No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
MAP (ASH), A NEW SCORING SYSTEM FOR THE PREDICTION OF INTERVENTION AND MORTALITY IN UGIB
Abstract
Background:
Risk stratification for upper gastrointestinal bleeding (UGIB) is recommended. However, scoring systems accuracy is suboptimal and score calculation can be complex. Our aim was to develop a new score, the MAP (ASH) score, with information available in the emergency room (ER), and to validate it.
Methods:
The score was built from a prospective database of patients with UGIB, and validated in an international database of 3,012 patients from six hospitals. Outcomes were 30-day mortality, endoscopic intervention, any intervention (red blood transfusion, endoscopic treatment, interventional radiology, surgery or death) and rebleeding. Accuracy to predict outcomes was assessed by the area under the receiver operating characteristic (AUROC) curve.
Results:
547 patients were included in the development cohort. Impaired mental status, Albumin<2.5 g/dL, pulse>100, American Society of Anesthesiologists (ASA) score>2, Systolic blood pressure<90 mmHg, and Hemoglobin<10 g/dl were included in the score. The model had a good predictive accuracy for intervention (AUROC=0.83; 95% CI: 0.79-0.88) and fair for mortality (AUROC=0.74; 95%CI: 0.68-0.81). Regarding endoscopic intervention, AUROC was 0.61 (95%CI: 0.56-0.66) in the original cohort, and 0.69 (95% CI: 0,66 to 0,71) in the validation cohort, showing a poor performance, similar to other scores. For rebleeding, the MAP (ASH) (AUROC 0.73; 95%CI: 0,69 to 0,77) was similar to GBS (AUROC=0.72; 95%CI: 0,67 to 0,76), but superior to AIMS65 (AUROC=0.64; 95% CI: 0,59 to 0,68).
Conclusion:
MAP (ASH) is a simple pre-endoscopy risk score to predict intervention after UGIB, with fair discrimination at predicting mortality. Because of its applicability, it could be an option in clinical practice.
... T-score is another pre-endoscopic score system that appears to predict high-risk endoscopic stigmata, mortality, and rebleeding [12]. Recently, several new scoring systems have been developed, including the MAP(ASH) and ABC scores [13,14]; however, their accuracies need to be verified. Recent guidelines suggested using risk scores for patients with UGIB; according to the guidelines, the scores should be used to identify and treat high-risk patients; however, their precise role in practice (especially for a daily growing number of elderly patients) remains uncertain [15]. ...
... The MAP(ASH) score was established in 2020 [13]. It is a pre-endoscopic risk score for predicting intervention of UGIB and can predict the risk of death (Table 3). ...
... It is a pre-endoscopic risk score for predicting intervention of UGIB and can predict the risk of death (Table 3). MAP(ASH) showed good predictive accuracy for intervention and was fair for mortality [13]. The ability to predict rebleeding is similar to GBS but superior to AIMS65. ...
Objectives:
To compare the predictive ability of six pre-endoscopic scoring systems (ABC, AIMS65, GBS, MAP(ASH), pRS, and T-score) for outcomes of upper gastrointestinal bleeding (UGIB) in elderly and younger patients.
Methods:
A retrospective study of 1260 patients, including 530 elderly patients (age [Formula: see text] 65) and 730 younger patients (age < 65) presenting with UGIB, was performed at Zhongda Hospital Southeast University, from January 2015 to December 2020. Six scoring systems were used.
Results:
ABC had the largest areas under the curve (AUCs) of 0.827 (0.792-0.858), and 0.958 (0.929-0.987) for elderly and younger groups for predicting mortality respectively. The differences of the AUCs for predicting the outcome of mortality and rebleeding between the two groups were significant for ABC and pRS (p < 0.01). For intervention prediction, significant differences were observed only for pRS [AUC 0.623 (0.578-0.669) vs. 0.699 (0.646-0.752)] (p < 0.05) between the two groups. For intensive care unit (ICU) admission, the AUC for MAP (ASH) [0.791 (0.718-0.865) vs. 0.891 (0.831-0.950)] and pRS [0.610 (0.514-0.706) vs. 0.891 (0.699-0.865)] were more effective for the younger group (p < 0.05 and p < 0.01, respectively). For comparison of scoring systems in the same cohort, ABC was significantly higher than pRS: AUC 0.710 (0.699-0.853, p < 0.05) and T-score 0.670 (0.628-0.710, p < 0.01) for predicting mortality in the elderly group. In the younger group, ABC was significantly higher than GBS and T-score (p < 0.01). MAP(ASH) performs the best in predicting intervention in both groups.
Conclusions:
ABC and pRS are more accurate for predicting mortality and rebleeding in the younger cohort, and pRS may not be suitable for elderly patients. There was no difference between the two study populations for GBS, AIMS65, and T-score. Except for ICU admission, MAP(ASH) showed fair accuracy for both cohorts.
... Regarding mortality prediction, AIM65 performs better than GBS and pRS; however, the areas under the receiver operator characteristics curves (AUCs of ROCs) are generally no higher than 0.80, suggesting that the clinical application of predicting this endpoint is limited [7]. Several new scoring systems have been developed, including the MAP(ASH) and the ABC scores [8,9]. Nevertheless, the accuracy of these scoring systems needs to be verified, especially in older adults with UGIB. ...
... Take the UK for example, only 52% of hospitals offer endoscopy during nonworking hours, and only 50% of patients can undergo endoscopy within 24 hours [19]. Also, in most hospitals, the major decisions about patient management are made in the emergency room, where a simple and accurate score is more clinically meaningful to determine whether a patient needs emergency intervention or may avoid admission [8]. Therefore, risk stratification based on clinical risk scores that do not require endoscopy is essential. ...
... The MAP(ASH) score was established in 2020 [8] and includes altered mental status, ASA score, pulse rate, albumin, systolic blood pressure, and hemoglobin. It is a preendoscopic risk score for predicting clinical intervention and predicts the risk of death. ...
Objectives:
To compare the ability of six preendoscopic scoring systems (ABC, AIMS65, Glasgow Blatchford score (GBS), MAP(ASH), pRS, and T-score) to predict outcomes of upper gastrointestinal bleeding (UGIB) in older adults.
