases presented 60 years. The results are similar to those obtained by most of the consulted authors who report that the The age at which these cases most frequently occur is 60 years or older. ...
... Usefulness of the Modified Rockall and Baylor Scales in Hemorrhage Upper Digestive Due to Peptic Ulcer elderly. The observed mean was similar to Mildred's study, (7) as well as in the rego studio, (8) where 118 of 161 cases presented 60 years. The results are similar to those obtained by most of the consulted authors who report that the The age at which these cases most frequently occur is 60 years or older. ...
This is a Original Article Research our investigations
Upper gastrointestinal hemorrhage is a common health problem worldwide and one of the
emergencies determining a huge number of admissions into general surgery services in our scenario, it is
therefore of great clinical and sanitary importance.
Objective: To determine the usefulness of the modified Rockall and Baylor scores in predicting rebleeding in
patients with upper gastrointestinal hemorrhage.
Method: A prospective, descriptive, observational study was carried out, including patients admitted for upper
gastrointestinal hemorrhage due to peptic ulcer in Enrique Cabrera, from January 1st, 2018 to december 31,
2022.
... Usefulness of the Modified Rockall and Baylor Scales in Hemorrhage Upper Digestive Due to Peptic Ulcer elderly. The observed mean was similar to Mildred's study, (7) as well as in the rego studio, (8) where 118 of 161 cases presented 60 years. The results are similar to those obtained by most of the consulted authors who report that the The age at which these cases most frequently occur is 60 years or older. ...
... Nevertheless, its clinical effectiveness remains unclear and there is little evidence available for North African population. Because of its simplicity, several teams (Table 6) have tried to validate it in their populations [5,[16][17][18][19][20]. ...
Introduction
Non-variceal upper gastrointestinal hemorrhage (NVUGIH) often leads to systematic hospitalization and emergency endoscopy. However, in most cases, it does not constitute an immediate life threat. This study aimed to evaluate the Glasgow-Blatchford Score (GBS) in predicting the need for transfusions, and/or endoscopic or surgical treatments.
Materials and methods
We conducted a retrospective monocentric study including 91 patients admitted in the general surgery department of the Hospital La Rabta Tunis for a NVUGIH.
Univariate analysis was performed with the Student t test for continuous variables and with the Chi-square test for categorical variables. For a cut-off point of 9, we calculated the sensibility and the sensitivity of the GBS to predict the need for transfusions and/or hemostatic procedure.
Results
During the study period, 91 patients were admitted for NVUGIH. Sixty-one patients (67%) were transfused. Seven patients (7.7%) underwent emergency surgery and two patients had endoscopic hemostasis.
The predictive factors for the use of transfusion and/or hemostasic treatments were: Age >50 years, ASA score, HR ≥ 90 bpm, pallor, Hb ≤ 9,5 g/dl, Urea ≥9,7 mmol/L.
For a cut-off of 9 points of the GBS, sensitivity was 85.71% and specificity 92.86%. The positive predictive value was 96%. The negative predictive value was 74%.
Conclusion
The main interest of the GBS lies in dispatching the patients between intensive care units for therapeutic intervention (if GBS> = 9) and ordinary hospitalization for surveillance (if GBS <9). It then makes it possible to rationalize the management of patients with digestive hemorrhage to identify those requiring hospital treatments (transfusion, endoscopic treatment, or surgery).
... In a prospective study conducted by Palmer, involving 14,000 people, the most common comorbidities were found to be HT and CAD.16 In a prospective study byKöksal et al., in which patients with upper GI bleeding were examined, the most common comorbidity was found to be chronic liver disease, with a rate of 30%.17 Stanley et al., on the other hand, showed that CAD was the most common comorbidity in patients with upper GI bleed- ...
Background:
Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients.
Objective:
To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding.
Design and setting:
Prospective cohort study in an emergency department in Bursa, Turkey.
Methods:
Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated.
Results:
A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001).
Conclusion:
The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.
... Also, the Rockall score established to show the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage [26] , avoiding complications of the haemoglobin level and some of the risk factors in these patients. About 105 patients (61.8%) in this study received interventions (endoscopy, blood transfusion, and may surgical intervention); this is in close range with Ozlem K. et al. [27] who found that 55.6% of patients need intervention after admission, whileAhn S. et al. [28] notice that 87.6% of patients received interventions and Stevenson J. et al. [29] who found that 43.2% of patients required intervention. Also, the Blatchford score has excellent sensitivity. ...
