Glasgow-Blatchford Research Articles

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

The emergency department (ED) admission rate for elderly patients with non-variceal upper gastrointestinal bleeding (UGIB) is increasing. The AIMS65 and Glasgow-Blatchford score (GBS) are two distinct scoring systems proposed to predict in-hospital and post-discharge mortality, length of stay (LOS), and health-related costs in these patients. The objective of the present study is to evaluate the accuracy of these scoring systems, in conjunction with the Charlson comorbidity index (CCI), to predict 30-day mortality and LOS in UGIB patients who are 80 years of age or older METHODS: A retrospective analysis was undertaken of 182 patients with non-variceal UGIB who were admitted to the ED of Canakkale Onsekiz Mart University Hospital. The AIMS65, GBS, and CCI scores were calculated and adverse patient outcomes were assessed. The mean age of patients was 85.59±4.33 years, and 90 (49.5%) of the patients were males. The AIMS65 was superior to the GBS (area under the receiver operating characteristic curve [AUROC] 0.877 vs. 0.695, respectively) and CCI (AUROC 0.877 vs. 0.526, respectively) in predicting the 30-day mortality. All three scores performed poorly in predicting the LOS in hospital. The cutoff threshold that maximized sensitivity and specificity for mortality was three for the AIMS65 score (sensitivity, 0.87; specificity, 0.80; negative predictive values [NPV], 0.977; positive predictive values [PPV], 0.392), 14 for GBS (sensitivity, 0.83; specificity, 0.51; NPV, 0.923; PPV, 0.367), and 5 for CCI (sensitivity, 0.91; specificity, 0.22; NPV, 0.946; PPV, 0.145). The AIMS65 is a simple, accurate, and non-endoscopic scoring system that can be performed easily in ED settings. It is superior to GBS and CCI in predicting 30-day mortality in elderly patients with UGIB.

Study of the benefit of blood urea nitrogen/creatinine ratio and some other parameters to detect site, cause, and severity of gastrointestinal hemorrhage noninvasively

Background and aim Gastrointestinal (GI) bleeding is a common medical condition that may lead to emergent endoscopy. The aim of our study was to design pre-endoscopic scores for GI bleeding to clarify the source of GI bleeding, to differentiate variceal and nonvariceal cases, and to identify complications and high-risk patients requiring urgent clinical management. Patients and methods One hundred patients with hematochezia or melena were enrolled in this study. Blood urea nitrogen (BUN)/creatinine ratio score, upper GI bleeding etiological score, C-WATCH score, and Glasgow-Blatchford score (GBS) were calculated. Upper GI endoscopy was performed by the consultant within 72 h, and lower endoscopy was done if indicated. Results This prospective study was done on 83 patients presented with upper gastrointestinal tract (GIT) bleeding and 17 patients presented with lower GIT bleeding. BUN/creatinine ratio was significantly higher in upper than lower GIT bleeding (P=0.019). Sensitivity of upper GI score was 45%, specificity was 86.96%, positive predictive value was 90.0%, and negative predictive value was 37.7%, with accuracy of 81.6%. Sensitivity and specificity of C-WATCH score were 38.33 and 78.26, respectively, and for GBS were 61.6 and 69.5%, respectively. Conclusion BUN/creatinine ratio had higher effectiveness in detecting upper than lower GI bleeding. Upper GI etiological score was significantly higher in diagnosis of variceal bleeding than nonvariceal bleeding. GBS is highly sensitive but not specific to anticipate complications of upper GIT bleeding; however, C-WATCH score can anticipate severity and complications of upper GI bleeding.

Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding.

BACKGROUNDAcute variceal bleeding is one of the deadliest complications of cirrhosis, with a high risk of in-hospital rebleeding and mortality. Some risk scoring systems to predict clinical outcomes in patients with upper gastrointestinal bleeding have been developed. However, for cirrhotic patients with variceal bleeding, data regarding the predictive value of these prognostic scores in predicting in-hospital outcomes are limited and controversial.AIMTo validate and compare the overall performance of selected prognostic scoring systems for predicting in-hospital outcomes in cirrhotic patients with variceal bleeding.METHODSFrom March 2017 to June 2019, cirrhotic patients with acute variceal bleeding were retrospectively enrolled at the Second Affiliated Hospital of Xi’an Jiaotong University. The clinical Rockall score (CRS), AIMS65 score (AIMS65), Glasgow-Blatchford score (GBS), modified GBS (mGBS), Canada-United Kingdom-Australia score (CANUKA), Child-Turcotte-Pugh score (CTP), model for end-stage liver disease (MELD) and MELD-Na were calculated. The overall performance of these prognostic scoring systems was evaluated.RESULTSA total of 330 cirrhotic patients with variceal bleeding were enrolled; the rates of in-hospital rebleeding and mortality were 20.3% and 10.6%, respectively. For in-hospital rebleeding, the discriminative ability of the CTP and CRS were clinically acceptable, with area under the receiver operating characteristic curves (AUROCs) of 0.717 (0.648-0.787) and 0.716 (0.638-0.793), respectively. The other tested scoring systems had poor discriminative ability (AUROCs < 0.7). For in-hospital mortality, the CRS, CTP, AIMS65, MELD-Na and MELD showed excellent discriminative ability (AUROCs > 0.8). The AUROCs of the mGBS, CANUKA and GBS were relatively small, but clinically acceptable (AUROCs > 0.7). Furthermore, the calibration of all scoring systems was good for either in-hospital rebleeding or death.CONCLUSIONFor cirrhotic patients with variceal bleeding, in-hospital rebleeding and mortality rates remain high. The CTP and CRS can be used clinically to predict in-hospital rebleeding. The performances of the CRS, CTP, AIMS65, MELD-Na and MELD are excellent at predicting in-hospital mortality.