Methods:
This was a retrospective study of 602 older adults (age ≥ 65) presenting with UGIB at Zhongda Hospital Southeast University from January 2015 to June 2021. Six scoring systems were used to analyze all patients.
Results:
ABC had the largest area under the curve (AUC) (0.833; 95% confidence interval (CI): 0.801-0.862) and was significantly higher than pRS 0.696 (95% CI: 0.658-0.733, p < 0.01) and T-score 0.667 (95% CI: 0.628-0.704, p < 0.01) in predicting mortality. MAP(ASH) (0.783; 95% CI: 0.748-0.815) performs the best in predicting intervention and was similar to GBS, T-score, ABC, and AIMS65. The AUCs for MAP(ASH) (0.732; 95% CI: 0.698-0.770), AIMS65 (0.711; 95% CI: 0.672-0.746), and ABC (0.718; 95% CI: 0.680-0.754) were fair for rebleeding, while those of GBS (0.662; 95% CI: 0.617-0.694), T-score (0.641; 95% CI: 0.606-0.684), and pRS (0.609; 95% CI: 0.569-0.648) were performed poorly. MAP(ASH) performs the best in predicting ICU admission (0.784; 95% CI: 0.749-0.816). All the five scores were significantly higher than pRS (p < 0.05 for ABC, AIMS65 and T-score, p < 0.01 for GBS and MAP).
Conclusions:
Mortality, intervention, rebleeding, and ICU admission in UGIB for older adults can be predicted well using MAP(ASH). ABC is the most accurate for predicting mortality. Except for rebleeding, GBS has an acceptable performance in predicting ICU admission, mortality, and intervention. AIMS65 and T-score performed moderately, and pRS may not be suitable for the target cohort.
... The higher the score, the more therapeutic intervention is required, but the evaluation of the point at which therapeutic intervention is required has not been established. Redondo-Cerezo et al. proposed the MAP score, which consists six indices: Glasgow Coma Scale score (< 15), American Society of Anesthesiologists score (> 2), pulse (> 100 beats/min), albumin (< 2.5 mg/dl), systolic blood pressure (< 90 mmHg), and hemoglobin (HB) (< 10 g/dl), and reported that it is highly predictive of therapeutic intervention including endoscopy and mortality in upper gastrointestinal bleeding [12] (Table 3). In order to predict the need for therapeutic intervention including endoscopy in upper gastrointestinal bleeding, the Modified GBS consisting of pulse rate, systolic blood pressure, blood urea nitrogen (BUN), and HB is useful [13,14] (Table 4). ...
... Iino et al. analysed 212 Japanese patients to predict the need for endoscopic treatment excluding blood transfusion. They evaluated the scores and factors that are included in the GBS and AIMS65 score and are In order to predict treatment intervention including endoscopy and mortality in upper gastrointestinal bleeding, evaluation is performed on a score of 0-9 using the above items [12] Item Standard Score (Table 5). However, the Iino score has not been widely used in clinical practice due to the lack of validation and the difficulty in interviewing all patients about syncope and antiplatelet medication before endoscopy. ...
Background
Gastrointestinal bleeding is one of the major gastrointestinal diseases. In this study, our objective was to compare Glasgow-Blatchford score (GBS), AIMS65 score, MAP score, Modified GBS, and Iino score as outcome measures for upper gastrointestinal bleeding. In addition, we extracted factors associated with hemostatic procedures including endoscopy, and proposed a new robust score model.
Methods
From January 2015 to December 2019, 675 patients with symptoms such as hematemesis who visited the National Hospital Organization Disaster Medical Center and underwent urgent upper endoscopy with diagnosis of suspected non-variceal upper gastrointestinal bleeding were retrospectively reviewed. We evaluated the GBS, AIMS65 score, MAP score, Modified GBS, and Iino score, and assessed the outcomes of patients requiring hemostatic treatments at the subsequent emergency endoscopy. We performed logistic regression analysis of factors related to endoscopic hemostasis and upper gastrointestinal bleeding, created a new score model, and evaluated the prediction of hemostatic treatment and mortality in the new score and the existing scores.
Results
The factors associated with endoscopic treatment were hematemesis, heart rate, HB (hemoglobin), blood pressure, blood urea nitrogen (BUN). Based on these predictors and the partial regression coefficients, a new score named H3B2 (using the initial letters of hematemesis, heart rate, HB, blood pressure, and BUN) was generated. H3B2 score was slightly more discriminatory compared to GBS and Modified GBS (area under the receiver operating characteristic curves (AUROC): 0.73 versus 0.721 and 0.7128, respectively) in predicting hemostatic treatment in emergency endoscopy. The H3B2 score also showed satisfactory prediction accuracy for subsequent deaths (AUROC: 0.6857. P < 0.001).
Conclusions
We proposed a new score, the H3B2 score, consisting of simple and objective indices in cases of suspected upper gastrointestinal bleeding. The H3B2 score is useful in identifying high-risk patients with suspected upper gastrointestinal bleeding who require urgent hemostatic treatment including emergency endoscopy.
... spective study comprising a large number of participants found that AIMS65 and PNED were useful for predicting mortality caused by UGIB (13), whereas other studies observed an insufficient power of the GBS, RS, and AIMS65 with regard to predicting mortality (14)(15)(16). In addition, these risk scores are based on many clinical and laboratory parameters, making them too complicated to apply in emergency situations. ...
... Notably, despite their simplicity, our novel criteria showed equivalent predictability to other useful but more complex scores, including AIMS65 and PNED. The AUCs of GBS, RS, AIMS65, and PNED for detecting UGIB-associated (12)(13)(14)(15)(16)(23)(24)(25). PNED reportedly outperforms RS in predicting the risk of death from UGIB (12). ...
Objective Conventional risk scores of peptic ulcer disease (PUD) are based on many parameters, and their application in clinical practice is therefore limited. The aim of this study was to establish simple and reliable criteria for predicting PUD-associated mortality.
Methods A total of 499 patients with PUD were divided into 2 groups: the training cohort (n=333) and the validation cohort (n=166). To minimize selection bias due to missing values, we used imputed datasets generated by the multiple imputation method (training-cohort dataset, n=33,300; validation-cohort dataset, n=16,600).
