Upper gastrointestinal bleeding (UGIB) is a common cause of hospital admissions worldwide. While health care systems are under significant strain during the COVID-19 pandemic, it is logical to reduce hospital admissions for patients at very low risk of poor outcomes. Additionally, upper gastrointestinal endoscopy is recognized as an aerosol-generating procedure that should be restricted during the pandemic, because of the risk of spreading COVID-19 and the limited availability of personal protection equipment 1 2 . Therefore, elective and even urgent endoscopy has been suspended in many centers worldwide. Current guidelines recommend the use of the Glasgow-Blatchford Score (GBS) for predicting the need for hospital-based intervention in patients with UGIB 3 4 . Patients with GBS ≤ 1 are recognized to be at very low risk and can safely be managed as outpatients with no need for inpatient endoscopy 3 4 .
Based on data from a large international multicenter study including 3012 consecutive patients with UGIB 5 , we have evaluated the outcomes associated with extended low risk GBS thresholds for identifying patients needing hospital admission and endoscopic therapy.
Table 1 shows the numbers of identified low-risk patients and outcomes for GBS thresholds 0 to ≤ 5. Use of GBS ≤ 2 or ≤ 3 as thresholds for avoiding hospital admission in UGIB would lead to avoidance of admission and in-hospital endoscopy in 26 % – 32 % of all UGIB patients. In patients classified as being at low risk, the risk of needing endoscopic therapy (3.3 % – 4.1 %), needing surgery or embolization (0.5 %), death within 30 days (0.8 % – 1.7 %), and delayed identification of upper gastrointestinal cancer (0.65 % – 0.75 %) would probably be acceptable in countries with a health care system facing significant strain or potential collapse from COVID-19. If such patients are admitted for other reasons, the very low risk of needing endoscopic therapy suggests endoscopy could be undertaken electively as an outpatient. Consistently with these suggested thresholds, re-analysis of data from a multicenter study of 1555 patients with UGIB found endoscopic therapy was required in 4.2 % – 4.4 % patients with GBS 2 or 3, but rose to 9.4 % for GBS 4 6 .
Table 1. Outcomes among patients (n = 3012 5 ) with upper gastrointestinal bleeding and low Glasgow-Blatchford Score (GBS), according to threshold used.
| GBS threshold | Patients classified as low risk, n (%) | Outcomes, n (%) | ||||
| Hemostatic intervention, and/or Need for transfusion, and/or, Death | Need for transfusion | Endoscopic therapy | Surgery/embolization | 30-day mortality | ||
| 0 | 254 (8.7) | 5 (2.0) | 0 (0) | 3 (1.2) | 1 (0.4) | 1 (0.4) |
| ≤ 1 | 564 (19) | 19 (3.4) | 10 (1.8) | 8 (1.4) | 2 (0.4) | 2 (0.4) |
| ≤ 2 | 770 (26) | 45 (5.9) | 20 (2.6) | 25 (3.3) | 4 (0.5) | 6 (0.8) |
| ≤ 3 | 934 (32) | 72 (7.7) | 28 (3.0) | 38 (4.1) | 5 (0.5) | 16 (1.7) |
| ≤ 4 | 1120 (38) | 105 (9.4) | 39 (3.5) | 60 (5.4) | 6 (0.5) | 22 (2.0) |
| ≤ 5 | 1299 (44) | 159 (12) | 61 (4.7) | 80 (6.2) | 7 (0.5) | 41 (3.2) |
Missing data: GBS, n = 80; need for transfusion, n = 23; endoscopic therapy, n = 20; surgery or embolization, n = 5; and mortality, n = 1.
Combining extended GBS thresholds with exclusion of patients with major risk factors including systolic blood pressure < 100 mmHg, syncope, or liver cirrhosis was not superior to use of GBS ≤ 2 – 3 alone. However, clinical judgment would still be required for specific patients.
In countries severely affected by COVID-19, we suggest that the low risk threshold for defining UGIB patients who require hospitalization and inpatient endoscopy could be raised to GBS ≤ 2 or even GBS ≤ 3. These patients could be treated with high dose oral proton pump inhibitors and evaluated with endoscopy once the epidemic has peaked.
Footnotes
Competing interests I.M. Gralnek is a consultant for Motus GI, Boston Scientific, Symbionix, and GI View; he has a financial interest in and is a member of the Medical Advisory Board of MOTUS GI. A.J. Stanley and S.B. Laursen declare that they have no conflicts of interest.
References
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