Gastrointestinal (GI) bleeding has created an increasing demand for medical and surgical care; in addition, It is potentially serious and considered life-threatening in all age groups. This prospective study aims to find out the most common causes of GI bleedings, the incidence, the mode of treatment, and to investigate whether a simplified clinical score was able to predict the level of severity in the emergency department. About 170 patients aged (19 – 73) years who had been admitted to the emergency department in Baghdad teaching hospital were prospectively evaluated according to the causes of GI bleeding they presented with, the mode of treatment, and the degree of severity. Out of 170 patients included in this study, 95 patients (55.88%) were males, and 75 patients (44.12%) were females, with an average age of 41.11 years. The causes of GI bleeding were peptic ulcer (29.41%), gastritis (18.82%), diverticulitis (8.82%), hemorrhoids (8.23%), colonic cancer (7.64%), inflammatory bowel diseases (7.64%), anal fissure (7.05%), mesenteric ischemia (7.05%) and oesophagal varices (5.29%). Most of the cases of a peptic ulcer due to duodenal ulcer. Diagnostic endoscopy and conservative management were the main modes of treatment in these patients. Peptic ulcer and gastritis appear to be the main causes of GI bleeding, especially upper GI bleeding, while diverticulitis seems to be the main cause of lower GI bleeding and can be managed conservatively. Haemorrhoids and anal fissures will be managed surgically, either elective or emergency surgery. Also, our simplified clinical score appeared to be associated with the detection of the level of severity, which may deserve urgent interventions.
Objective:
We aimed to identify the clinical, biochemical, and endoscopic features associated with in-hospital mortality after acute upper gastrointestinal bleeding (AUGIB), focusing on cross-validation of the Glasgow-Blatchford score (GBS), full Rockall score (RS), and Cedars-Sinai Medical Center Predictive Index (CSMCPI) scoring systems.
Methods:
Our prospective cross-sectional study included 156 patients with AUGIB. Several statistical approaches were used to assess the predictive accuracy of the scoring systems.
Results:
All three scoring systems were able to accurately predict in-hospital mortality (area under the receiver operating characteristic curve [AUC] > 0.9); however, the multiple logistic model separated the presence of hemodynamic instability (state of shock) and the CSMCPI as the only significant predictive risk factors. In compliance with the overall results, the CSMCPI was consistently found to be superior to the other two systems (highest AUC, highest sensitivity and specificity, highest positive and negative predictive values, highest positive likelihood ratio, lowest negative likelihood ratio, and 1-unit increase in CSMCPI associated with 6.3 times higher odds of mortality), outperforming the GBS and full RS.
Conclusions:
We suggest consideration of the CSMCPI as a readily available and reliable tool for accurately predicting in-hospital mortality after AUGIB, thus providing an essential backbone in clinical decision-making.
To describe the current epidemiology of acute upper gastrointestinal haemorrhage.
Population based, unselected, multicentre, prospective survey.
74 hospitals receiving emergency admissions in four health regions in the United Kingdom.
4185 cases of acute upper gastrointestinal haemorrhage in which patients were aged over 16 years identified over four months.
Incidence and mortality.
The overall incidence of acute upper gastrointestinal haemorrhage in the United Kingdom is 103/100,000 adults per year. The incidence rises from 23 in those aged under 30 to 485 in those aged over 75. At all ages incidence in men was more than double that in women except in elderly patients. 14% of the haemorrhages occurred in inpatients already in hospital for some other reason. In 27% of cases (37% female, 19% male) patients were aged over 80. Overall mortality was 14% (11% in emergency admissions and 33% in haemorrhage in inpatients). In the emergency admissions, 65% of deaths in those aged under 80 were associated with malignancy or organ failure at presentation. Mortality for patients under 60 in the absence of malignancy or organ failure at presentation was 0.8%.
The incidence of acute upper gastrointestinal haemorrhage is twice that previously reported in England and similar to that reported in Scotland. The incidence increases appreciably with age. Although the proportion of elderly patients continues to rise and mortality increases steeply with age, age standardised mortality is lower than in earlier studies. Deaths occurred almost exclusively in very old patients or those with severe comorbidity.
Acute upper gastrointestinal hemorrhage (UGIH) is a common reason for hospitalization with substantial associated morbidity, mortality, and cost. Differentiation of high- and low-risk patients using established risk scoring systems has been advocated. The aim of this study was to determine whether these scoring systems are more accurate than an emergency physician's clinical decision making in predicting the need for endoscopic intervention in acute UGIH.
Patients presenting to a tertiary care medical center with acute UGIH from 2003 to 2006 were identified from the hospital database, and their clinical data were abstracted. One hundred ninety-five patients met the inclusion criteria and were included in the analysis. The clinical Rockall score and Blatchford score (BS) were calculated and compared with the clinical triage decision (intensive care unit vs non-intensive care unit admission) in predicting the need for endoscopic therapy.