Results In the training-cohort dataset, the heart rate-to-systolic blood pressure ratio (HR/SBP) and serum albumin (s-Alb) level were significant independent predictive factors for mortality according to the multivariate analysis (HR/SBP, odds ratio [OR]: 1.72; 95% confidence interval [CI], 1.06-2.80, p=0.028; s-Alb, OR: 0.23, 95% CI, 0.11-0.51, p<0.001). The model comprising HR/SBP and s-Alb was able to detect mortality due to PUD with an area under the curve (AUC) of 0.855. In the validation-cohort dataset, this model also showed good efficacy with an AUC of 0.835. The novel criteria combining HR/SBP and s-Alb developed by a decision tree analysis showed 73.3% sensitivity and 87.6% specificity for predicting mortality in the total-cohort dataset. Our criteria were superior to the Glasgow Blatchford and Rockall scores and similar to the AIMS65 and Progetto Nazionale Emorragia Digestiva scores for predicting mortality.
Conclusion The combination of the HR/SBP ratio and s-Alb level is a good predictor of mortality in patients with PUD.
... Fifth, we could not compare other recent scoring systems, such as the quick Sequential Organ Failure Assessment, 34 MAP (ASH) score, 35 The Manchester Triage System, 36 or the machine learning model, 37 given that those scores were developed after the inception of our study. Although the superiority of the HARBINGER to these recent scores cannot be ascertained, the HARBINGER is still a straightforward method compared with these novel scores. ...
Background and aims
Although upper gastrointestinal bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3 variable score (1 point each for: absence of daily proton pump inhibitors use in the week before the index presentation, shock index (heart rate/systolic blood pressure ≥1, and blood urea nitrogen/creatinine ≥30), the Horibe gAstRointestinal BleedING prEdiction score(HARBINGER) with the 8 variable Glasgow Blatchford Score (GBS) and 5 variable AIMS65, to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy.
Methods
Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. Upon presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata.
Results
Of 1486 enrolled patients, 637 (43%) of patients harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver-operating characteristic curve (AUC) for the HARBINGER was 0.76 (95% confidence interval [CI], 0.72-0.79), which was significantly superior both to the GBS (AUC, 0.68; 95% CI, 0.64-0.71; p<0.001) and to the AIMS65 (AUC, 0.54; 95% CI, 0.50-0.58; p<0.001). When the HARBINGER cut-off value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively.
Conclusion
The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and the AIMS65.
... In this issue of the Journal of Gastroenterology and Hepatology, Redondo-Cerezo et al. have developed a "simple" risk score named MAP (ASH) score (using six parameters namely mental status, American Society of Anesthesiologists score, pulse and blood pressure, and albumin and hemoglobin levels and a simple calculator) that performs well and is easily implementable at the point of care. 4 This score was developed from an international cohort of patients with UGIB and validated in a single tertiary referral center. It performed similarly to the best performing risk score (Glasgow-Blatchford Score) in predicting need for hospital-based intervention (area under the curve [AUC] 0.83), 30-day mortality (AUC 0.74), endoscopic intervention (AUC 0.61), and rebleeding (AUC 0.73). ...
Introduction
Outcomes in old patients with upper gastrointestinal bleeding (UGIB) have been scarcely studied. Our aim was to compare very old individuals (>80 years old) with younger patients with UGIB, and to identify risk factors for the main outcomes.
Methods
A single-center prospectively collected database was analysed. Descriptive, inferential, and multivariate logistic regression models were performed. Main clinical outcomes were in-hospital and delayed 6-months mortality.
Results
698 patients were included, 143 very old and 555 aged<80. Old patients differed from younger ones in comorbidities (85.9% vs. 62%, p<0,0001), oral anticoagulants (32.3% vs 12.7%; p<0.0001), and antiplatelets intake (32.3% vs. 21.2 %; p<0.007). No differences were found in the need for endoscopic interventions, blood unit transfusions, hospital stay, in-hospital rebleeding and mortality. Among very old patients, creatinine levels were higher in those who died compared to the ones who survived (1.92±1.46 vs. 1.25±0.59 mg/dl; p=0,002), they had lower hemoglobin levels (8.1±1.4 vs. 9.1±2.4 g/dl; p=0.04) and longer hospital stays (17.75±15.5 vs. 8.1±8.4 days; p<0.0001). Logistic regression showed creatinine levels (OR: 2.42; 95%CI: 1.24-4.74; p=0.01), cirrhosis (OR: 2.88, 95%CI: 1.88-17.34; p=0.04) and being an impatient (OR: 3.90; 95%CI: 1.11-20; p=0.035) were independent risk factors for mortality in older patients. They had an increased delayed 6-month mortality compared to younger patients (17.5% vs 8%, p=0.001).
Conclusions
Creatinine levels, cirrhosis or the onset of UGIB while being an inpatient were independent risk factors for mortality in very old patients. Delayed mortality was higher among them, mostly caused by cardiovascular events and neoplasms, but not in-hospital mortality.
Background and Aim
Several scoring systems for predicting outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB) have recently been devised, but not sufficiently validated. We compared the predictive accuracy of several scoring systems and assessed the usefulness of new scoring systems.
Methods
The medical records of 1048 patients with NVUGIB were reviewed to collect demographic, clinical, laboratory, and endoscopic data. The areas under the receiver operating characteristic curve (AUROC) were calculated for the ABC, new Japanese scoring system, Progetto Nazionale Emorrhagia Digestiva (PNED), and other scores to compare their predictive accuracy for 30-day mortality, therapeutic intervention, rebleeding, and prolonged hospital stay (≥ 10 days). Outcome predictors were identified by multivariate analysis.
Results
The ABC, new Japanese scoring system, and PNED score best predicted 30-day mortality (AUROC 0.907), need for therapeutic intervention (AUROC 0.707), and rebleeding (AUROC 0.874), respectively (all P < 0.001). The ABC and PNED scores were similarly better at predicting prolonged hospital stay (ABC AUROC: 0.765; PNED, AUROC: 0.790; both P < 0.001). Thirty-day mortality was related to sex, systolic blood pressure (SBP), syncope, estimated glomerular filtration rate (eGFR), albumin, heart failure, disseminated malignancy, chronic obstructive pulmonary disorder (COPD), and liver cirrhosis. Sex, age, SBP, hematemesis, blood urea nitrogen, and eGFR independently predicted the need for therapeutic intervention. Sex, SBP, pulse, albumin level, heart failure, disseminated malignancy, and COPD predicted rebleeding.
