Abstract
Background:
Upper gastrointestinal bleeding (UGIB) remains a common medical emergency associated with significant morbidity and mortality. Early risk stratification is essential to identify patients who require urgent intervention. The Glasgow-Blatchford Score (GBS) is widely used to assess UGIB severity at presentation; however, data regarding its performance in the Indian population are limited. This study aimed to evaluate the ability of the GBS to predict the need for blood transfusion and early endoscopy among patients presenting with UGIB.
Methods:
A retrospective observational study was conducted at a tertiary care hospital in South India over a period of 2.5 years. Medical records of adult patients (18–80 years) presenting to the emergency department with clinical features of UGIB were reviewed. Demographic, clinical, and laboratory parameters required for calculating the GBS were collected. Statistical analysis included independent t-tests and Chi-square tests to evaluate associations between GBS and clinical outcomes. Receiver operating characteristic (ROC) curve analysis was performed to determine optimal cutoff values for predicting blood transfusion and early endoscopy.
Results:
A total of 100 patients were included, with a mean age of 59 ± 12 years, and 78% were male. Chronic liver disease was present in 61% of the cohort. Patients requiring blood transfusion had significantly higher GBS values compared with those who did not (P = 0.006). ROC analysis showed moderate predictive ability for blood transfusion (area under the curve [AUC] 67.8%) with an optimal cutoff score of 8 (sensitivity 86% and specificity 46%). For early endoscopy, the AUC was 71.8%, with a cutoff score of 9 (sensitivity: 80.6% and specificity: 54%).
Conclusion:
The GBS demonstrated significant predictive value for identifying patients with UGIB who are likely to require blood transfusion and early endoscopic evaluation. Incorporation of GBS into emergency department triage protocols may facilitate timely risk stratification and support evidence-based management of UGIB.
Keywords: Blood transfusion, endoscopy, Glasgow-Blatchford score, risk assessment, upper gastrointestinal hemorrhage
INTRODUCTION
Upper gastrointestinal bleeding (UGIB), defined as bleeding originating proximal to the ligament of Treitz, remains a common and potentially life-threatening medical emergency encountered in emergency departments and intensive care units worldwide.[1] Despite advances in diagnostic and therapeutic strategies, UGIB continues to account for a significant proportion of hospital admissions and is associated with considerable morbidity and mortality.[2] Patients with UGIB may present with a wide range of clinical manifestations, from mild bleeding to severe hemorrhage, resulting in hemodynamic instability and life-threatening complications. Early identification of patients at high risk of adverse outcomes is therefore essential to facilitate prompt intervention and improve clinical outcomes.
The etiological profile of UGIB has evolved over time. Peptic ulcer disease was historically the most common cause; however, recent evidence suggests an increasing contribution from other conditions such as esophagitis and variceal bleeding, particularly among patients with chronic liver disease (CLD).[2,3] Several clinical factors, including advanced age, underlying comorbidities, and the use of antiplatelet or anticoagulant medications, may influence disease severity and prognosis. Initial clinical evaluation typically involves assessment of hemodynamic status and laboratory parameters such as hemoglobin level, coagulation profile, and the blood urea nitrogen-to-creatinine ratio, which may increase in the setting of hypovolemia and reduced renal perfusion.[4] Early management of UGIB focuses on hemodynamic stabilization and supportive care, including keeping the patient nil per oral and initiating acid-suppressive therapy and prokinetic agents before endoscopy.[5] However, certain interventions, such as nasogastric lavage and routine use of tranexamic acid, have not consistently demonstrated clear clinical benefit in patients with UGIB.[6,7] In patients with significant coagulopathy or thrombocytopenia, correction with blood products such as prothrombin complex concentrate, fresh frozen plasma, or platelet transfusion may be required, depending on the severity of coagulation abnormalities and ongoing bleeding.[8,9] Current evidence also supports a restrictive transfusion strategy in most patients, with transfusion generally recommended when hemoglobin levels fall below 7 g/dL, although higher thresholds may be considered in patients with cardiovascular disease.[10,11] Early endoscopy, usually performed within 24 h of presentation, remains a key component of management as it allows identification of the bleeding source and enables therapeutic intervention when necessary.[12]