The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding (UGIB) remains a major cause of hospital admission worldwide. The recent UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on severe gastrointestinal bleeding used the Shock Index to assess bleeding severity and found an association between Shock Index and mortality. However, this has never been prospectively validated as a predictor of outcome in UGIB. To compare the Shock Index with existing pre-endoscopic UGIB risk scores in predicting outcomes after UGIB METHODS: In an international, prospective study of 3012 consecutive patients with UGIB, we compared the Shock Index with existing scores including the Glasgow Blatchford score (GBS), admission Rockall score, AIMS65, and the newly described "ABC" score. Pre-determined endpoints were need for major (≥4 units red cells) transfusion, need for endoscopic therapy and 30-day mortality. The Shock Index was inferior to the GBS in predicting need for major transfusion (area under the receiver operator characteristic curve [AUROC] 0.655 vs 0.836, P<0.001) and need for endotherapy (AUROC 0.606 vs 0.747, P<0.001). The Shock Index was inferior to all other scores for 30-day mortality: for example, AUROC 0.611 vs 0.863 for ABC score (P<0.001). Adding the Shock Index to the ABC score did not improve accuracy of the ABC score in predicting mortality (AUROC 0.864 vs 0.863, P=0.95). The Shock Index performed poorly with AUROCs <0.66 and was inferior to existing pre-endoscopy scores at predicting major clinical endpoints after UGIB. We found no clear evidence that the Shock Index is clinically useful at predicting outcomes in UGIB. [Correction added on 20 December 2019, after first online publication: Summary section has been changed for clarification.].

595 The Glasgow-Blatchford Score: Pitfalls and Cost of Generalization

INTRODUCTION: Non-variceal acute upper gastrointestinal bleeding (NVAUGIB) is one of the most common causes of hospitalization worldwide. The Glasgow-Blatchford Score (GBS) was developed to identify subjects who would benefit from hemostatic endoscopic intervention (HEI), in this and other types of GIB. According to the literature, a GBS score &lt;2 identifies with up to 99% accuracy subjects who do not need emergent HEI. Experience at our center suggests that the average GBS of our patients with NVAUGIB is consistently &gt;2 and yet our rate of HEI is low. Therefore, the primary aim of this study was to accurately determine the rate of significant HEI in subjects with NVAUGIB with GBS &gt;2. The secondary aim was to determine the cost of esophagogastroduodenoscopy (EGD) in patients in whom no significant HEI was performed. METHODS: Medical records of subjects admitted for NVAUGIB who underwent EGD from January 2015 – December 2017 were reviewed. NVAUGIB was defined as the presence of any of the following: hematemesis, hematochezia, coffee ground emesis, + FOBT, melena, drop in Hgb &gt;2 g/dl and absence of varices on EGD. The GBS was calculated on the day of EGD on all subjects. Data obtained was compared using a Kolmogorov-Smirnov Test of Normality first to ensure normal distribution, then an independent T-test was used to evaluate for significance. EGD cost was obtained from the hospital administration. RESULTS: A total of 586 subjects underwent EGD for the evaluation of NVAUGIB, and their demographic characteristics are listed in Table 1. The mean GBS for subjects with ≤2 and &gt;2 were 1 and 8.8 respectively. Of those with a GBS &gt;2 (503/586), only 16.9% (85/503) underwent a HEI. On the other hand, only 1% (1/83) of those with GBS ≤2 (83/586), underwent HEI. Overall, subjects who received HEI (86) had higher GBS compared to those who didn't (9.29, SD 3.51) vs. (7.42, SD 4.06) (P ≤ 0.05). A total of 418 EGDs without HEI were performed in subjects with GBS &gt;2. The cost of a diagnostic EGD at our institution is approximately $2,866.00. Therefore, the cost of these procedures was approximately $1,200,000.00. CONCLUSION: In our population, a GBS cutoff of &gt;2 did not identify patients requiring HEI accurately as previously reported in the literature. The cost of performing non-therapeutic endoscopic evaluation in these subjects is alarming. Further research regarding the generalizability of the GBS is needed at this time.