Conclusion
The outcomes of patients with NVUGIB were better predicted by newly developed than by old scoring systems.
Introduction: Acute upper-gastrointestinal bleeding (AUGIB) is a common medical emergency, with an incidence of 103–172 per 100,000 in the United Kingdom (UK) and mortality of 2% to 10%. Early and accurate prediction of the severity of an AUGIB episode may help guide management, including in or outpatient management, level of care required, and timing of endoscopy. This article aims to address the clinical utility of the various pre-endoscopic risk assessment tools used in AUGIB.
Areas covered: The authors undertook a literature review of the current evidence on the pre-endoscopic risk assessment scores. Additional the authors discuss the recently published novel risk assessment scores.
Expert opinion: The evidence shows that GBS is the most clinically useful risk assessment score in correctly identifying very low-risk patients suitable for outpatient management. At present, research is ongoing to assess machine learning in the assessment of patients presenting with AUGIB. More research is needed but it shows promise for the future.
Objective To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.
Design International multicentre prospective study.
Setting Six large hospitals in Europe, North America, Asia, and Oceania.
Participants 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.
Main outcome measures Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.
Results The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.
Conclusions The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.
Trial registration Current Controlled Trials ISRCTN16235737.
This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH).
The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH).
To compare the 2 scores' performance in predicting important outcomes in UGIH.
A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome.
A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer's D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively.
The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.
Background:
The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy.
Methods:
We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis.
Results:
A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy.
Conclusions:
As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).
Objective: To describe the current epidemiology of acute upper gastrointestinal haemorrhage.
Design: Population based, unselected, multicentre, prospective survey.
Setting: 74 hospitals receiving emergency admissions in four health regions in the United Kingdom.
Subjects: 4185 cases of acute upper gastrointestinal haemorrhage in which patients were aged over 16 years identified over four months.
Outcome measures: Incidence and mortality.
Results: The overall incidence of acute upper gastrointestinal haemorrhage in the United Kingdom is 103/100000 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%.
Conclusions: 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.
This guideline presents recommendations for the step-wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk-stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre-endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre-endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 24h. The endoscopic features of ulcers direct further management. Patients with active bleeding or non-bleeding visible vessels receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and those with an adherent clot may receive endoscopic therapy; these patients then receive intravenous PPI with a bolus followed by continuous infusion. Patients with flat spots or clean-based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. H. pylori is eradicated and after cure is documented anti-ulcer therapy is generally not given. Nonsteroidal anti-inflammatory drugs (NSAIDs) are stopped; if they must be resumed low-dose COX-2-selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re-institute aspirin soon after bleeding ceases (within 7 days and ideally 1-3 days). Patients with idiopathic ulcers receive long-term anti-ulcer therapy.
Although the early use of a risk stratification score in upper GI bleeding is recommended, existing risk scores are not widely used in clinical practice.
We sought to develop and validate an easily calculated bedside risk score, AIMS65, by using data routinely available at initial evaluation.
Data from patients admitted from the emergency department with acute upper GI bleeding were extracted from a database containing information from 187 U.S. hospitals. Recursive partitioning was applied to derive a risk score for in-hospital mortality by using data from 2004 to 2005 in 29,222 patients. The score was validated by using data from 2006 to 2007 in 32,504 patients. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve.
Mortality, length of stay (LOS), and cost of admission.
The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years. For those with no risk factors, the mortality rate was 0.3% compared with 31.8% in patients with all 5 (P < .001). The model had a high predictive accuracy (AUROC = 0.80; 95% CI, 0.78-0.81), which was confirmed in the validation cohort (AUROC = 0.77, 95% CI, 0.75-0.79). Longer LOS and increased costs were seen with higher scores (P < .001).
Database data used does not include outcomes such as rebleeding.
AIMS65 is a simple, accurate risk score that predicts in-hospital mortality, LOS, and cost in patients with acute upper GI bleeding.
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.
From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting.
Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes.
One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata.
These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.
Background:
upper gastrointestinal bleeding (UGIB) is one of the main causes of hospital admission in gastroenterology departments and is associated with a significant morbidity and mortality. Rebleeding after initial endoscopic therapy occurs in 10-20% of cases and therefore, there is a need to define predictive factors for rebleeding.
Aim:
the aim of our study was to analyze risk factors and outcomes in a population of patients who suffered a rebleed.
Methods:
five hundred and seven patients with gastrointestinal bleeding were included. Clinical and biochemical data, as well as procedures and outcome six months after admission, were all collected. Documented clinical outcome included in-hospital and six-month delayed mortality, rebleeding and six-month delayed hemorrhagic and cardiovascular events.
Results:
according to a logistic regression analysis, high creatinine levels were independent risk factors for rebleeding of non-variceal and variceal UGIB. In non-variceal UGIB, tachycardia was an independent risk factor, whereas albumin levels were an independent protective factor. Rebleeding was associated with in-hospital mortality (29.5% vs 5.5%; p < 0.0001). In contrast, rebleeding was not related to six-month delayed mortality or delayed cardiovascular and hemorrhagic events.
Conclusions:
tachycardia and high creatinine and albumin levels were independent factors associated with rebleeding, suggestive of a potential predictive role of these parameters. The incorporation of these variables into predictive scores may provide improved results for patients with UGIB. Further validation in prospective studies is required.
Background: Detailed analyses of mortality after upper gastrointestinal (GI) bleeding are lacking. Follow-up rarely extends beyond 30 days.
Aims: Our aim was to analyze in-hospital and delayed 6-months mortality, identifying risk factors.
Methods: This was a prospective study on patients with upper GI bleeding over 36 months. Clinical outcomes were in-hospital and delayed-6 month-mortality.