Because the clinical presentation and severity of UGIB vary widely, several risk stratification tools have been developed to assist clinicians in early decision-making. Commonly used scoring systems include the Glasgow-Blatchford Score (GBS, Refer Appendix 1), Rockall Score, and AIMS65 score. Among these, the GBS is widely used because it relies on readily available clinical and laboratory parameters at the time of presentation, including blood urea nitrogen, hemoglobin level, systolic blood pressure, pulse rate, and clinical features such as melena, syncope, hepatic disease, and cardiac failure.[3] Previous studies have demonstrated that the GBS is useful in predicting the need for clinical interventions such as blood transfusion, endoscopic therapy, or hospital admission.[13] Evidence from systematic reviews indicates that patients with a GBS of zero have a very low risk of requiring urgent intervention and may be safely managed in an outpatient setting.[14] Compared with other scoring systems, the GBS has the advantage of being applicable during the initial emergency department assessment because it does not require endoscopic findings for calculation.[15]
Despite its widespread validation in several international studies, evidence regarding the performance of the GBS in the Indian population remains limited. Regional variations in disease epidemiology, particularly the higher prevalence of CLD and variceal bleeding in South India, may influence the predictive accuracy and optimal cutoff values of the score.
Therefore, the present study was undertaken to evaluate the clinical utility of the GBS in adult patients presenting with UGIB and to determine the optimal cutoff values for predicting the need for blood transfusion and early endoscopy in this population.
METHODS
Study design
This study was a retrospective comparative observational study designed to evaluate the ability of the GBS to predict the need for blood transfusion and early endoscopy among patients presenting with UGIB.
Study setting and duration
The study was conducted in the Department of Emergency Medicine and Critical Care at a tertiary care hospital in South India. Medical records of eligible patients presenting to the emergency department with UGIB were reviewed over a study period of 2.5 years.
Ethical approval for the study was obtained from the Institutional Ethics Committee on January 21, 2020 (IEC No. IRB-AIMS-2020-011). As the study involved retrospective analysis of anonymized medical records, the requirement for individual informed consent was waived by the ethics committee.
Patient selection
The study population consisted of adult patients aged 18–80 years who presented to the emergency department with clinical features of UGIB, including hematemesis or melena. Patients were identified through review of hospital medical records and emergency department registers. All patients who met the inclusion criteria and had adequate clinical documentation were included in the study.
Patients of either sex between 18 and 80 years of age presenting with clinical evidence of UGIB were eligible for inclusion. The lower age limit of 18 years was selected because the GBS is primarily validated for adult populations, while pediatric gastrointestinal bleeding has different clinical characteristics and management approaches.
Patients were excluded if they were pregnant, presented in cardiac arrest, or had bleeding originating from nongastrointestinal sources such as the upper airway or lungs (for example, hemoptysis). Additional exclusion criteria included confirmed lower gastrointestinal bleeding, incomplete clinical records, patients who left against medical advice, patients referred to other hospitals before completion of evaluation, and those with a documented do-not-resuscitate status.
A total of 100 patients with UGIB were included in the study. Among them, 50 patients received blood transfusion in the emergency department, whereas the remaining 50 patients did not receive blood transfusion.
Clinical management
Blood transfusion was initiated based on predefined clinical criteria. In general, transfusion was considered when the hemoglobin level was <7 g/dL, or <10 g/dL in patients with underlying coronary artery disease, ongoing bleeding, or evidence of hemodynamic instability. The decision to perform early endoscopy in the emergency department was guided by the patient’s clinical condition, evidence of ongoing bleeding, hemodynamic parameters, and the treating physician’s clinical judgment.
Data collection and study variables
Patient demographic and clinical information was collected from medical records. The variables included sex, heart rate, systolic blood pressure, blood urea level, hemoglobin concentration, and history of melena or syncope. Information regarding the presence of CLD was also recorded. Patients were additionally evaluated for clinical and radiological features suggestive of cardiac failure. Clinical findings included elevated jugular venous pressure, basal lung crepitations, and peripheral edema. Radiological findings on chest X-ray, such as increased bronchovascular markings, cardiomegaly, and Kerley B lines, were also documented when available. These clinical and laboratory parameters were used to calculate the GBS for each patient.
