Glasgow-Blatchford Research Articles

The Effects of COVID-19 on Clinical Outcomes of Non-COVID-19 Patients Hospitalized for Upper Gastrointestinal Bleeding during the Pandemic.

This study aims to investigate the effects of COVID-19 on clinical outcomes of non-COVID-19 patients hospitalized for upper gastrointestinal bleeding (UGIB) during the pandemic. A retrospective review is conducted. We recruited patients with UGIB admitted during the pandemic’s first wave (April 2020 to June 2020), and the year before the pandemic. The outcomes between the two groups were compared using propensity score matching (PSM). In total, 60 patients (pandemic group) and 460 patients (prepandemic group) are included. Patients admitted during the pandemic (mean age of 67 ± 14 years) had a mean Glasgow–Blatchford score of 10.8 ± 3.9. They were older (p = 0.045) with more underlying malignancies (p = 0.028), had less history of NSAID use (p = 0.010), had a lower platelet count (p = 0.007), and had lower serum albumin levels (p = 0.047) compared to those admitted before the pandemic. Esophagogastroduodenoscopy (EGD) was performed less frequently during the pandemic (43.3% vs. 95.4%, p < 0.001). Furthermore, the procedure was less likely to be performed within 24 h after admission (p < 0.001). After PSM, admissions during the pandemic were significantly associated with decreased chances of receiving an endoscopy (adjusted odds Ratio (OR), 0.02; 95% CI, 0.003–0.06, p < 0.001) and longer hospital stay (adjusted OR, 2.17; 95% CI, 1.13–3.20, p < 0.001). Additionally, there was a slight increase in 30-day mortality without statistical significance (adjusted OR, 1.92; 95% CI, 0.71–5.19, p = 0.199) and a marginally higher rebleeding rate (adjusted OR, 1.34; 95% CI, 0.44–4.03, p = 0.605). During the pandemic, the number of EGDs performed in non-COVID-19 patients with UGIB decreased with a subsequent prolonged hospitalization and potentially increased 30-day mortality and rebleeding rate.

Prediction of in-hospital mortality after acute upper gastrointestinal bleeding: cross-validation of several risk scoring systems.

ObjectiveWe aimed to identify the clinical, biochemical, and endoscopic features associated with in-hospital mortality after acute upper gastrointestinal bleeding (AUGIB), focusing on cross-validation of the Glasgow-Blatchford score (GBS), full Rockall score (RS), and Cedars-Sinai Medical Center Predictive Index (CSMCPI) scoring systems.MethodsOur prospective cross-sectional study included 156 patients with AUGIB. Several statistical approaches were used to assess the predictive accuracy of the scoring systems.ResultsAll three scoring systems were able to accurately predict in-hospital mortality (area under the receiver operating characteristic curve [AUC] > 0.9); however, the multiple logistic model separated the presence of hemodynamic instability (state of shock) and the CSMCPI as the only significant predictive risk factors. In compliance with the overall results, the CSMCPI was consistently found to be superior to the other two systems (highest AUC, highest sensitivity and specificity, highest positive and negative predictive values, highest positive likelihood ratio, lowest negative likelihood ratio, and 1-unit increase in CSMCPI associated with 6.3 times higher odds of mortality), outperforming the GBS and full RS.ConclusionsWe suggest consideration of the CSMCPI as a readily available and reliable tool for accurately predicting in-hospital mortality after AUGIB, thus providing an essential backbone in clinical decision-making.

A27 COMPARATIVE EVALUATION OF THE ABC SCORE TO OTHER RISK STRATIFICATION SCALES IN MANAGING HIGH-RISK PATIENTS PRESENTING WITH ACUTE UPPER GASTROINTESTINAL BLEEDING