Results: Four hundred and forty-none patients were included. Overall inpatient mortality was 9.8% but mortality directly related to bleeding was 5.1%. Patients who died presented lower systolic blood pressures, platelet recounts, prothrombin times and lower levels of hemoglobin, calcium, albumin, urea, creatinine and total proteins. Cirrhosis and neoplasms determined a higher in-hospital mortality. Albumin levels were protective, whereas creatinine and an active bleeding were risk factors for in-hospital death in multivariate analysis. Up to 12.6% of patients discharged died in the first 6 months. Neoplasms, chronic kidney disease, coronary disease and esophageal varices were related to delayed mortality. Coronary disease and neoplasms were independent risk factors for mortality, but albumin levels were protective in multivariate analysis.
Conclusion: Comorbidities were risk factors for delayed mortality, whereas albumin levels were a protective factor for in-hospital and delayed deaths. Six months mortality is proportionately as important as in-hospital mortality. Half of the delayed deaths might be preventable.
Background & aims:
We performed a prospective multi-national study of patients presenting to the emergency department with upper gastrointestinal bleeding (UGIB) and assessed the relationship of time to presentation after onset of UGIB symptoms with patient characteristics and outcomes.
Methods:
Consecutive patients presenting with overt UGIB (red-blood emesis, coffee-ground emesis and/or melena) from March 2014 to March 2015 at 6 hospitals were included. Multiple pre-defined patient characteristics and outcomes were collected. Rapid presentation was defined as ≤6 hours.
Results:
Among 2944 patients, 1068 (36%) presented within 6 hours and 576 (20%) beyond 48 hours. Significant independent factors associated with presentation ≤6 hours versus >6 hours on logistic regression included melena (OR=0.22, 0.18-0.28), hemoglobin ≤80 g/L (OR=0.47, 0.36-0.61), altered mental status (OR=2.06, 1.55-2.73), albumin ≤30 g/L (OR=1.43, 1.14-1.78), and red-blood emesis (OR=1.29, 1.06-1.59). Patients presenting ≤6 hours versus >6 hours required transfusion less often (286 (27%) versus 791 (42%), difference = -15%, -19% to -12%) due to a smaller proportion with low hemoglobin levels, but were similar in hemostatic intervention (189 (18%) versus 371 (20%)), 30-day mortality (80 (7%) versus 121 (6%)), and hospital days (5.0±0.2 vs 5.0±0.2).
Conclusions:
Patients with melena alone delay their presentation to the hospital. A delayed presentation is associated with a decreased hemoglobin and increases the likelihood of transfusion. Other outcomes are similar with rapid versus delayed presentation. Time to presentation should not be used as an indicator for poor outcome. Patients with delayed presentation should be managed with the same degree of care as those with rapid presentation.
Background:
Predictors of worse outcomes (rebleeding, surgery and death) of peptic ulcer bleeds (PUBs) are essential indicators because of significant morbidity and mortality rates of PUBs. However those have been infrequently reported since changes in medical therapy (PPI, proton pump inhibitors) and application of newer endoscopic haemostatic technique.
Aims:
To determine: (i) independent risk factors for 30-day rebleeding, surgery, and death and (ii) whether ulcer size is an independent predictor of major outcomes in patients with severe PUB after successful endoscopic haemostasis and treatment with optimal medical (high dose IV PPI) vs. prior treatment (high dose IV histamine 2 antagonists - H2RAs).
Methods:
A large prospectively followed population of patients hospitalised with severe PUBs between 1993 and 2011 at two US tertiary care academic medical centres, stratified by stigmata of recent haemorrhage (SRH) was studied. Using multivariable logistic regression analyses, independent risk factors for each outcome (rebleeding, surgery and death) up to 30 days were analysed. Effects for medical treatment (H2RA patients 1993-2005 vs. PPIs 2006-2011) were also analysed.
Results:
A total of 1264 patients were included. For ulcers ≥10 mm, the odds of 30-day rebleeding increased 6% per each 10% increase in ulcer size (OR 1.06, 95% CI 1.02-1.10, P = 0.0053). Other risk factors for 30-day rebleeding were major SRH, in-patient start of bleeding, and prior GI bleeding. Major SRH and ulcer size≥10 mm were predictors of 30-day surgery. Risk factors for 30-day death were major SRH, in-patient bleeding, and any initial platelet transfusion or fresh frozen plasma transfusion ≥2 units. Among patients with major SRH and out-patient start of bleeding, larger ulcer size was also a risk factor for death (OR 1.08 per 10% increase in ulcer size, 95% CI 1.02-1.14, P = 0.0095). Ulcer size was a significant independent variable for both time periods.
Conclusions:
Ulcer size is a risk factor for worse outcomes after PUB and should be carefully recorded at initial endoscopy to improve patient triage and management.
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.
Objectives
The aim of this study was to compare the performance of the Glasgow-Blatchford and the AIMS65 scoring systems as early risk assessment tools for accurately identifying patients with upper gastrointestinal (GI) bleeding who are at a low risk of requiring clinical interventions, including emergency endoscopy. The secondary objective was to compare their performance regarding relevant clinical outcomes.Methods
Data were collected prospectively over a 2-year period in the emergency department of a university hospital. Adult patients with upper GI bleeding from either variceal or nonvariceal sources were included. Composite clinical outcomes consisted of a need for surgical or endoscopic intervention, rebleeding, intensive care unit admission, or in-hospital mortality. Patients who required blood transfusions or suffered composite clinical outcomes were considered high-risk patients. Glasgow-Blatchford score (GBS) and AIMS65 score were calculated for each patient. The sensitivity and specificity of the scoring systems were calculated. The areas under the receiver-operating characteristic curve (AUC) of the scores were compared.ResultsThere were 254 patients in the study, of whom 163 (64.2%) were men. The median age was 61 years (interquartile range = 45 to 72 years). Among the patients, 211 (83.1%) underwent endoscopy, of whom 49 (19.3%) required endoscopic intervention to achieve hemostasis. Five (2%) patients required surgical intervention. Rebleeding was observed in 33 (13%) patients. A total of 143 (56.3%) patients received blood transfusions. A total of 152 (59.8%) were defined as high risk. Eighty-one (31.9%) experienced at least one component of the composite clinical outcomes, 18 (7.1%) of whom suffered in-hospital mortality. A GBS of 0 was observed in 16 patients (6.3%) in the study group. Two of these were high-risk patients. A total of 101 (39.8%) patients had AIMS65 scores of 0. Thirty-four of these were high-risk patients. A GBS of 0 had higher sensitivity than an AIMS65 score of 0 (98.68% vs. 77.6%). The negative predictive values of the GBS and AIMS65 of 0 were 87.5 and 66.3%, respectively. The GBS and AIMS65 were similar with regard to the composite outcome prediction, with AUCs of 0.795 (95% confidence interval [CI] = 0.74 to 0.843) and 0.746 (95% CI = 0.688 to 0.798), respectively (p = 0.137). The scores were also similar with respect to predicting in-hospital mortality (AUCs of 0.85 vs. 0.81; p = 0.342). The GBS was superior to the AIMS65 in identifying high-risk patients, with AUCs of 0.896 (95% CI = 0.85 to 0.93) and 0.771 (95% CI = 0.714 to 0.821; p < 0.001), respectively. The GBS was also more accurate than the AIM65 in predicting the need for blood transfusions (AUCs of 0.904 vs. 0.796; p < 0.001) and interventions (AUCs of 0.727 vs. 0.647; p = 0.05).Conclusions
These results suggest that the GBS has superior sensitivity relative to the AIMS65 in identifying patients who were not likely to require interventions, including emergency endoscopy. Additional work to determine the use in real-time decision making may be warranted and helpful in providing guidance to clinicians.