Baseline clinical characteristics of the study population were also recorded, including age, presence of CLD, Child–Pugh score, Model for End-Stage Liver Disease (MELD) score, ascites, hepatic encephalopathy, C-reactive protein levels, international normalized ratio, lactate levels, serum albumin, creatinine levels, endoscopic findings, and duration of hospital stay.
Outcome measures
The primary objective of the study was to compare the mean GBS between patients who required blood transfusion and those who did not.
The secondary objectives were to evaluate the association between GBS and the need for blood transfusion and to determine the optimal GBS cutoff value for predicting the need for blood transfusion and early endoscopy in patients presenting with UGIB.
Laboratory measurements and study tools
Vital signs were recorded at presentation in the emergency department. Serum urea levels were measured using a colorimetric method, and blood urea nitrogen was calculated by dividing the urea value by 2.14. Arterial blood gas parameters and lactate levels were measured using the ABL 800 Flex analyzer.
Complete blood counts, including hemoglobin levels, were measured using the HORIBA Microsemi analyzer, while prothrombin time and international normalized ratio were assessed using the CoaguChek Pro II system. Serum ammonia levels were measured using a turbidimetric method, high-sensitivity C-reactive protein was analyzed using the COBAS Integra 400 system, and serum albumin levels were determined using a colorimetric assay method.
Statistical analysis
Statistical analyses were performed with SPSS software, version 25.0 (IBM Corp., Armonk, New York, USA). Categorical variables were expressed as frequency and percentage, whereas continuous variables were presented as mean and standard deviation.
The independent samples t-test was used to compare the mean GBSs between patients who required blood transfusion and those who did not. The Chi-square test with continuity correction was used to assess the association between GBS and the need for blood transfusion and early endoscopy.
Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal GBS cutoff values for predicting the need for blood transfusion and early endoscopy. The Youden index was used to identify the optimal cutoff point. Effect sizes were calculated using Glass’s delta and Cramer’s V. P < 0.05 was considered statistically significant.
RESULTS
Baseline characteristics of the study population
A total of 100 patients presenting with UGIB were included in the study. The mean age of the study population was 59 ± 12 years, and the majority of patients were male (78%), whereas 22% were female.
CLD was common in this cohort. Fifty-eight percent of patients had a previously documented diagnosis of CLD, whereas 3% were newly diagnosed during the emergency department evaluation, resulting in an overall 61% prevalence of CLD in the study population. Among patients with CLD, Child–Pugh classification showed that 28% were class A, 22% class B, and 11% class C. The mean MELD score in patients with CLD was 15 ± 5. The remaining 39% of patients had no evidence of underlying liver disease.
Clinical complications related to liver disease were also observed. Hepatic encephalopathy was present in 54% of patients, most commonly Grade 1 (33%), followed by Grade 2 (13%), whereas 46% had no encephalopathy. Ascites was documented in 25% of the study population.
Laboratory evaluation demonstrated a mean hemoglobin level of 8.39 ± 2.97 g/dL, mean lactate level of 3.61 ± 3.80 mmol/L, and mean INR of 1.61 ± 0.97. Other laboratory parameters included a mean C-reactive protein level of 24.79 ± 53.10 mg/L, a mean serum creatinine of 1.49 ± 1.86 mg/dL, and a mean serum albumin of 2.94 ± 0.65 g/dL. Most patients (76%) required intensive care unit admission, and the mean duration of hospital stay was 5.99 ± 4 days.
Etiology of upper gastrointestinal bleeding
The etiological distribution of UGIB in the study population is shown in Figure 1. Variceal bleeding was the most common cause, accounting for more than half of the cases. Other causes included peptic ulcer disease-related bleeding, gastric antral vascular ectasia, esophagitis, gastric mass lesions, and erosive gastroduodenal lesions. Less common etiologies included Dieulafoy lesions and extrahepatic portal vein obstruction. In a small number of patients who died before endoscopic evaluation, the exact source of bleeding could not be determined.
Figure 1.