Clinical Rockall score greater than 0 and BS greater than 0 were sensitive predictors of the need for endoscopic therapy (95% and 100%) but were poorly specific (9% and 4%), with overall accuracies of 41% and 39%. At higher score cutoffs, clinical Rockall score greater than 2 and BS greater than 5 remained sensitive (84% and 87%) and were more specific (29% and 33%), with overall accuracies of 48% and 52%. Clinical triage decision, as a surrogate for predicting the need for endoscopic therapy, was moderately sensitive (67%) and specific (75%), with an overall accuracy (73%) that exceeded both risk scores.
The clinical use of risk scoring systems in acute UGIH may not be as good as clinical decision making by emergency physicians.
This study aimed to identify pre-endoscopic clinical parameters independently associated with 6-week mortality and to develop a prognostic model in cirrhotic patients with acute upper gastrointestinal (UGI) bleeding.
A total of 542 consecutive admissions of 389 cirrhotic patients with acute UGI bleeding were retrospectively investigated. Pertinent clinical data obtained at the emergency department were analyzed. Multivariate logistic regression analysis was performed to determine risk factors for 6-week mortality and to develop a predictive model.
Forty-four patients (8.12%) died within 6 weeks. The 6-week mortality was independently associated with male sex, hepatocellular carcinoma, non-hepatocellular carcinoma malignancy, hypoxemia with peripheral oxygen saturation less than 95%, serum bilirubin, and prothrombin time. A predictive model consisting of these 6 simple parameters was built. The c statistic of our model was 0.84, significantly superior to that (0.71) of the model for end-stage liver disease score (P = .002).
Simple pre-endoscopic clinical parameters are valuable for early risk stratification in cirrhotic patients with acute UGI bleeding. Our prognostic model warrants prospective validation by further studies.
The need for therapeutic endoscopy in patients with upper GI hemorrhage is important in determining the risk and disposition of these patients. Pre-endoscopic risk scores may be helpful in predicting this need.
To test the Blatchford and pre-endoscopic Rockall scores with the need for therapeutic endoscopy as the primary outcome.
Prospective validation study.
Tertiary-care university-affiliated hospital.
Between January 1, 2006 and February 28, 2007, 1087 patients with upper GI hemorrhage who had undergone an inpatient EGD within 24 hours were entered in the study.
Blatchford and pre-endoscopic Rockall scores were prospectively calculated for all patients, and the need for therapeutic endoscopy was determined during the EGD.
Of the 1087 patients, 297 (27.3%) needed therapeutic endoscopy. The mean Blatchford score for those who needed therapeutic endoscopy was significantly higher (mean [standard deviation]: 10.3 [3.5] vs 7.0 [4.4], P < .001). The area under a receiver-operating characteristic curve was 0.72 (95% CI, 0.68-0.75). A threshold of 0 (low risk) predicted the need for therapeutic endoscopy with 100% sensitivity and 6.3% specificity. Fifty (4.6%) patients were identified as low risk. The pre-endoscopic Rockall score was unable to predict this need.
The decision to perform therapeutic endoscopy is a subjective one, although endoscopists are trained to follow international consensus guidelines.
The Blatchford score is more useful for predicting low-risk patients who do not need therapeutic endoscopy and who may be suitable for outpatient management. A threshold of 0 for low risk should be used. The Rockall score is not helpful in predicting the presence of low-risk lesions.
Upper gastrointestinal (UGI) haemorrhage is a frequent cause of hospital admission. Scoring systems have been devised to identify those at risk of adverse outcomes. We evaluated the Glasgow Blatchford score's (GBS) ability to identify the need for clinical and endoscopic intervention in patients with UGI haemorrhage.
A retrospective observational study was performed in all patients who attended the A&E department with UGI haemorrhage during a 12-month period. Patients were separated into low and high risk categories. High risk encompassed patients who required blood transfusions, operative or endoscopic interventions, management on high dependency or intensive care units, and those who re-bled, represented with further bleeding, or who died.
A total of 174 patients were seen with UGI bleeding. Eight of them self-discharged and were excluded. Of the remaining 166, 94 had a 'low risk' bleed, and 72 'high risk'. The GBS was significantly higher in the high risk (median = 10) than in the low risk group (median 1, p < 0.001). To assess the validity of the GBS at separating low and high risk groups, receiver-operator characteristic (ROC) curves were plotted. The GBS had an area under ROC curve of 0.96 (95% CI 0.95-1.00). When a cut-off value of > or = 3 was used, sensitivity and specificity of GBS for identifying high risk bleeds was 100% and 68%. Thus at a cut-off value of < or = 2 the GBS is useful for distinguishing those patients with a low risk UGI bleed.
The GBS accurately identifies low risk patients who could be managed safely as outpatients.
Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals.
Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients.
Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001).
The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.