BackgroundThe ABC risk score identifies patients at high-risk of mortality in acute lower and upper gastro-intestinal bleeding (UGIB).AimsWe aimed to externally validate the ABC score, while comparing it to other prognostication scales when assessing UGIB patients at high-risk of negative outcomes prior to endoscopy.MethodsUGIB patients from a national Canadian registry (REASON) were studied, with mortality prediction as primary outcome. Secondary endpoints included prognostication of rebleeding, intensive care unit (ICU) admission, ICU and hospitalization lengths of stay (LOS), and a previously proposed composite outcome measure. Univariable and areas under the Receiver Operating Characteristic Curve (AUROC) analyses compared discriminatory abilities of the ABC score to the AIMS65, Glasgow Blatchford (GBS) and clinical Rockall Scores.ResultsThe REASON registry included 2020 patients (89.4% nonvariceal; mean age [± SD] 66.3±16.4 years; 38.4% female). Overall mortality, rebleeding, ICU admission, transfusion and composite score rates were 9.9%, 11.4%, 21.1%, 69.0%, and 67.3% respectively. ICU and hospitalization LOS were 5.4 ± 9.3 days and 9.1 ± 11.5 days, respectively. The ABC score displayed superior 30-day mortality prediction (0.78 (0.73; 0.83)) compared to GBS (0.69 (0.63; 0.75) or clinical Rockall (0.64 (0.58; 0.70) but not AIMS65 (0.73 (0.67; 0.79)). Although most scales significantly prognosticated secondary outcomes in univariable analysis except for ICU LOS, discriminatory abilities on AUROC analyses were poor.ConclusionsABC and AIMS65 display similar good prediction of mortality. Clinical usefulness in prognosticating secondary outcomes was modest for all scales, limiting their adoptions when informing early management of high-risk UGIB patients.Funding AgenciesInternational Scientific Partnership Program ISPP at King Saud University for funding this research work through ISPP-21–156

Over-the-Scope Clip Applications as First-Line Therapy in the Treatment of Upper Non-variceal Gastrointestinal Bleeding, Perforations, and Fistulas.

BackgroundThe over-the-scope clip (OTSC) is an innovative device and has been successfully used in endoscopic treatment, however, there is a lack of clinical data from China. The aim of this study is to investigate the OTSC applications in the treatment of upper non-variceal gastrointestinal bleeding (UNVGIB), perforations, and fistulas in China.MethodsIn total, 80 patients were treated with one OTSC respectively as first-line therapy in our endoscopy center between January 2016 and November 2020. Among them, 41 patients had UNVGIB, 34 patients had perforations, and five patients had fistulas. The technical and clinical success rates were used to assess the efficacy of OTSC on the above diseases. In addition, we compared the hemostatic efficacy of OTSC with the standard endoscopic therapy in ulcer bleeding and Dieulafoy's lesion by propensity score matching analysis.ResultsIn general, the OTSCs were applied successfully in all patients and achieved 100% (80/80) technical success. The clinical success of all patients was 91.3% (73/80). Among 41 patients with UNVGIB, the clinical success was 85.4% (35/41); 6 patients presented with recurrence. For patients of Dieulafoy's lesion and under antithrombotic therapy, we found that OTSC treatment had both efficient and reliable hemostasis effects. In addition, according to the characteristics of ulcers, site of bleeding lesion, and Blatchford score, all patients received similar and reliable clinical success rates. After propensity score matching, we found that OTSC treatment had low rebleeding rates when compared with standard endoscopic therapy in both Dieulafoy's lesion (15.0 vs 30.0%) and ulcer bleeding (17.6 vs 29.4%). Among 34 patients with perforations, the clinical success was 100% (34/34). Among five patients with fistulas, only one patient failed in maintaining the OTSC before esophageal fistula healing, and the clip achieved an overall clinical success of 80% (4/5).ConclusionThe OTSC represents a safe and effective endoscopic therapy for UNVGIB, perforations, and fistulas as first-line treatment, especially for Dieulafoy's lesion or patients under antithrombotic therapy for UNVGIB, etc. However, OTSC application in these specific lesions or patients lacks adequate evidence as first-line treatment. Therefore, further larger sample and multi-center clinical trials are required to improve its indications in clinical treatment.

Establishment of a risk prediction model for acute upper gastrointestinal rebleeding in elderly patients

