ArticlesOutpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation
Introduction
Upper-gastrointestinal haemorrhage is a frequent cause of acute admission to hospital, with an incidence in the UK of 103–172 per 100 000 adults per year.1, 2 The severity of the disorder varies from mild coffee-ground vomiting to exsanguination. However, most patients do not need endoscopic treatment, surgery, or blood transfusion and do not rebleed or die.1, 3 Individuals presenting with upper-gastrointestinal haemorrhage have traditionally been admitted for a period of observation, with or without endoscopy.
Admission and endoscopy on the next available list is recommended in the 2002 British Society of Gastroenterology guideline for people with mild-to-moderate upper-gastrointestinal haemorrhage,4 although very low-risk young people with a minor bleed and without haemodynamic compromise can be discharged without endoscopy. We know from our experience and in other hospitals that some clinicians use their judgment informally to avoid admittance of individuals they view as being at low risk. However, objective identification of such patients with clinical confidence is sometimes difficult.
Several risk assessment and scoring systems for upper-gastrointestinal haemorrhage have been developed in an attempt to stratify risk for poor outcome.2, 5, 6, 7, 8, 9, 10, 11, 12 However, most, including the widely used Rockall score,3 include endoscopic findings; therefore, many patients are kept in hospital until this procedure is undertaken. Although many hospitals in the UK have an emergency endoscopy rota, this facility is usually for individuals with major haemorrhage only, with others waiting until the next day or longer for a semi-elective procedure. Furthermore, non-emergency endoscopy is unavailable at weekends in many hospitals. An abbreviated pre-endoscopy admission Rockall score, which excludes endoscopic findings, is sometimes used, but this measure has not been fully validated.3
In a previous report from Glasgow, UK, logistic regression was used to derive the Glasgow-Blatchford bleeding score (GBS; table 1), which is used to predict either a patient's need for hospital-based intervention (blood transfusion, endoscopic treatment, or surgery) or death.5 The score was derived from data of 1748 people presenting with upper-gastrointestinal haemorrhage but was only validated locally in a few affected individuals presenting to three Glasgow hospitals, not including the Glasgow Royal Infirmary. It is based on simple variables from a patient's history, examination, and laboratory results. A GBS score of 0 fulfils low-risk criteria (panel), which seems to identify people at very low (0·5%) risk of needing intervention, as described above.5
The aim of our study was to assess and externally validate the GBS in four large general hospitals in Scotland and England. We also prospectively looked at the effect of the introduction of GBS low-risk criteria on accident and emergency (A&E) departments, with the intention to avoid admission for patients assessed as low risk.
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Data collection
We divided our study into two phases. In phase one, we obtained data prospectively from consecutive patients presenting with upper-gastrointestinal haemorrhage over a 12-month period at Royal Cornwall Hospital, Truro, for 6 months at Glasgow Royal Infirmary, Glasgow, and over 3 months at Ninewells Hospital, Dundee, and retrospectively for 3 months at University Hospital of North-Tees, Stockton. We defined upper-gastrointestinal haemorrhage as haematemesis, coffee-ground vomit, or melaena. We
Results
From the four study centres, a total of 676 patients were included in phase one. Table 2 outlines demographic characteristics and outcomes for these people.
19 individuals had data missing for measurement of admission Rockall score and 27 had omissions for GBS. Of those with complete data, GBS was 0 (low-risk criteria met) in 105 (16%) and admission Rockall score was 0 in 184 (28%). The GBS low-risk group consisted of 27 people (12%) from Truro, 17 (17%) from Stockton, 36 (17%) from Glasgow, and
Discussion
Our findings show that simple GBS low-risk criteria can identify a significant proportion of individuals presenting with upper-gastrointestinal haemorrhage who are suitable for outpatient management. Furthermore, use of these criteria in A&E departments leads to a reduction in admissions for this disorder, with no apparent deleterious effects on patients' care.
Although most scoring systems for upper-gastrointestinal haemorrhage incorporate endoscopic findings, outcomes of an audit by the
References (24)
- et al.
A risk score to predict need for treatment for upper gastrointestinal haemorrhage
Lancet
(2000) - et al.
Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial
Gastrointest Endosc
(2002) - et al.
Outpatient care of selected patients with acute non-variceal upper gastrointestinal haemorrhage
Lancet
(1995) - et al.
Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series
Gastrointest Endosc
(1998) - et al.
Outpatient care for selected patients with acute upper gastrointestinal bleeding
Lancet
(1995) - et al.
Risk scoring systems to predict need for clinical intervention for patients with non-variceal upper gastrointestinal tract bleeding
Am J Emerg Med
(2007) - et al.
Artificial neural network as a predictive instrument in patients with acute non-variceal upper gastrointestinal hemorrhage
Gastroenterology
(2008) Outpatient management of “low-risk” nonvariceal upper GI hemorrhage: are we ready to put evidence into practice?
Gastrointest Endosc
(2002)- et al.
Incremental value of upper endoscopy for triage of patients with acute non-variceal upper-GI hemorrhage
Gastrointest Endosc
(2004) - et al.
Incidence of and mortality from acute upper gastrointestinal haemorrhage in the UK
BMJ
(1995)
Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study
BMJ
Risk assessment after acute upper gastrointestinal haemorrhage
Gut
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