520 Pre-Endoscopic Risk Stratification Scores Associated With Intubation for Emergent Endoscopy for Severe Gastrointestinal Hemorrhage

INTRODUCTION: Approximately 300,000 patients are admitted annually for gastrointestinal bleeding (GIB) in the US and many require emergent endoscopy. Many patients are prophylactically intubated to protect the airway in hopes of avoiding respiratory complications intra-operatively. Currently there are no guidelines to determine which patients should be intubated prior to endoscopy. STUDY AIM: To identify pre-procedural factors associated with intubation compared to those who undergo endoscopy without intubation and compare post-procedural outcomes. METHODS: Retrospective chart review from Sept 2017 to Dec 2018 of all emergent endoscopies for acute GIB. Data are presented as means with 95% ± t-test confidence intervals, or frequency (%). Analysis of variance (ANOVA), or univariate logistic regression was used for continuous variables, the Pearsons χ2 test was used for categorical variables. RESULTS: There were 210 procedures performed during this time frame. 142 patients were included in the final analysis after excluding endoscopies done for non-GIB indications. There was no statistically significant difference between the intubated and non-intubated groups for the following: gender, race, BMI, number of transfusions needed, or anticoagulation use [Table 1]. Mean Glasgow-Blatchford scores (GBS) and APACHE scores were higher in the intubated group than in the non-intubated group (12 vs. 10, P = .03 and 20 vs. 12, P &lt; .01, respectively). In the intubated group, 28% of patients developed pneumonia (PNA) [Table 1]. The difference in cardiovascular outcomes trended towards significance (P = 0.07). The intubated group had higher cardiac arrest (5.7% vs. 0%) and mortality rates (24% vs. 11%) than the non-intubated group. CONCLUSION: We found that higher GBS and APACHE scores were associated with intubation. We also found that patients with cirrhosis or who were on pressors were more likely to be intubated. In our study, 28% of intubated patients developed pneumonia, whereas prior studies report a 14% incidence of pneumonia after intubation. The decision to intubate a patient is complex but gastroenterologists and intensivists must weigh the risks associated with intubation, such as PNA, ICU delirium, and increased length of stay in the ICU, and avoid reflexively intubating all patients. Our study shows significant differences in pre-procedure GBS and APACHE scores that could be useful for future studies as a possible tool to aid in this decision-making process.

581 Factors Associated With In-Hospital Mortality in Acute Variceal Bleeding

INTRODUCTION: Risk stratification scoring systems for upper gastrointestinal bleeds, including the Glasgow Blatchford and Rockall scores, don't accurately predict outcomes in acute variceal bleeds (AVB). Similarly, the Child–Pugh score has poor prognostic value in AVB, likely due to its subjective parameters. The goal of this retrospective study was to identify factors that predict in-hospital mortality in patients presenting with AVB. METHODS: Data was obtained through the Medical Information Mart for Intensive Care III (MIMICIII), which is a large, freely available database comprised of patients admitted to Beth Israel Deaconess Medical Center. 236 patients were included in this study who were admitted to the ICU from 2001 to 2012 with an ICD code of cirrhosis and variceal bleed. After excluding 136 patients who did not undergo esophagogastroduodenoscopy (EGD) during admission, 100 patients remained and were analyzed. Factors such as transfusion requirements, number of EGDs, demographics, and laboratory values were collected using postgresql queries. Statistical analysis was done using R 3.5.1. RESULTS: 19 of the 100 patients died during admission (mortality rate of 19%). There were no significant differences between the deceased and survival groups with regards to age, sex, race and insurance type. There were significant differences between both groups regarding hemoglobin nadir (P = .0001), MELD-Na score (P &lt; .0001), MELD score (P &lt; .0001), INR (P &lt; .0001) and bilirubin (P = .005). Other factors analyzed included number of EGDs during admission, length of admission and blood product requirements. Compared with the survival group, the deceased group received a larger number of red blood cell transfusions (P = .02) and fresh frozen plasma (P = .007). The number of cryoprecipitate and platelet transfusions between both groups was not statistically significant (P = 0.14 and P = 0.07) respectively. The number of EGDs in the deceased group was higher, compared with the survival group (P = 0.008). CONCLUSION: We were able to identify several risk factors of mortality in variceal bleeders admitted to the intensive care unit. We found the MELD-Na score, INR as well as hemoglobin nadir to have the strongest association with mortality. Number of EGDs was also associated with increased mortality suggesting that in-hospital rebleeding is a strong predictor of outcome. The MELD score was as strongly associated with mortality as the MELD-Na score, contrary to previous studies of mortality in cirrhosis.