Etiological distribution of upper gastrointestinal bleeding in the study population. GI: Gastrointestinal
Glasgow-Blatchford score and requirement for blood transfusion
The mean age of patients who received blood transfusions was 61 ± 12 years, compared with 57 ± 13 years among those who did not receive transfusion. Patients who required blood transfusion had significantly higher GBSs at presentation. Comparison of the mean GBS between the two groups demonstrated a statistically significant difference, with a large effect size of 0.93, indicating a strong association between higher score values and the need for blood transfusion [Table 1].
Table 1.
Comparison of Glasgow-Blatchford score variables between patients transfused with blood and those not transfused
| Variables of GBS | Transfused with blood, mean±SD | Not transfused with blood, mean±SD | P | |||
|---|---|---|---|---|---|---|
| Hemoglobin (g/dL) | 6.4±2.2 | 10.4±2.3 | <0.01 | |||
| BUN | 22.0±12.6 | 22.5±13.3 | 0.86 | |||
| Systolic BP (mmHg) | 111.4±29.6 | 122.6±20.7 | 0.03 | |||
| Sex – male (%) | 74.0±44.3 | 82±38.8 | 0.34 | |||
| Heart rate | 95.7±23.9 | 89.2±16.8 | 0.12 | |||
| Melena history | 0.7±0.5 | 0.6±0.5 | 0.68 | |||
| Syncope history | 0.0±0.1 | 0.0±0.0 | 0.32 | |||
| Hepatic disease | 0.7±0.5 | 0.7±0.5 | 1 | |||
| Cardiac failure | 0.1±0.2 | 0.0±0.0 | 0.08 | |||
| Overall score | 11.1±2.8 | 8.5±3.9 | <0.01 |
GBS: Glasgow-Blatchford Score, BP: Blood pressure, SD: Standard deviation, BUN: Blood urea nitrogen
Further analysis demonstrated a significant association between GBS and the requirement for blood transfusion (P = 0.006), with a moderate effect size (Cramer’s V = 0.27) [Table 2]. ROC analysis showed an area under the curve (AUC) of 67.8%, indicating moderate discriminative ability of the GBS for predicting the need for transfusion. A cutoff score of 8 provided a sensitivity of 86% and specificity of 46% [Figure 2].
Table 2.
Association between Glasgow-Blatchford Score and blood transfusion
| Blood transfusion | GBS |
P | ||||
|---|---|---|---|---|---|---|
| GBS <8, n (%) | GBS ≤8, n (%) | |||||
| Not transfused (n=50) | 19 (38) | 31 (62) | 0.006 | |||
| Transfused (n=50) | 7 (14) | 43 (86) | ||||
GBS: Glasgow-Blatchford Score
Figure 2.
Receiver operating characteristic curve of Glasgow-Blatchford score for predicting blood transfusion. ROC: Receiver operating characteristic
Glasgow-Blatchford score and early endoscopy
Patients who underwent early endoscopy also had higher GBSs at presentation. Statistical analysis demonstrated a significant association between elevated GBSs and the likelihood of early endoscopic intervention [Table 3], with a moderate effect size (Cramer’s V = 0.32). ROC curve analysis demonstrated an AUC of 71.8%, suggesting good discriminative ability of the GBS for predicting the need for early endoscopy. A cutoff score of 9 yielded a sensitivity of 80.6% and specificity of 54% [Figure 3].
Table 3.
Association between Glasgow-Blatchford Score and early endoscopy
| Early endoscopy | GBS |
P | ||||
|---|---|---|---|---|---|---|
| GBS <9, n (%) | GBS ≤9, n (%) | |||||
| Done (n=31) | 6 (19.4) | 25 (80.6) | 0.001 | |||
| Not done (n=69) | 37 (53.6) | 32 (46.4) | ||||
GBS: Glasgow-Blatchford Score
Figure 3.
Receiver operating characteristic curve of Glasgow-Blatchford Score for predicting early endoscopy. ROC: Receiver operating characteristic
DISCUSSION
UGIB remains a common medical emergency and is associated with significant morbidity and mortality if not recognized and managed promptly. Early risk stratification plays a critical role in identifying patients who require urgent intervention, blood transfusion, and endoscopic evaluation. In the present study, we evaluated the clinical utility of the GBS in predicting the need for blood transfusion and early endoscopy among patients presenting with UGIB in a tertiary care center in South India. Our findings demonstrated that patients requiring blood transfusion and those undergoing early endoscopy had significantly higher GBS values at presentation, indicating that the score may be useful for early risk stratification in emergency settings.