Background
& Aims: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients’ risk for hospital-based intervention or death. Patients with GBSs of 0 are at low risk for poor outcome and could be managed as outpatients. Some have therefore proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cut-off value or modification.
Methods
We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low-risk.
Results
There were differences in age (P=.0001), need for intervention (P<.0001), mortality (P<.015), and GBS (P=.0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-offs ≤1 and ≤2, and both modifications, identified low-risk patients with higher levels of specificity (40%−49%) than the GBS with a cut-off of 0 (22% specificity, P<.001). The GBS at cut-off ≤2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-offs, and score modifications, had low levels of specificity when tested in New Zealand (2.5%−11%).
Conclusions
A GBS cut-off ≤1and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at cut-off of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15%−20%.
Introduction:
We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB).
Objective:
To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS).
Design:
Retrospective cohort study.
Patients:
Adults with a primary diagnosis of UGIB.
Main outcome measurements:
Primary outcome:
inpatient mortality.
Secondary outcomes:
composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score.
Results:
Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes.
Limitations:
Retrospective, single-center study.
Conclusion:
The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.
Acute upper gastrointestinal haemorrhage is a common medical emergency, initially managed with inpatient care. Bleeding stops spontaneously in over 80% of cases, indicating that patients with low-risk upper gastrointestinal haemorrhage may be more optimally managed in the community, without the need for admission to hospital.
To assess the safety of managing patients with low-risk upper gastrointestinal haemorrhage without admission to hospital.
Prospective/retrospective study of all patients presenting to a UK teaching hospital with low-risk upper gastrointestinal haemorrhage who were managed without admission to hospital over 5 years. Low risk was defined as Glasgow Blatchford Score of 2 or less, age below 70 years, no other active medical problems, not taking warfarin and suspected nonvariceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death.
One hundred and forty-two patients fulfilled the inclusion criteria, and were managed without admission to hospital. No patients required endoscopic intervention, blood transfusion or surgery. The 28-day mortality was nil. Forty-one patients had normal endoscopic examination and 11 had significant endoscopic findings (peptic ulceration=10, oozing Mallory-Weiss tear=1) but did not require intervention.
Patients presenting with a primary upper gastrointestinal haemorrhage aged below 70 years with a Glasgow Blatchford Score of 2 or less are at a low risk, and can be safely managed in the community.
An increased mortality in patients presenting to hospital at weekends has been observed for several medical conditions. The aim of this study is to examine the relationship between weekend presentation to hospital following acute upper gastrointestinal bleeding and mortality.
Data were collected on 6,749 patients presenting to 212 UK hospitals. A logistic regression model was used to examine the relationship between weekend presentation to hospital and mortality.
Patients presenting at the weekend were more likely to present with shock (39% vs. 36%), hematemesis (41% vs. 38%), and receive red cell transfusion (42% vs. 39%). Only 38% of those presenting at weekends underwent endoscopy within 24 h compared with 55% admitted on weekdays (adjusted odds ratio (OR)=0.47, 95% confidence interval (CI)=0.41-0.54), although the proportion of all patients receiving endoscopic therapy was identical at weekends compared with weekdays (24%). After adjustment for confounders, there was no evidence of a difference between weekend and weekday mortality (OR=0.93; 95% CI=0.75-1.16). Similar results were seen when restricting the analysis to those patients who underwent endoscopy (n=5,004) (OR=0.87, 95% CI=0.65-1.16). There was no difference in the OR for mortality for weekend compared with weekday presentation between patients presenting to hospitals with an out-of-hours (OOH) endoscopy rota compared with those presenting to hospitals without such a facility.
In this large prospective study of acute upper gastrointestinal bleeding in the United Kingdom, there was no increase in mortality for weekend vs. weekday presentation despite patients being more critically ill and having greater delays to endoscopy at weekends. Provision of an OOH endoscopy service at weekends in the remaining UK hospitals may not lead to further reductions in case fatality, although a reduction in OOH endoscopy provision from current levels could lead to an increase in mortality at weekends.
To describe the patient characteristics, diagnoses and clinical outcomes of patients presenting with acute upper gastrointestinal bleeding (AUGIB) in the 2007 UK Audit.
Multi-centre survey.
All UK hospitals admitting patients with AUGIB.
All adults (>16 years) presenting in or to UK hospitals with AUGIB between 1 May and 30 June 2007.