2898 Factors Influencing the Length of Hospital Stay in Patients With Non-Variceal Upper Gastrointestinal Bleeding

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is one of the most common GIemergencies, which frequently requires hospitalization. This condition accounts for 400,000 hospital admissions per year and costs more than $2 billion annually. The purpose of our study was to identify risk factors associated with prolonged hospital stay in non-variceal UGIB patients. METHODS: We conducted a retrospective study through an electronic medical record review of patients admitted at University Medical Center, Lubbock, Texas between January 2012 and December 2015. Patients older than 18 years with UGIB identified by the ICD-9 diagnosis code 578.9 (hemorrhage of gastrointestinal tract, unspecified) were enrolled into the study. Admissions were excluded if patients did not undergo EGD or if they had documented underlying cirrhosis. Statistical Package for Social Sciences (SPSS™) version 22 was used for statistical analysis. RESULTS: 143 patients met inclusion criteria. 83 were men (58.0%), 92 were Caucasian (64.3%), 33 were Hispanic (22.4%), and the mean age was 60.9 + 17.1 years. 33% of patients requiring FFP transfusion underwent endoscopic therapy. The mean length of stay (LOS) was significantly increased in patients requiring endoscopic therapy, FFP transfusion, and inthose who had underwent EGD after 24 hours. LOS was also significantly increased in patients that presented with acute kidney injury (AKI) or hypoalbuminemia. There was no correlation between prolonged hospital stay and Glasgow-Blatchford bleeding score, pre-endoscopic Rockall score, Rockall score, AIMS65 score, shock index score, PRBC transfusion, the use of NSAIDs, antiplatelet drugs, or anticoagulants. CONCLUSION: Our study demonstrates that delayed EGD (after 24 hours), endoscopic therapy, the need for FFP transfusion, and acute kidney injury are associated with prolonged hospital stay. Coagulopathy requiring FFP transfusion and AKI reflects the severity of UGIB. Urgent EGD and endoscopic intervention in these patients may decrease the LOS and improve outcomes.

624 Clinical Outcomes and Endoscopist's Perception of the Use of Hemospray for Gastrointestinal Bleeding: Outcomes From a U.S. Academic Tertiary Care Medical Center

INTRODUCTION: Endoscopic management of gastrointestinal bleeding (GIB) has evolved with current standard treatment modalities including epinephrine injection, hemostatic clips, and thermal therapies. A growing body of evidence has demonstrated clinical efficacy of Hemospray in GIB. Recently, the FDA approved Hemospray for treatment of non-variceal GIB in the USA. METHODS: Consecutive patients treated with Hemospray for management of GIB between 10/2018 and 1/2019 were included in this prospective case series. IRB approval was obtained. Patient demographics, clinical parameters, outcomes, and endoscopist's perceptions on the ease of use of Hemospray were collected. Hemospray was used by an attending as monotherapy, dual therapy with other standard endoscopic techniques, or as a rescue therapy. RESULTS: Hemospray was used during 12 cases for GIB. Immediate hemostasis was achieved in 10/12 (83.3%) cases with an average time to hemostasis of 3 minutes and an average of 6.8 sprays used per endoscopy. The mean Blatchford score was 13.7 and the mean Rockall score was 6.3. Hemospray failed in one case of failed band ligation and in one case as rescue therapy for a Forest Class 1a duodenal ulcer. Hemospray was used as a primary modality in 3/12 cases, adjunctive therapy in 3/12 cases, and as rescue therapy in 6/12 cases. Etiologies of GIB included Forest 1a ulcers (n = 3), Forest 1b ulcers (n = 3), MW tear (n = 2), GAVE (n = 1), APC induced rectal ulcer (n = 1), post polypectomy bleed (n = 1) and esophageal variceal bleed (n = 1). No adverse events occurred. Interventional radiology was utilized in 5/12 cases. The 3 day and 7 day rebleeding rates were 0% (0/12) and 25% (3/12) respectively. All-cause mortality was 8% (1/12) at both 7 and 30 days. Hemospray was technically easier to use compared to clips (6/12), epinephrine (4/12), and thermal modalities (5/12) according to the attending endoscopists (Table 1). Difficulties reported during administration of Hemospray included a clogged catheter (n = 2) which required use of a second catheter. CONCLUSION: Hemospray is effective in achieving immediate hemostasis in non-variceal GIB with no adverse events in our cohort. Low 3 and 7 day rebleeding rates were below the predicted rebleeding rates. Overall, a majority of attending endoscopists reported that Hemospray was similar or easier to use than conventional methods of hemostasis. Our study is limited by our small patient cohort, but represents real US experience with this recently FDA approved GIB treatment modality.