The results of our study are consistent with previous literature demonstrating the usefulness of GBS in predicting clinical interventions in UGIB. Ryan et al. reported that the GBS effectively identifies patients presenting to the emergency department who are likely to require hospital-based interventions such as transfusion or endoscopy.[1] Similarly, Stanley and Laine emphasized the importance of early risk stratification using validated scoring systems in the management of acute gastrointestinal bleeding.[2] Comparative studies evaluating multiple risk scores have also demonstrated that GBS performs well in predicting the need for clinical intervention when compared with other scoring systems such as Rockall and AIMS65.[3,4,13]
In the present study, a significant association was observed between higher GBS values and the need for blood transfusion. Patients who required transfusion had significantly higher mean GBS values compared with those managed without transfusion. Similar findings were reported by Köksal et al., who demonstrated that patients receiving blood transfusions had significantly higher GBSs than those managed conservatively.[16] Likewise, Mohanty and Kannan highlighted the usefulness of GBS in triaging patients with UGIB and predicting the need for therapeutic intervention.[17] Although the cutoff values reported in different studies vary, the consistent association between higher scores and increased intervention requirements reinforces the clinical utility of the GBS.
The GBS also showed a significant association with the need for early endoscopy in our study. Early endoscopic evaluation remains an essential component of the management of acute UGIB because it allows both diagnostic assessment and therapeutic intervention. International guidelines recommend performing endoscopy within 24 h in most patients with acute UGIB.[11,12] Previous studies have similarly demonstrated that higher GBS values are associated with an increased likelihood of endoscopic intervention. For instance, Bryant et al. reported that higher GBS values were strongly associated with the need for clinical intervention and early endoscopic therapy.[18] Samreen and Khurram also demonstrated that high-risk GBS categories accurately predicted the need for endoscopic intervention in patients presenting with UGIB.[19] In an Indian cohort, Navgale et al. validated the GBS and found that it was useful in predicting both blood transfusion and therapeutic endoscopic intervention.[20]
However, the optimal GBS cutoff values reported in different studies vary. These variations may be explained by differences in study populations, healthcare settings, and underlying causes of bleeding. In our study population, a relatively large proportion of patients had CLD, which is known to increase the risk of variceal bleeding and severe hemorrhage. Patients with cirrhosis frequently present with hemodynamic instability and coagulopathy, which may result in higher baseline GBS values and a greater need for transfusion or endoscopic intervention. Similar observations have been reported in studies evaluating risk stratification tools in diverse patient populations.[3,4]
Recent studies have continued to support the role of GBS in emergency department risk stratification. Nik Pa et al. compared the performance of GBS with AIMS65 and the pre-endoscopic Rockall score and reported that GBS remains a reliable tool for predicting clinical outcomes among patients presenting with UGIB.[21] Likewise, Zhang et al. demonstrated that the GBS can be effectively integrated into fast-track emergency management pathways to identify patients requiring urgent intervention.[22]
It is important to note that the original purpose of the GBS was to identify low-risk patients who could be safely discharged from the emergency department without hospital admission. In our cohort, most patients presented with moderate-to-severe bleeding and therefore required hospitalization and active management. Consequently, the number of patients with very low GBS values suitable for safe discharge was limited. Nevertheless, the role of GBS in identifying low-risk patients has been well established in previous studies. Garcia-Corella et al. demonstrated that implementing GBS-guided triage protocols improved safe patient disposition and reduced unnecessary hospital admissions in patients presenting with UGIB.[23]
The findings of this study also have practical implications for clinical practice. Based on the results of this research, our institution has increasingly emphasized the routine calculation of the GBS at the time of emergency department presentation for patients with suspected UGIB. Early risk stratification allows clinicians to prioritize high-risk patients for intensive monitoring, early blood transfusion, and urgent gastroenterology consultation. In addition, incorporating GBS into emergency department triage protocols may help optimize resource utilization, particularly in healthcare settings with limited access to urgent endoscopy services.