Data on 6750 patients (median age 68 years) was collected from 208 participating hospitals. New admissions (n=5550) were younger (median age 65 years) than inpatients (n=1107, median age 71 years), with less co-morbidity (any co-morbidity 46% vs 71%, respectively). At presentation 9% (599/6750) had known cirrhosis, 26% a history of alcohol excess, 11% were taking non-steroidal anti-inflammatory drugs and 28% aspirin. Peptic ulcer disease accounted for 36% of AUGIB and bleeding varices 11%. In 13% there was evidence of further bleeding after the first endoscopy. 1.9% underwent surgery and 1.2% interventional radiology for AUGIB. Median length of stay was 5 days. Overall mortality in hospital was 10% (675/6750, 95% CI 9.3 to 10.7), 7% in new admissions and 26% among inpatients. Mortality was highest in those with variceal bleeding (15%) and with malignancy (17%).
AUGIB continues to result in substantial mortality although it appears to be lower than in 1993. Mortality is particularly high among inpatients and those bleeding from varices or upper gastrointestinal malignancy. Surgical or radiological interventions are little used currently.
The role of urgent endoscopy in high-risk nonvariceal upper gastrointestinal bleeding (NVUGIB) is unclear. The aim of this study was to determine whether esophagogastroduodenoscopy (EGD) performed sooner than the currently recommended 24 h in high-risk patients presenting with NVUGIB is associated with lower all-cause in-hospital mortality.
All adult patients undergoing EGD for the indications of coffee-grounds vomitus, hematemesis or melena at a university hospital over an 18-month period were enrolled. Patients with variceal and lower gastrointestinal bleeding were excluded. Data were prospectively collected.
A total of 934 patients were included. The area under the receiver operating characteristic curve (AUROC) for the Glasgow-Blatchford score (GBS) was 0.813 for predicting all-cause in-hospital mortality, with a cut-off score of ≥ 12 resulting in 90 % specificity. In low-risk patients with GBS < 12, presentation-to-endoscopy time in those who died and in those who survived was similar. In high-risk patients with GBS of ≥ 12, presentation-to-endoscopy time was significantly longer in those who died than in those who survived. Multivariate analysis of the high-risk cohort showed presentation-to-endoscopy time to be the only factor associated with all-cause in-hospital mortality. For high-risk patients, the AUROC for presentation-to-endoscopy time in predicting all-cause in-hospital mortality was 0.803, with a sensitivity of 100 % at the cut-off time of 13 h. All-cause in-hospital mortality in high-risk patients was significantly higher in those with presentation-to-endoscopy time of > 13 h compared with those undergoing endoscopy in < 13 h from presentation (44 % vs. 0 %; P < 0.001).
Endoscopy within 13 h of presentation was associated with lower mortality in high-risk but not low-risk NVUGIB.
We sought (i) to validate a new prediction rule of mortality (Progetto Nazionale Emorragia Digestiva (PNED) score) on an independent population with non-variceal upper gastrointestinal bleeding (UGIB) and (ii) to compare the accuracy of the Italian PNED score vs. the Rockall score in predicting the risk of death.
We conducted prospective validation of analysis of consecutive patients with UGIB at 21 hospitals from 2007 to 2008. Outcome measure was 30-day mortality. All the variables used to calculate the Rockall score as well as those identified in the Italian predictive model were considered. Calibration of the model was tested using the chi2 goodness-of-fit and performance characteristics with receiver operating characteristic (ROC) analysis. The area under the ROC curve (AUC) was used to quantify the diagnostic accuracy of the two predictive models.
Over a 16-month period, data on 1,360 patients were entered in a national database and analyzed. Peptic ulcer bleeding was recorded in 60.7% of cases. One or more comorbidities were present in 66% of patients. Endoscopic treatment was delivered in all high-risk patients followed by high-dose intravenous proton pump inhibitor in 95% of them. Sixty-six patients died (mortality 4.85%; 3.54-5.75). The PNED score showed a high discriminant capability and was significantly superior to the Rockall score in predicting the risk of death (AUC 0.81 (0.72-0.90) vs. 0.66 (0.60-0.72), P<0.000). Positive likelihood ratio for mortality in patients with a PNED risk score >8 was 16.05.
The Italian 10-point score for the prediction of death was successfully validated in this independent population of patients with non-variceal gastrointestinal bleeding. The PNED score is accurate and superior to the Rockall score. Further external validation at the international level is needed.
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.
Acute upper gastrointestinal bleeding (UGIB) continues to be a common cause of hospital admission and morbidity and mortality. This study reviews 469 patients admitted to a surgical service of an urban hospital. There were 562 total admissions because 53 patients were readmitted 93 times (recurrence rate, 20%). The most common causes of bleeding, all endoscopically diagnosed, included acute gastric mucosal lesion (AGML) (135 patients, 24%), esophageal varices (EV) (121 patients, 22%), gastric ulcer (108 patients, 19%), duodenal ulcer (78 patients, 14%), Mallory-Weiss tear (61 patients, 11%), and esophagitis (15 patients, 3%). Nonoperative therapy was sufficient in 504 cases (89.5%). Endoscopic treatment was used in 144 cases. Operations were performed in 58 cases (10.5%), including 29% of ulcers. Emergency operations to control hemorrhage were required in only 2.5% of all cases. The rate of major surgical complications was 11% and the mortality rate was 5.2%. There were 58 deaths (12.6%), with 36 deaths directly attributable to UGIB. Factors correlating with death include shock at admission (systolic blood pressure less than 80), transfusion requirement of more than five units, and presence of EV (all p less than 0.001). Most cases of UGIB can be treated without operation, including endoscopic treatment, when diagnostic endoscopy establishes the source. Subsequent operation in selected patients can be done with low morbidity and mortality rates.
Methods of evaluating and comparing the performance of diagnostic tests are of increasing importance as new tests are developed and marketed. When a test is based on an observed variable that lies on a continuous or graded scale, an assessment of the overall value of the test can be made through the use of a receiver operating characteristic (ROC) curve. The curve is constructed by varying the cutpoint used to determine which values of the observed variable will be considered abnormal and then plotting the resulting sensitivities against the corresponding false positive rates. When two or more empirical curves are constructed based on tests performed on the same individuals, statistical analysis on differences between curves must take into account the correlated nature of the data. This paper presents a nonparametric approach to the analysis of areas under correlated ROC curves, by using the theory on generalized U-statistics to generate an estimated covariance matrix.