Patients with upper gastrointestinal haemorrhage (UGIH) are usually cared for in hospital. To evaluate the efficacy and safety of outpatient care of selected patients with acute non-variceal UGIH who had endoscopy, we retrospectively analysed 4.5 years' experience of patients treated without hospital admission. We developed practice guidelines for outpatient care, and prospectively studied patients treated during the first 6 months of their use. 78 (8.4%) of 933 patients in the retrospective series and 34 (24.1%) of 141 in the prospective series received outpatient care. The guidelines comprised early notification of a gastroenterologist, urgent endoscopy, clinical, laboratory, and endoscopic criteria for outpatient care, and details of care. In the prospective study patients treated as outpatients were younger than those admitted (52.8 [SE 3.6] vs 63.0 [1.5] years) and had a slightly longer time from onset of bleeding to endoscopy (2.4 [0.2] vs 2.1 [0.2] days). Outpatients were less likely to have alcoholism, other major concomitant disease, syncope or presyncope, or supine tachycardia. Outpatients had higher haemoglobin concentrations than inpatients (125 [4] vs 106 [3] g/L). Most patients in both groups had peptic ulcers. There were no complications in the retrospective series; 1 of the 34 prospective outpatients was admitted with rebleeding. All outpatients survived. The estimated hospital cost saved per outpatient was about $990. A substantial proportion of carefully selected patients with acute non-variceal UGIH can be effectively cared for without admission to hospital.
To obtain epidemiological data on hospitalization for acute upper gastrointestinal hemorrhage (AUGIH) in a demographically defined population.
Adults hospitalized in 1991 with AUGIH [from a San Diego health maintenance organization (270,699 adult members)] were identified from discharge codes in the International Classification of Diseases, 9th Revision, Clinical Modifications, and their records were reviewed.
There were 276 hospitalizations among 258 patients, an annual incidence rate of 102.0 hospitalizations per 100,000. Patient analysis, including the first admission of 15 patients with multiple hospitalizations, revealed rates of 128.3 in males and 65.8 in females. The rate increased with age in males (p = 0.008) and females (p = 0.001) more than 30-fold between the 3rd and 9th decades of life. AUGIH started before admission in 242 (93.8%) patients and after admission for other disorders in 16 (6.2%) patients. Endoscopy was performed in 241 (93.4%) patients. Diagnoses were: peptic ulcer, 159 (61.6%); mucosal erosive disease, 37 (14.3%); varices, 16 (6.2%); miscellaneous, 25 (9.7%); and unknown, 21 (8.1%). Peptic ulcer patients were similar to other patients (mean +/- SE) in age [60.6 +/- 1.2 vs. 60.7 +/- 1.5 yr] and gender [104 (65.4%) vs. 60 (60.6%) males], but were more often nonsteroidal anti-inflammatory drug (NSAID)-users [87 (54.7%) vs. 34 (34.3%) (p = 0.002)]. Older age, female gender, and NSAID use independently predicted gastric ulcer (p < or = 0.03). The severity of bleeding was similar in patients with peptic ulcers and in those with mucosal erosive disease and was not related to NSAID use in peptic ulcer patients. Patients whose AUGIH started after admission were older than those whose AUGIH began before admission [70.4 +/- 2.9 vs. 60.0 +/- 1.0 yr (p = 0.002)], and they had a higher mortality rate [4 (25%) vs. 9 (3.7%) (p = 0.005)].
1) The annual incidence of hospitalization for AUGIH was 102.0 per 100,000, increased markedly with age, and was twice as high in males as in females. 2) Peptic ulcer was the most common cause. 3) Gastric ulcer was associated with older age, female gender, and NSAID use. 4) Mortality rates were high when AUGIH started after hospitalization for another disorder.
Current risk-stratification systems for patients with acute upper-gastrointestinal bleeding discriminate between patients at high or low risks of dying or rebleeding. We therefore developed and prospectively validated a risk score to identify a patient's need for treatment.
Our first study used data from 1748 patients admitted for upper-gastrointestinal haemorrhage. By logistic regression, we derived a risk score that predicts patients' risks of needing blood transfusion or intervention to control bleeding, rebleeding, or dying. From this score, we developed a simplified fast-track screen for use at initial presentation. In a second study, we prospectively validated this score using receiver operating characteristic (ROC) curves--a measure of the validity of a scoring system--and chi2 goodness-of-fit testing with data from 197 patients. We also validated the quicker screening tool.
We calculated risk scores from patients' admission haemoglobin, blood urea, pulse, and systolic blood pressure, as well as presentation with syncope or melaena, and evidence of hepatic disease or cardiac failure. The score discriminated well with a ROC curve area of 0.92 (95% CI 0.88-0.95). The score was well calibrated for patients needing treatment (p=0.84).
Our score identified patients at low or high risk of needing treatment to manage their bleeding. This score should assist the clinical management of patients presenting with upper-gastrointestinal haemorrhage, but requires external validation.