The results of this study further highlight the practical utility of the GBS as an early bedside risk stratification tool in the emergency department. In resource-limited settings, particularly in regions with a high burden of CLD and variceal bleeding, a GBS-guided approach may assist clinicians in prioritizing blood transfusion and early endoscopy, optimizing resource allocation or emergency referral, and potentially improving patient outcomes.
Hospitals facing similar challenges may benefit from implementing standardized clinical pathways that include early risk assessment using validated scoring systems such as the GBS. Such strategies may improve early identification of high-risk patients, facilitate timely therapeutic intervention, and potentially reduce delays in care while improving overall patient outcomes.
Limitations of the study
This study has certain limitations that should be acknowledged. As a retrospective analysis, the study relied on available medical records, which may be subject to minor variations in documentation. The study was conducted at a single tertiary care center; therefore, the patient profile reflects the case mix typically seen in such referral hospitals, including a relatively higher proportion of patients with CLD. Clinical decisions regarding blood transfusion and timing of endoscopy were made by treating physicians based on standard clinical practice and individual patient condition. While this reflects real-world clinical management, it may introduce some variability in practice patterns. Nevertheless, the study provides valuable insight into the applicability of the GBS in routine clinical settings. Further prospective multicenter studies with larger and more diverse patient populations may help strengthen the evidence and refine optimal GBS cutoff values across different healthcare settings.
CONCLUSION
The GBS demonstrated strong predictive value in identifying patients with UGIB who were more likely to require blood transfusion and early endoscopic evaluation. In our study population from South India, a GBS cutoff of 8 for predicting the need for blood transfusion and 9 for early endoscopy appeared clinically useful for early risk stratification. These findings highlight the practical role of the GBS as a simple and effective bedside tool in emergency settings. Incorporating the score into emergency department triage protocols can assist clinicians in rapidly identifying high-risk patients, facilitating timely decision-making, prioritizing endoscopic evaluation, and optimizing the use of available healthcare resources. Overall, routine use of the GBS may support more structured, evidence-based management of patients presenting with UGIB and contribute to improved early clinical outcomes.
Research quality and ethics statement
This study was approved by the Institutional Review Board (IRB)/Ethics Committee (Approval No. IRB-AIMS-2020-011) on January 21, 2020. As the study involved a retrospective analysis of anonymized medical records, the requirement for informed consent was waived by the ethics committee. The authors conducted the study in accordance with ethical principles and followed the applicable reporting guidelines recommended by the EQUATOR Network (http://www.equator-network.org/), specifically the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline, throughout the design, conduct, and reporting of this research.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors sincerely acknowledge Ms. Niveditha Kartha, Department of Statistics, Amrita Institute of Medical Sciences, Kochi, for her valuable support and expert guidance in the statistical analysis of the data for this study.
Appendix 1.
Components of Glasgow-Blatchford Score
| Value | Score | |||
|---|---|---|---|---|
| Urea (mg/dL) | <18 | 0 | ||
| 18–22 | 2 | |||
| 23–27 | 3 | |||
| 28–70 | 4 | |||
| >70 | 6 | |||
| Hemoglobin (mg/dL) | >13 | 0 | ||
| Male | 12–12.9 | 1 | ||
| 10–11.9 | 3 | |||
| <10 | 6 | |||
| Hemoglobin (mg/dL) | >12 | 0 | ||
| Female | 10–11.9 | 1 | ||
| <10 | 6 | |||
| Systolic BP (mmHg) | >110 | 0 | ||
| 100–110 | 1 | |||
| 90–99 | 2 | |||
| <90 | 3 | |||
| Other markers | Heart rate >100/min | 1 | ||
| Presented with melena | 1 | |||
| Presented with syncope | 2 | |||
| Hepatic disease | 2 | |||
| Cardiac failure | 2 | |||
| BUN (mmol/L) | 6.5–7.9 | - | ||
| 8–9.9 | - | |||
| 10–24.9 | - | |||
| ≥25 | - |
BP: Blood pressure, BUN: Blood urea nitrogen
Funding Statement
Nil.
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