To establish a prediction model of acute upper gastrointestinal rebleeding (AUGIRB) for elderly patients by combining and applying multiple indicators. A retrospective observational study was conducted. The clinical data of 161 elderly patients (age ≥ 65 years old) who suffered from acute upper gastrointestinal bleeding (AUGIB) and who were hospitalized in Shanghai General Hospital from July 2018 to December 2020 were recorded. The patients were divided into the rebleeding group (31 cases) and the non-rebleeding group (130 cases) according to whether gastrointestinal rebleeding occurred. Univariate analysis was adopted to screen AUGIRB-related risk factors and Logistic regression analysis was used to screen independent predictors of AUGIRB so that a predictive model was constructed. Based on the area under the curve (AUC) of the receiver operator characteristic curve (ROC curve), the predictive ability of the prediction model for AUGIRB was evaluated, the optimal cut-off value was determined, and the odds ratio (OR) and its 95% confidence interval (95%CI) were calculated. Bootstrap resampling technology was used to validate the predictive ability of the model. Univariate Logistic analysis showed that oral anticoagulant drugs, oral antiplatelet drugs, albumin (ALB), platelet count (PLT), Glasgow-Blatchford bleeding score (GBS), D-dimer, fibrinogen (FIB), and international normalized ratio (INR) all had a significant effect on the occurrence of AUGIRB among elderly patients. Multivariate Logistic regression analysis showed that the oral antiplatelet drugs (OR = 11.150, 95%CI was 1.888-65.852, P < 0.05) and GBS score (OR = 2.503, 95%CI was 1.523-4.114, P < 0.05) were the independent risk factors of AUGIRB among elderly patients, while the ALB (OR = 0.764, 95%CI was 0.626-0.932, P < 0.05) and FIB (OR = 0.065, 95%CI was 0.011-0.370, P < 0.05) were the protective factors of AUGIRB among elderly patients. The AUC of the above four indexes joint prediction model was 0.979. The verification results of the model showed that the consistency index (C-index) of the model was 0.986. The prediction model fitted in this research has a high prediction accuracy and it also has a certain reference value for the judgment of elderly patients who suffer from AUGIRB.

Evaluation of Six Preendoscopy Scoring Systems to Predict Outcomes for Older Adults with Upper Gastrointestinal Bleeding.

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.

Comparison of Pre-Endoscopic C-WATCH Score with Established Risk Assessment Tools in Patients with Upper Gastrointestinal Bleeding

Introduction: Use of risk scores for early assessment of patients with upper gastrointestinal bleeding (UGIB) is recommended by various guidelines. We compared Cologne-WATCH (C-WATCH) score with Glasgow-Blatchford score (GBS), Rockall score (RS), and pre-endoscopic RS (p-RS). Methods: Patients with UGIB between January and December 2017 were retrospectively analyzed for 30-day mortality and composite endpoints risk of complications and need for intervention using areas under the receiver-operating characteristics curve (AUROC). Subgroup analysis was conducted for patients with UGIB on admission and in-hospital UGIB. Results: A total of 252 patients were identified (67.5% men, mean age 63.8 ± 14.9 years). In-hospital UGIB occurred in 49.6%. AUROCs for 30-day mortality, risk of complications, and need for intervention (not applicable to RS) were 0.684 (95% confidence interval [CI]: 0.606–0.763), 0.665 (95% CI: 0.594–0.735), and 0.694 (95% CI: 0.612–0.775) for C-WATCH score, 0.724 (95% CI: 0.653–0.796) and 0.751 (95% CI: 0.687–0.815) for RS, 0.652 (95% CI: 0.57–0.735), 0.653 (95% CI: 0.579–0.727), and 0.673 (95% CI: 0.602–0.745) for p-RS and 0.652 (95% CI: 0.572–0.732), 0.663 (95% CI: 0.592–0.734), and 0.752 (95% CI: 0.683–0.821) for GBS. RS outperformed pre-endoscopic scores in predicting risk of complications, while there were no significant differences between pre-endoscopic scores except GBS outperforming p-RS in predicting need for intervention. The subgroup analysis obtained similar results. Positive predictive values for patients with estimated low risk for all three endpoints (C-WATCH score ≤1, RS ≤2, p-RS <1, and GBS ≤1) were 89%, 69%, 78%, and 92%. Conclusion: C-WATCH score performed similar to the established pre-endoscopic risk scores in patients with UGIB regarding relevant patient-related endpoints with no significant differences between both the subgroups.

Risk Stratification in Cancer Patients with Acute Upper Gastrointestinal Bleeding: Comparison of Glasgow-Blatchford, Rockall and AIMS65, and Development of a New Scoring System.

