Sending Upper GI Bleeds Home

February 23, 2017

Short Attention Span Summary

Wait…another Glasgow score?
The Glasgow Blatchford score was best among 4 others at predicting which patients were safe for outpatient management, with sensitivity 98.6%, specificity 34.6% for a score of  ≤1.  The others were not even close to helpful for ED use.  MDCalc to the rescue!

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A Glasgow Blatchford score of ≤1 accurately predicted which patients presenting with upper GI bleed could be safely managed as outpatients.

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Abstract

BMJ. 2017 Jan 4;356:i6432. doi: 10.1136/bmj.i6432.

Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.

Stanley AJ1, Laine L2, Dalton HR3, Ngu JH4, Schultz M5,6, Abazi R7, Zakko L2, Thornton S8, Wilkinson K3, Khor CJ4, Murray IA3, Laursen SB7; International Gastrointestinal Bleeding Consortium.

Author information:

1Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK adrian.stanley@ggc.scot.nhs.uk.

2Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, CT, USA.

3Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, UK.

4Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore.

5Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.

6Gastroenterology Unit, Southern District Health Board, Dunedin Hospital, Dunedin, New Zealand.

7Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark.

8Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK.

Abstract

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.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

PMCID: PMC5217768 Free PMC Article

PMID: 28053181 [PubMed – in process]