Validation of a Machine Learning Model That Outperforms Clinical Risk Scoring Systems for Upper Gastrointestinal Bleeding

Scoring systems are suboptimal for determining risk in patients with upper gastrointestinal bleeding (UGIB); these might be improved by a machine learning model. We used machine learning to develop a model to calculate the risk of hospital-based intervention or death in patients with UGIB and compared its performance with other scoring systems. We analyzed data collected from consecutive unselected patients with UGIB from medical centers in 4 countries (the United States, Scotland, England, and Denmark; n= 1958) from March 2014 through March 2015. We used the data to derive and internally validate a gradient-boosting machine learning model to identify patients who met a composite endpoint of hospital-based intervention (transfusion or hemostatic intervention) or death within 30 days. We compared the performance of the machine learning prediction model with validated pre-endoscopic clinical risk scoring systems (the Glasgow-Blatchford score [GBS], admission Rockall score, and AIMS65). We externally validated the machine learning model using data from 2 Asia-Pacific sites (Singapore and New Zealand; n= 399). Performance was measured by area under receiver operating characteristic curve (AUC) analysis. The machine learning model identified patients who met the composite endpoint with an AUC of 0.91 in the internal validation set; the clinical scoring systems identified patients who met the composite endpoint with AUC values of 0.88 for the GBS (P= .001), 0.73 for Rockall score (P < .001), and 0.78 for AIMS65 score (P < .001). In the external validation cohort, the machine learning model identified patients who met the composite endpoint with an AUC of 0.90, the GBS with an AUC of 0.87 (P= .004), the Rockall score with an AUC of 0.66 (P < .001), and the AIMS65 with an AUC of 0.64 (P < .001). At cutoff scores at which the machine learning model and GBS identified patients who met the composite endpoint with 100% sensitivity, the specificity values were 26% with the machine learning model versus 12% with GBS (P < .001). We developed a machine learning model that identifies patients with UGIB who met a composite endpoint of hospital-based intervention or death within 30 days with a greater AUC and higher levels of specificity, at 100% sensitivity, than validated clinical risk scoring systems. This model could increase identification of low-risk patients who can be safely discharged from the emergency department for outpatient management.

Outcomes from an international multicenter registry of patients with acute gastrointestinal bleeding undergoing endoscopic treatment with Hemospray.

Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314=53%) and Forrest Ib the most common bleed type in PUD (100/167=60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.

MAP(ASH): A new scoring system for the prediction of intervention and mortality in upper gastrointestinal bleeding.

Risk stratification for upper gastrointestinal bleeding (UGIB) is recommended. However, scoring system 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 and to validate it. The score was built from a prospective database of patients with UGIB and validated in an international database of 3012 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 curve (AUROC). Five hundred forty-seven patients were included in the development cohort. Impaired mental status, albumin<2.5g/dL, pulse>100, American Society of Anesthesiologists score>2, systolic blood pressure<90mmHg, and hemoglobin<10g/dL were included in the score. The model had a good predictive accuracy for intervention (AUROC=0.83; 95% confidence interval [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: 0.66-0.71) in the validation cohort, showing a poor performance, similar to other scores. For rebleeding, the MAP(ASH) (AUROC 0.73; 95% CI: 0.69-0.77) was similar to Glasgow Blatchford score (AUROC=0.72; 95% CI: 0.67-0.76) but superior to AIMS65 (AUROC=0.64; 95% CI: 0.59-0.68). 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.

Results of a Prospective Study to Evaluate the Impact of Point-of-Care Ultrasound in the Enhancement of Gastrointestinal Bleeding Risk Scores.

Gastrointestinal (GI) bleeding is a common illness seen in the emergency department. The prognosis varies from self-limited to potentially life threatening. Currently available GI bleeding risk scores have only a modest predictive value, limiting their wide implementation. The aim of this study was to assess the association and capability of point-of-care ultrasound (POCUS) used by emergency physicians to improve common GI bleeding scores for predicting complications and long-term outcomes of patients with GI bleeding, which to our knowledge have never been studied. Between August 2015 and April 2017, 203 hemodynamically stable patients with acute GI bleeding admitted to the emergency department were prospectively investigated. Using ultrasound, we measured the inferior vena cava diameter, cardiac output with surrogate markers such as the velocity time integral before and after the passive leg-raising test, and the presence of systolic obliteration of the left ventricle. The Rockall and Glasgow-Blatchford scores were calculated for patients with upper GI bleeding and the Velayos score for lower GI bleeding. The patients had follow-up during hospitalization and 30 days later to assess for early and late adverse events (AEs). Then we integrated the ultrasound findings of hypovolemia into the GI bleeding scores, assessing the capability to detect AEs. In our cohort, patients with upper GI bleeding who showed left ventricle kissing walls had a worse evolution, with a greater presence of late AEs (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.32-10.96; P = .01). Patients with lower GI bleeding who showed a collapse of the inferior vena cava (>50%) after passive leg raising had a greater presence of early AEs (OR, 3.6; 95% CI, 1.46-9.00; P = .004). The predictive performance of the Rockall score (receiver operating characteristic analysis: area under the curve [AUC], 77.6%; 95% CI, 66.3%-88.8%) increased with POCUS (AUC, 80.3%; 95% CI, 69.5%-91.1%); that of the Glasgow-Blatchford score (AUC, 72.5%; 95% CI, 59.9%-85.2%) increased with POCUS (AUC, 73.2%; 95% CI, 61.1%-85.4%); and that of Velayos score (AUC, 55.7%; 95% CI, 42.5%-69.0%) also increased with POCUS (AUC, 72.2%; 95% CI, 61.1%-83.3%). The use of POCUS in GI bleeding is feasible and enhances common GI bleeding risk scores, showing better predictive performance in detecting AEs.