Background/AimsFew studies have measured the accuracy of prognostic scores for upper gastrointestinal bleeding (UGIB) among cancer patients. Thereby, we compared the prognostic scores for predicting major outcomes in cancer patients with UGIB. Secondarily, we developed a new model to detect patients who might require hemostatic care. MethodsA prospective research was performed in a tertiary hospital by enrolling cancer patients admitted with UGIB. Clinical and endoscopic findings were obtained through a prospective database. Multiple logistic regression analysis was performed to gauge the power of each score. ResultsFrom April 2015 to May 2016, 243 patients met the inclusion criteria. The AIMS65 (area under the curve [AUC] 0.85) best predicted intensive care unit admission, while the Glasgow-Blatchford score best predicted blood transfusion (AUC 0.82) and the low-risk group (AUC 0.92). All scores failed to predict hemostatic therapy and rebleeding. The new score was superior (AUC 0.74) in predicting hemostatic therapy. The AIMS65 (AUC 0.84) best predicted in-hospital mortality. ConclusionsThe scoring systems for prognostication were validated in the group of cancer patients with UGIB. A new score was developed to predict hemostatic therapy. Following this result, future prospective research should be performed to validate the new score.

Damage control strategy in surgical treatment of patients with severe gastroduodenal bleeding

To objectify patient condition and improve treatment outcomes in patients with benign severe gastroduodenal bleeding. We analyzed the immediate results of staged surgical treatment of patients with benign severe gastroduodenal bleeding according to the accepted concept of «Damage Control Surgery». The Rockall risk scoring system and the Glasgow-Blatchford score (GBS) were used. We preferred two-stage intervention in patients with Rockall score ≥5 and Glasgow-Blatchford score ≥11. Staged approach according to the concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding ensures positive results by minimizing surgical trauma and perioperative bleeding, early stabilization of hemostasis and subsequent successful restoration of digestive function. The concept of «Damage Control Surgery» in patients with benign severe gastroduodenal bleeding can reduce mortality and incidence of postoperative complications.

Comparison of Risk Scores for Predicting In-hospital Mortality among Patients Presenting with Acute Upper Gastrointestinal Bleed: A Retrospective Study from a Tertiary Care Centre, Chennai, India

Introduction: Acute Gastrointestinal (GI) bleeding results in 5% of admissions to an Emergency Department/Room (ER), with mortality rates ranging from 2 to 15%. To predict the outcomes of these patients, multiple scoring systems have been developed. Early detection of individuals at high risk of mortality could allow for more targeted care including specialised care and early therapies, which could improve outcomes. Glasgow Blatchford Score (GBS), Pre-endoscopy and Rockall score, AIMS65 (Albumin, International Normalized Ratio , Altered Mental status, Systolic blood pressure, Age &gt;65 years), and the recently proposed ABC (Age, Blood parameters, Co-morbidities) score are some of the risk scores that have been devised for risk stratification. According to recent studies, the discriminative performance of these current scores for predicting patient mortality is relatively weak. Aim: To compare the risk scores for predicting in-hospital mortality among patients presenting with acute upper gastrointestinal bleed. Materials and Methods: A retrospective observational study was conducted on patients referred to the Emergency Department/ Room of a tertiary care hospital, Chennai, Tamil Nadu, India, with an acute upper GI bleed (characterised as haematemesis, coffee-colored vomitus, or melena) from July 2018 to June 2020. Data collected from medical records included detailed clinical history, vitals, relevant blood investigations, patient requirement for blood transfusion, endoscopic therapy, surgical procedures, radiological intervention along with mortality. The data was analysed using appropriate biostatistics Statistical Package for Social Sciences (SPSS) version 26.0, paired t-tests were performed to calculate the p-values and a p-value &lt;0.05 was considered significant. Results: The study comprised a total of 112 patients. The study population's median age was 53 years, with a male predominance (83.92%). The presenting complaint was haematemesis in 76.79% of the patients and melena in 23.21%. Ischaemic heart disease (10.71%), cirrhosis (25%), and malignancy (2.68%) were the most common co-morbidities. American Society of Anesthesiologists (ASA) grade III accounted for 45.3%, ASA grade II for 25.6%, and ASA grade I for 28.6%. Following endoscopy, the source of upper gastrointestinal bleed was noted to be variceal in 39.3% of cases, gastric/duodenal ulcers in 25.9%, erosive changes in 16.1%, and tumour bleed in 2.7% of cases. Endoscopic mode of treatment was performed in 44.6% and 0.9% required surgical intervention. Mortality occurred in 11 patients (9.82%). Based on Area Under the Receiver Operating Characteristics (AUROC), AIMS65 excelled over other scores in predicting mortality {AIIMS-65 (AUROC; 95% CI) 0.908 (0.85 to 0.97); p-value &lt;0.001, GlasgowBlatchford score (GBS) 0.818 (0.71-0.93) p-value &lt;0.001, PreRockall 0.756 (0.63-0.89) p-value &lt;0.001, Rockall 0.894 (0.82- 0.97) p-value &lt;0.001, ABC 0.778 (0.65-0.90) p-value=0.003}. Conclusion: Systolic blood pressure, heart rate, blood urea, International Normalized Ratio (INR), and albumin showed significant association with mortality. Risk scores encompassing albumin have better mortality prediction. AIMS65 outperformed other risk scores in predicting mortality, even outperforming the postendoscopy rockall score. Hence, AIMS65 can be used to stratify patients in the emergency room early to reduce mortality

Comparison of risk scoring systems for critical care patients with upper gastrointestinal bleeding: predicting mortality and length of stay.