We prospectively and randomly compared heat probe and ethanol injection in 80 patients with major nonvariceal upper gastrointestinal hemorrhage who were bleeding actively or had endoscopic stigmata associated with a high risk for rebleeding. We also attempted to predict which patients would rebleed within 72 h after successful endoscopic therapy, using a three-component scoring system. Heat probe and ethanol injection proved to be similar in efficacy and safety. Active bleeding was controlled with equal success with heat probe and ethanol injection (92% vs. 82%), and there was no difference in the rebleeding rate (11% vs. 13%). The scoring system was useful in predicting which patients would rebleed. Significant differences were seen in the mean values of all three scores, and specific cut-offs in the pre-endoscopy and post-endoscopy scores predicted patients who rebled. High likelihood ratios and post-test probabilities for rebleeding were found for the number and severity of concurrent illnesses, but not for endoscopic stigmata, implying that the excess risk associated with stigmata is eliminated after effective endoscopic therapy, and clinical factors become the primary determinants of rebleeding.
Acute upper gastrointestinal haemorrhage is a common medical emergency and hospital admission has usually been regarded as obligatory until the risk of further haemorrhage has receded. This policy means that some patients at low risk stay in hospital for longer than is necessary especially when diagnostic endoscopy is delayed. We attempted to identify patients who had negligible risk of further bleeding or death and for whom early discharge or even outpatient management would be possible with no adverse effect on standards of care.
We used a validated risk scoring system based on age (score 0-2), presence of shock (0-2), comorbidity (0-3), diagnosis (0-2), and endoscopic stigmata of recent haemorrhage (0-2); the maximum possible score was 11. We studied patients identified through the UK national Audit of acute upper gastrointestinal haemorrhage; they had been admitted with upper gastrointestinal haemorrhage to hospitals in the UK during 4 months of 1993. This analysis was based on the 2531 patients from the national audit who underwent endoscopy after an acute admission.
744 (29.4%) of the 2531 patients scored 2 or less on the risk score. Of these patients only 32 (4.3% [95% Cl 3.0-6.0] rebled and only one (0.1% [0.006-0.75] died). Thus, the risk score identifies patients at low risk of rebleeding or death. The median hospital stay increased with risk score. Within risk score categories of 5 or less, there was a trend of increasing hospital stay as the time between admission and endoscopy increased.
Our risk score identifies a large proportion of patients with acute upper gastrointestinal haemorrhage who are at low risk of further bleeding or death. Early endoscopy and discharge of such patients could allow substantial resource savings.
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.
The aim of this study was to examine recent time trends in incidence and outcome of upper GI bleeding.
Prospective data collection on all patients presenting with acute upper GI bleeding from a defined geographical area in the period 1993/1994 and 2000.
Incidence decreased from 61.7/100,000 in 1993/94 to 47.7/100,000 persons annually in 2000, corresponding to a 23% decrease in incidence after age adjustment (95% CI = 15-30%). The incidence was higher among patients of more advanced age. Rebleeding (16% vs 15%) and mortality (14% vs 13%) did not differ between the two time periods. Ulcer bleeding was the most frequent cause of bleeding, at 40% (1993/94) and 46% (2000). Incidence remained stable for both duodenal and gastric ulcer bleeding. Almost one half of all patients with peptic ulcer bleeding were using nonsteroidal anti-inflammatory drugs or aspirin. Also, among patients with ulcer bleeding, rebleeding (22% vs 20%) and mortality (15% vs 14%) did not differ between the two time periods. Increasing age, presence of severe and life-threatening comorbidity, and rebleeding were associated with higher mortality.
Between 1993/1994 and 2000, among patients with acute upper GI bleeding, the incidence rate of upper GI bleeding significantly decreased, but no improvement was seen in the risk of rebleeding or mortality in these patients. The incidence rate of ulcer bleeding remained stable. Prevention of ulcer bleeding is important.
Hypoalbuminemia occurs in a variety of disease states and is associated with an increased rate of complications during hospitalization, resulting in an increased length of stay. However, there are no data about hypoalbuminemia in patients with non-variceal upper gastrointestinal bleeding. The purpose of this study is to evaluate the prevalence of hypoalbuminemia in patients with non-variceal upper gastrointestinal bleeding and to examine its significance in relation to severity and outcome of bleeding.
This is a retrospective analysis of data collected prospectively on consecutive patients admitted to the Emergency Department of Taichung Veterans General Hospital with upper GI bleeding, and variceal bleeding was excluded. Hypoalbuminemia is defined as serum albumin < 3.5 g/dL. The outcome assessments in the hypoalbuminemia and normal albumin groups were compared.
There were three hundred and twenty-nine patients with non-variceal upper GI bleeding identified from July 2000 to January 2001. Two hundred and fifty were male, and 79 were female. Their ages ranged from 21 to 90 (64.60 +/- 14.84) years. Of these 329 patients eligible for the study, hypoalbuminemia was seen in 204 (62.0%). When compared to patients with normal serum albumin, the hypoalbuminemia group was older (66.81 +/- 13.45 vs. 60.98 +/- 16.29 years, P < 0.01), had more associated with underlying diseases (78.4% vs. 57.6%, P < 0.01), and had more leukocytosis (47.5% vs. 35.2%, P < 0.05), had lower hemoglobin (71.1% vs. 29.6% P < 0.01), and elevated BUN (85.3% vs. 72.8%, P < 0.01) at admission. In addition, these patients had longer hospital stay (6.82 +/- 9.45 vs. 2.38 +/- 3.48 days, P < 0.01), greater requirements of blood transfusion (5.76 +/- 7.43 vs. 1.38 +/- 2.20 units, P < 0.01), need of therapeutic endoscopy (41.7% vs. 16.0%, P < 0.01), with higher rebleeding rate (13.2% vs. 0%, P < 0.01), surgery rate (5.4% us. 0.8% P < 0.05), and mortality rate (9.3% vs. 0%, P < 0.01).
Hypoalbuminemia is common in patients with non-variceal upper GI bleeding, appears to reflect the severity of the bleeding episode, and is associated with a more complicated course.
Management of patients with ulcer bleeding. The American journal of gastroenterology
- L Laine
- D M Jensen
Laine L, Jensen DM. Management of patients with ulcer bleeding. The American journal of
gastroenterology. 2012;107(3):345-60; quiz 61.