Treatment of nonvariceal upper gastrointestinal bleeding: endoluminal-endovascular-surgical

Nonvariceal upper gastrointestinal bleeding (UGIB) has a high mortality. Hematemesis sometimes with melena are the leading clinical symptoms. Peptic ulcers and (erosive) inflammation are common, whereas Mallory-Weiss syndrome, neoplasms, angiodysplasia and diffuse UGIB are less common. A risk stratification is based on the medical history, clinical presentation and laboratory tests, which are considered in the Glasgow-Blatchford score; however, which treatment approach is optimal? After stabilisation under restricted transfusion indications, temporary stoppage of anticoagulants and optimized coagulation is beneficial and proton pump inhibitors (PPI) should be started. Prokinetics improve the endoscopic conditions in UGIB. The use of an endoscopic Doppler probe optimizes localization of the bleeding site. The use of the Forrest classification and Helicobacter pylori diagnostics are recommended. Mechanical (clips, injection), thermal (argon plasma coagulation, APC) and topical (hemostatic powder) endoscopic treatment procedures are available. Endoluminal hemostasis is very effective. Only clip application is suitable as monotherapy whereas all other endoscopic options should be combined. Angiography followed by transarterial embolization (TAE) can be used for therapy. Despite the high primary success rate, the risk of rebleeding is high. Surgery as the primary treatment is rarely necessary, although effective. Compared to TAE complications are higher, but there is no difference regarding mortality. Endoscopy remains the gold standard for the initial diagnostics and treatment of UGIB. In cases of rebleeding repeated endoscopy is recommended. With persistent UGIB an endovascular procedure should be evaluated. Surgery remains an important salvage option.

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

BackgroundRisk stratification for patients with nonvariceal upper gastrointestinal (NVUGI) bleeding is crucial for successful prognosis and treatment. Recently, the AIMS65 score has been used to predict mortality risk and rebleeding. The purpose of this study was to compare the performance of the AIMS65 score with the Glasgow-Blatchford score (GBS), Rockall score, and pre-endoscopic Rockall score in Korea.MethodsWe retrospectively studied 512 patients with NVUGI bleeding who were treated at a university hospital between 2013 and 2016. The AIMS65, GBS, Rockall score, and pre-endoscopic Rockall score were used to stratify patients based on their bleeding risk. The primary outcome was in-hospital mortality. The secondary outcomes were composite clinical outcomes of mortality, rebleeding, and intensive care unit (ICU) admission. Each scoring system was compared using the receiver-operating curve (ROC).ResultsA total of 17 patients (3.3%) died and rebleeding developed in 65 patients (12.7%). Eighty-six patients (16.8%) required ICU admission. The AIMS65 (area under the curve (AUC) 0.84, 95% confidence interval, 0.81–0.88)) seemed to be superior to the GBS (AUC 0.72, 0.68–0.76), the Rockall score (AUC 0.75, 0.71–0.79), or the pre-endoscopic Rockall score (AUC 0.74, 0.70–0.78) in predicting in-hospital mortality, but there was not a statistically significant difference between the groups (P = 0.07). The AUC value of the AIMS65 was not significantly different from the other scoring systems in prediction of rebleeding, endoscopic intervention, or ICU admission.ConclusionsThe AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting the mortality, rebleeding, or ICU admission. Because AIMS65 is a much easier, readily calculated scoring system compared to the others, we would recommend using the AIMS65 in daily practice.

Comparison of risk scores and shock index in hemodynamically stable patients presenting to the emergency department with nonvariceal upper gastrointestinal bleeding.