Upper gastrointestinal bleeding (UGIB) is a common reason for intensive care admission. While there exist a number of UGIB scoring systems which are used to predict mortality, there are limited studies assessing the discriminative value of these scores in intensive care unit (ICU) patients. The purpose of this study was to analyse five different UGIB scoring systems in predicting ICU mortality and length of stay and compare them to two commonly used ICU mortality scoring systems. We retrospectively identified all patients requiring ICU admission for UGIB to St James's Hospital over an 18-month period. We calculated their AIM65, Glasgow- Blatchford score, pre- and post-Rockall score, ABC, APACHE II and SOFA scores. We used area under the receiver operating characteristic curve (AUROC) to compare the predictive values of these six scoring systems for ICU and hospital mortality as well as ICU length of stay greater than seven days. APACHE II showed excellent discriminative value in predicting mortality in ICU patients (AUROC: 0.87; CI: 0.75-0.99) while the SOFA score showed good discriminative value (AUROC: 0.71; CI: 0.50-0.93). None of the UGIB scoring systems predicted mortality in these patients. All scoring systems showed poor discriminative value in predicting ICU length of stay. We were not able to validate any of these UGIB scoring systems for mortality or length of stay prediction in ICU patients. This study supports the validity of APACHE II as a clinical tool for predicting mortality in ICU patients with UGIB.

COVID-19 Pandemisinde Acil Servise Başvuran Üst Gastrointestinal Kanamalı Hastaların Sayısı Azaldı mı?: Tek Merkez Deneyimi

Objective: In the period of the coronavirus disease-19 (COVID-19) pandemic, upper gastrointestinal endoscopy was either postponed or canceled, except for emergencies, due to the high risk of transmission. Our study aimed to evaluate the effect of the COVID-19 pandemic on patients with upper gastrointestinal bleeding presenting to the emergency department and to compare it with the data before the pandemic. Material and Methods: In this single-center, retrospective study, patients were divided into 2 groups: pre-COVID-19 (pre-C) (March 2019-March 2020) and post-COVID-19 (post-C) (March 2020- March 2021). Patients who presented to the emergency department with upper gastrointestinal bleeding during these periods and underwent endoscopic examination were included in the study. Results: Endoscopy for upper gastrointestinal bleeding was urgently performed in 125 patients in the pre-C period and in 89 (29% decrease) patients in the post- C period. The Glasgow-Blatchford Score was higher in the pre-C period (p=0.02). Peptic ulcers were the most common cause of bleeding in both groups. High-risk peptic ulcer (forrest 1a/1b/2a/2b), and malignancy were observed more frequently in the post-C period (p=0.003, p=0.04; respectively). Endoscopic combined treatment rate was higher in the post-C group (p<0.001). Re-bleeding ratios were similar for both the groups (p=0.48). Conclusion: During the post-C period, the number of upper gastrointestinal bleeding cases admitted to the emergency department decreased significantly. However, the rate of high-risk peptic ulcer and malignancy in the etiology of upper gastrointestinal bleeding increased in the post-C period.

Glasgow-Blatchford versus Rockall Scoring Systems for Predicting Outcomes of Patients with Upper Gastrointestinal Bleeding

Acute upper gastrointestinal bleeding is a common emergency and potentially fatal health problem that associated with high mortality and morbidity. Gastrointestinal endoscopy can identify the cause of bleeding and remains the cornerstone of diagnosis and therapy in gastrointestinal bleeding. Aim: The aim of this study is to compare between the Glasgow-Blatchford score and Rockall score in predicting the clinical outcomes of patients with upper gastrointestinal bleeding during hospitalization. Study design: Retrospective observational cohort research design was used to conduct this study. Setting: This study was conducted in the medicine department 1 and 2 at medical hospital affiliated to Ain Shams University Hospitals, Cairo, Egypt. Subjects: Purposive sample of 95 adult patients who were admitted to the previously mentioned settings from October 2020 to March 2021 were included in the study. Data collection tools: (1) Patients' Clinical Outcomes Assessment Questionnaire, (2) The Glasgow-Blatchford Scale, (3) The pre-endoscopic Rockall Score. Results: Regarding re-bleeding prediction, (AUC for GBS= 0.573, RS 0.534). As for mortality prediction, GBS was similar to RS (AUC 0.754 and 0.744 respectively). Regarding need for blood transfusion (AUC for GBS= 0.868 and 0.691 for RS), prediction of need for endoscopic intervention revealed that GBS was superior to RS (AUC 0.785 and 0.675 respectively). In terms of length of hospital stay, GBS and RS were quietly equivalent (AUC 0.654 and 0.657 respectively). Conclusion: The study concluded that there was no statistically significant difference between the Glasgow Blatchford Score and pre-endoscopic Rockall Score in predicting accuracy of clinical outcomes for patients with upper gastrointestinal bleeding. Recommendations: It is recommended that the pre-endoscopic Glasgow Blatchford Score and Rockall Score are considered useful tools that can be safely used to predict clinical outcomes of patients with gastrointestinal bleeding.

The effectiveness of Glasgow-Blatchford Score in early risk assessment of hemodialysis patients.

In the emergency departments (ED), the incidence of admission is increasing gradually due to gastrointestinal system (GIS) complications of hemodialysis (HD) patients. With this increasing number of patients, there are many classification systems developed in early risk assessment before endoscopy. In this study, we aimed to evaluate the Glasgow-Blatchford Score's (GBS) effectiveness in HD patients with suspected GIS hemorrhage in the ED.The files of 169 patients who received HD treatment were retrospectively reviewed. 64 patients who were examined and treated for reasons other than GIS hemorrhage in the ED were excluded, and the files of a total of 105 were analyzed retrospectively. The demographic characteristics and laboratory values of the patients were recorded from the patient files. When the patients were evaluated according to GBS parameters, a significant difference was found between the two groups in terms of pulse pressure, systolic blood pressure, hemoglobin value, melena, and accompanying comorbid diseases (p < 0.05). Of the 16 patients who presented to the ED due to syncope, 2 were in the GIS hemorrhage (+) group, and 14 patients were in the control group. In this study, we aimed to show that the increase in the number of admissions in the ED due to complications secondary to HD treatment and the accompanying serious changes in laboratory parameters may cause misleading results in patients with suspected GIS hemorrhage, and it is necessary to plan comprehensive and multi-center studies on new alternative scoring systems to GBS in specific patient groups such as HD patients.

Management of acute upper gastrointestinal bleeding: Urgent versus early endoscopy.

For decades, timing of endoscopy has been a controversy in the management of patients who present with upper gastrointestinal bleeding (GIB). The advent of endoscopic hemostatic therapy led to reduced further bleeding, surgery and mortality. Observational studies suggest that in patients at low risk of further bleeding, early endoscopy establishes diagnosis and allows their prompt hospital discharge. In the high-risk patients, early endoscopy with hemostatic treatment can stop bleeding and improve outcomes. Sample size in early randomized controlled trials (RCTs) was small. They included low-risk patients or patients with poorly defined risks. We designed a RCT to test the hypothesis that in high-risk patients (defined by those with an admission Glasgow Blatchford Score of 12 or greater), endoscopy within 6 h of gastrointestinal consultation, when compared to the standard of care i.e. endoscopy within 24 h, would improve outcomes.The primary outcomes, all-cause mortality at 30 days did not differ between groups; 23 of 258 (8.9%) in the urgent-endoscopy group and 17 of 258 (6.6%) in the early-endoscopy group died (difference 2.3%, 95% confidence interval -2.3 to 6.9%). Further bleeding was similar (10.9% vs. 7.8%) between groups. A higher rate in endoscopic hemostatic treatment was observed in the urgent-endoscopy group (60.1% vs. 48.4%). In patients with peptic ulcers, active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) and in 76 of 159 (47.8%) in the respective group. In the majority of patients with GIB, endoscopy earlier than 24 h is not indicated.