Risk assessment in nonvariceal upper gastrointestinal bleeding (UGIB) is not well validated and remains unclear in hemodynamically stable patients at emergency department admission. We compared the prognostic value of risk-scoring systems for predicting adverse outcomes in patients with nonvariceal UGIB and normotension. A single-center prospective observational study was carried out. Patients with consecutive nonvariceal UGIB, presenting with normotension (systolic blood pressure ≥90 mmHg) to the emergency department, were included. We compared the areas under the curves (AUC) of Glasgow Blatchford score (GBS), the pre-endoscopy Rockall score, AIMS65, the shock index, and the modified shock index with respect to adverse outcomes defined as embolization, surgery, ICU admission, rebleeding, and in-hospital mortality. In total, 1233 patients were included. Adverse outcomes occurred in 165 (13.4%) patients; in-hospital mortality was 1.2%. AUC of the GBS for adverse outcome was higher than that of the shock index, but not significantly different (0.647 vs. 0.569, P=0.23). AUC values of the modified shock index, AIMS65, and the pre-endoscopy Rockall score were 0.565, 0.593, and 0.533, respectively. The cut-off value of the GBS (≥8) was associated with 85% sensitivity and 35% specificity for predicting adverse outcome. Pre-existing risk scores have shown suboptimal predictive ability for adverse events in normotensive patients with nonvariceal UGIB. The GBS (≥8) might help to identify patients prone to adverse events; however, further studies with risk scores or new scores are needed because of the low accuracy of these scores.

LO25: Use of Glasgow Blatchford Score, time to endoscopy, and proton pump inhibitor use in patients presenting with upper gastrointestinal bleeding to the emergency department

Introduction: Upper gastrointestinal bleeding (UGIB) is a common presentation to the emergency department (ED). Early endoscopy within 24 hours has been shown to reduce re-bleeding rates and lower mortality. However, low-risk patients can often be managed through outpatient follow-up. The aim of this study was to compare the timing and appropriateness of endoscopy and proton pump inhibitor (PPI) use in a tertiary care ED setting for low- and high-risk patients determined using the Glasgow Blatchford Score (GBS). Methods: Retrospective chart review was conducted to examine the management of patients presenting with an UGIB in 2016 to the University of Alberta Hospital ED. TANDEM and Emergency Department Information System (EDIS) databases were used to identify patients using specific ICD-10 codes and the CEDIS presenting complaints of vomiting blood or blood in stool/melena. Patients with GBS 0-3 were categorized as low-risk and those with GBS &amp;gt; 3 were considered high-risk with appropriateness of and time to endoscopy, disposition of patient at 24 hours, and use of PPIs determined for each group. Results: A total of 400 patients were included. A total of 319/400 patients (80%) underwent esophagogastroduodenoscopy (EGD). EGD was performed within 24 hours in 37% of patients (29/78) with GBS 0 to 3 and in 77% (248/322) with GBS greater than 3. Of the remaining high-risk patients, 11% (36/322) underwent EGD after 24 hours and 12% (38/322) did not undergo EGD. The endoscopic diagnoses were peptic ulcer disease (PUD) in 41% of patients (130/319), esophagitis in 18% (56/319), and varices in 14% (45/319). PPIs (data available 375/400) were administered (mainly intravenously) to 93% (279/300) of high-risk and 79% (59/75) of low-risk patients. Data on patient disposition showed 60/322 (19%) high-risk patients were discharged from the ED within 24 hours and only 31/60 (52%) of these underwent EGD before discharge. Of 29 low-risk patients undergoing EGD within 24 hours, 9 (31%) were admitted, 17 (59%) were discharged from ED, and 3 (10%) were kept for observation in the ED greater than 24 hours. Of low-risk patients, 76% (59/78) were discharged from the ED within 24 hours. Conclusion: A majority of patients presenting with UGIB appropriately received endoscopy within 24 hours. 19% of high-risk patients were discharged from the ED. Earlier discharge for low-risk patients can be improved as only 76% of low-risk patients were discharged from the ED within 24 hours. As expected, PPI use was high in these patients.

Comparison of the Glasgow-Blatchford and Rockall Scores for prediction of nonvariceal upper gastrointestinal bleeding outcomes in Chinese patients.

The Glasgow-Blatchford scores (GBS) and Rockall scores (RS) are commonly used for stratifying patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Although predictive value of these scoring methods has been extensively validated, their clinical effectiveness remains unclear. The following study evaluated the GBS and RS scoring system with reference to bleeding, needs for further surgery, endoscopic intervention and death, in order to verify their effectiveness and accuracy in clinical application.Patients who presented with NVUGIH, or who were consequently diagnosed with the disease (by endoscopy examination) between January 1, 2008, and December 31, 2012 were enrolled in the study. GBS and RS scores were compared to predict bleeding, the needs for further surgery, endoscopic intervention, death by ROC curves and AUC value.Among 2977 patients, the pre-endoscopic RS and complete RS score (CRS) were superior to the GBS score (AUC: 0.842 vs 0.804 vs 0.622, respectively) for predicting the mortality risk in patients. The pre-endoscopic RS score predicting re-bleeding was significantly higher than the CRS and the GBS score (AUC: 0.658 vs 0.548 vs 0.528, respectively). In addition, the 3 scoring systems revealed to be poor predictors of surgical operation effectiveness (AUC: 0.589 vs 0.547 vs 0.504, respectively).Our data demonstrated that the GBS and RS scoring systems could be used to predict outcomes in patients with nonvariceal upper gastrointestinal bleeding.