S670 The Glasgow Blatchford Score (GBS) Is Associated With the Need for Endoscopic Intervention and Blood Transfusion in Patients With Upper Gastrointestinal Bleeding

Introduction: At an incidence of 48-160/100,000 individuals, upper gastrointestinal bleeding (UGIB) is the most common gastroenterological emergency, in the United States, accounting for 300,000 hospitalizations and $3.3 billion in healthcare spending, yearly. GBS, a quick tool that uses non-endoscopic criteria for clinical stratification of UGIB, allows for early diagnosis and outcome prediction, including need for intervention. The goals of this study are to determine the GBS scores of patients who underwent esophagogastroduodenoscopy (EGD) and if the need for endoscopic intervention and blood transfusion are related to GBS in patients with UGIB. Methods: This is a cross-sectional retrospective study that included patients ≥18 years, who were admitted for UGIB to McLaren Macomb Medical Center (MMMC) and underwent EGD between July, 2018 and July, 2020. The patient encounters of interest were identified using international classification of disease (ICD 10) procedure codes for EGD. Demographics and the need for intervention or blood transfusion, variables comprising GBS, and other explanatory variables were extracted. Frequencies, percentages, and student T-test were used when appropriate. A stepwise regression analysis was performed to determine predictors of GBS. SPSS version 25 was used to analyze the data. Statistical significance was set at a p< 0.05. Results: A total of 130 observations were included in this analysis. No patients were noted to have a GBS ≤2, indicating successful evidence-based allocation of resources, as a GBS ≤1 to ≤2 is associated with safe outpatient management. We found that GBS was statistically significantly related to the need for intervention, blood transfusion, and age group. Additionally, those who needed intervention and blood transfusion scored 1.493 [mean GBS 13.13±3.28 versus 10.62±3.83 (P=0.004)] and 3.486 [mean GBS 13.12±2.68 versus 9.16±3.83 (P=0.000)] higher, respectively. Also, those who are ≤60 years-old scored 1.77 [mean GBS 9.38±4.11 versus 11.7±3.57 (P=0.002)] less. Conclusion: Our study is among a few that investigated and found a mean GBS associated with need for intervention and blood transfusion. Even at higher GBS, we may be able to further stratify patients’ risk and predict need for intervention and blood transfusion. Further research is needed to investigate this nuance.Table 1.: Study Methodology Quality Assessment on Newcastle-Ottawa Scale.

S661 Glasgow Blatchford Score for Triage of Gastrointestinal Bleeding in a Metropolitan ED

Introduction: Gastrointestinal bleeding (GIB) is a common cause of hospitalization with a significant economic impact. Appropriate utilization of endoscopic resources could decrease costs. There are numerous risk stratifying tools that can aid in disposition for patients with upper GIB. The Glasgow Blatchford Score (GBS) is a validated scoring system that identifies patients who will require inpatient management. We aim to retrospectively assess the role of GBS in the triage of upper GIB at a metropolitan emergency department (ED). Methods: We performed a retrospective chart review examining management of suspected GI bleed over one year in an urban medical center. Patients with suspected GIB based on ICD-10 were recruited to the study. Clinical characteristics were collected and GBS was calculated at admission. Disposition and need for intervention were collected with primary endpoints of use of endoscopy, embolization, or surgery. Results: We examined 105 patients, 60 (57.1%) were male and 45 (42.9%) were female. Of these patients, 67 (63.8%) patients were admitted to general medicine floors, 8 (7.6%) patients required ICU admission, and 30 (28.6%) patients were admitted to the medicine telemetry/ICU-step down unit. Fifty-eight patients (56.3%) received blood transfusions. Seventy-four percent of the patients presented with melena. Ninety-two percent of the patients underwent endoscopy after admission; however, only 20 patients required hemostatic treatment. Five patients were admitted with GBS of 1 or less, three underwent endoscopy without hemostatic therapy while the other two did not. The length of stay for admitted patients ranged from 1 day to 20 days. None of the charts reviewed included patients who underwent a surgical procedure. Fifteen (14.3%) patients had hepatic disease and 42 (40.4%) patients had cardiac disease. Eleven patients (10.5%) were readmitted after intervention and discharge; 94 (89.5%) patients were not readmitted after discharge. Conclusion: GBS allows simple triage of patients and reliably identifies those requiring inpatient management. Most patients underwent an endoscopy and only one-fifth required endoscopic hemostatic therapy. Those admitted with GBS of 1 or less, did not require endoscopic hemostatic therapy and further validates its utility to decrease unnecessary healthcare utilization. While it is emerging as a promising tool, clinician awareness and acceptance deserve recognition.

COMPARISON OF NON-ENDOSCOPIC SCORES FOR THE PREDICTION OF OUTCOMES IN PATIENTS OF UPPER GASTROINTESTINAL BLEED IN AN EMERGENCY OF A TERTIARY CARE REFERRAL HOSPITAL: A PROSPECTIVE COHORT STUDY.

Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.

S665 AIMS65 Score Predicts ICU Admission and Prolonged Length of Stay in Patients with Non-Variceal Upper Gastrointestinal Bleed on Dual Anti-Platelet Therapy

Introduction: ICU admission and prolonged length-of-stay (PLOS) is associated with increased resources need, healthcare cost and poorer outcomes for the patients. There is a paucity of predictive parameters to assess ICU admission and PLOS in non-variceal upper gastrointestinal bleeding (NVUGIB) patients taking dual antiplatelet therapy (DAPT). Methods: A retrospective chart review was done for all consecutive adult patients between 2015-2020 who presented with NVUGIB on DAPT (aspirin, clopidogrel; aspirin, ticagrelor; aspirin, prasugrel) to Allegheny Health Network and underwent endoscopy. Patients who had DAPT held as per ASGE guidelines were excluded from the study. An exploratory analysis was done to assess predictive ability of four GI bleeding risk scores [Glasgow Blatchford score (GBS), AIMS65, qSOFA and Rockall] to predict ICU admission and prolonged Length of Stay (PLOS). PLOS was defined as ≥5 days based on institutional experience in NVUGIB patients. Logistic regression was used to identify variables independently associated with ICU admission and PLOS and estimate their odds ratios and 95% CI. P value < 0.05 was considered as the level of significance. Results: 75 patients (M: F 53:22), mean age±S.D. 70.1±11.2 years, meeting inclusion criteria were included for final analysis. 22/75 (29%) patients had ICU admission. AIMS65 and qSOFA predicted ICU admission (Table 1A). Sensitivity, specificity, PPV, NPV and accuracy of AIMS65 and qSOFA for ICU admission has been shown in Table 1B. Median LOS was 6; IQR=8 (range 2-43) days. 47/75 (63%) patients had PLOS. GBS and AIMS65 predicted PLOS (Table 1A). Sensitivity, specificity, PPV, NPV and accuracy of GBS and AIMS65 for PLOS has been shown in Table 1B. Conclusion: AIMS65 is a simple scoring system, originally developed to predict mortality in patients with UGIB. This study provides preliminary evidence for the use of AIMS65 to predict longer LOS and ICU admission in patients with NVUGIB taking DAPT which may help resource allocation and prognostication. However, the study needs to be validated in a larger study population before it can be used in clinical practice.Table 1.: Comparison of Inpatient Outcomes of NVUGIB Patients.

Risk stratification with video capsule endoscopy leads to fewer hospital admissions in emergency department patients with low-risk to moderate-risk upper gastrointestinal bleed: A multicenter clinical trial.

ObjectiveIn US emergency departments (EDs), the physician has limited ability to evaluate for common and serious conditions of the gastrointestinal (GI) mucosa such as a bleeding peptic ulcer. Although many bleeding lesions are self‐limited, the majority of these patients require emergency hospitalization for upper endoscopy (EGD). We conducted a clinical trial to determine if ED risk stratification with video capsule endoscopy (VCE) reduces hospitalization rates for low‐risk to moderate‐risk patients with suspected upper GI bleeding.MethodsWe conducted a randomized controlled trial at 3 urban academic EDs. Inclusion criteria included signs of upper GI bleeding and a Glasgow Blatchford score <6. Patients were randomly assigned to 1 of the following 2 treatment arms: (1) an experimental arm that included VCE risk stratification and brief ED observation versus (2) a standard care arm that included admission for inpatient EGD. The primary outcome was hospital admission. Patients were followed for 7 and 30 days to assess for rebleeding events and revisits to the hospital.ResultsThe trial was terminated early as a result of low accrual. The trial was also terminated early because of a need to repurpose all staff to respond to the coronavirus disease 2019 pandemic. A total of 24 patients were enrolled in the study. In the experimental group, 2/11 (18.2%) patients were admitted to the hospital, and in the standard of care group, 10/13 (76.9%) patients were admitted to the hospital (P = 0.012). There was no difference in safety on day 7 and day 30 after the index ED visit.ConclusionsVCE is a potential strategy to decrease admissions for upper GI bleeding, though further study with a larger cohort is required before this approach can be recommended.