MP15: Blood transfusion in upper gastrointestinal bleeding: evaluating physician practices in the emergency department

Introduction: Acute upper gastrointestinal bleeding (UGIB) is a common presentation to emergency departments (ED). Of these patients, 35-45% receive a blood transfusion. Guidelines for blood transfusion in UGIB have been well established, and recommend a hemoglobin (Hb) level below 70 g/L as the transfusion target in a stable patient. There is no consensus on a transfusion threshold for unstable UGIB. There is limited data regarding physician practices in the ED. The aim of our study is to determine the appropriateness, by expert consensus, of blood transfusions in UGIB in a tertiary care hospital ED. Methods: We retrospectively reviewed patients presenting with UGIB to the University of Alberta Hospital ED in 2016. These patients were then screened for blood transfusions. Data were obtained from the patient records. Chart derived data were verified with records obtained from the blood bank. For each patient, the history, vitals, Glasgow Blatchford Score (GBS), relevant labs, and record of blood transfusions were collected and organized into a case summary. Each patient summary was presented individually to a panel of three expert clinicians (2 Gastroenterology, 1 Emergency Medicine), who then decided on the appropriateness of each blood transfusion by consensus. Results: Blood transfusions (data available 395/400) were given to 51% (202/395) of patients presenting with UGIB. Of these, 86% (174/202) were judged to be appropriate. Of the 395 patients, 34% (135/395) had a Hb of &amp;lt;70 g/L. Of these, 93% (126/135) were transfused, and all of these were considered appropriate. 18% (70/395) had a Hb between 71-80. 74% (52/70) of these patients were given blood, and 79% (41/52) were considered appropriate. 13% (50/395) of the patients had a Hb between 81-90, with 28% (14/50) receiving a transfusion. Of these, 36% (5/14) were deemed to be appropriate. 35% (140/395) of patients had a Hb of &amp;gt;90. 7% (10/140) of these received blood. 20% (2/10) were considered appropriate. Conclusion: The panel of expert clinicians judged 86% of the blood transfusions to be appropriate. All transfusions under the recommended guideline of 70 g/L were considered appropriate. In addition, the majority of transfusions above a Hb of 70 g/L were considered appropriate, but 37% were not. Further studies evaluating the feasibility of current guideline recommendations in an ED setting are required. Educational interventions should be created to reduce inappropriate blood transfusions above a Hb 70 g/L.

Comparison of risk scores in upper gastrointestinal bleeding in western India: A prospective analysis.

To study the upper gastrointestinal bleeding (UGIB) characteristics and to validate the Rockall and Glasgow-Blatchford scores (GBS), Progetto Nazionale Emorragica Digestiva (PNED) and albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age > 65 (AIMS65) risk scores in predicting outcomes in patients with UGIB. Three hundred subjects with hematemesis and/or melena were prospectively enrolled and followed up for 30days. All patients were assessed by hematological investigations, imaging, and endoscopy and risk scores were calculated. The mean age was 43.5 ± 17.2years, and 207 (69%) were males. Hematemesis was the most common presentation (94%). Variceal bleeding was the most common etiology (47.7%). Thirty patients died (10%) and 50 had rebleeding (16.7%). On univariate analysis, serum albumin ≤ 2.7gm% (p = 0.008), Glasgow Coma scale ≤ 13.9 (p = 0.001), serum bilirubin > 3mg/dL (p = 0.004), serum bicarbonate ≤ 15.7mEq/L (p = 0.001), systolic blood pressure < 90mmHg (p = 0.004), and arterial pH ≤ 7.3 (p = 0.003) were found to be the predictors of mortality. No variable was found significant on multivariate analysis. All four scores were significant in predicting mortality, but Rockall (area under receiver operating characteristic [AUROC] 0.728) was better than others. Rebleeding was better predicted by PNED (modified) (AUROC 0.705). In predicting the need for transfusion and surgical or radiological intervention, GBS score > 0 was significant while score of < 2 classified patients into low risk for mortality with high negative predictive value. Our study showed that the variceal bleeding was the commonest cause of UGIB. Rockall score was more significant in predicting mortality while PNED for rebleeding. Low risk for mortality, need for blood transfusion, or interventions were accurately predicted by GBS.