title: Simple clinical predictors may obviate urgent endoscopy in selected patients with nonvariceal upper gastrointestinal tract bleeding.
abstract: BACKGROUND
  The validated Blatchford risk score (BRS) predicts outcomes in patients with nonvariceal upper gastrointestinal tract bleeding, before endoscopy; completion of the Rockall score requires endoscopy. The aims of this study were to predict whether the modified BRS (mBRS) can predict (1) endoscopic high-risk stigmata (HRS) and (2) rebleeding and mortality.
  
  
  METHODS
  Clinical and demographic characteristics on 1869 patients from 6 Canadian provinces were prospectively entered into the Registry for Upper GI Bleeding and Endoscopy database, recording 30-day rebleeding and mortality. The Rockall score and mBRS (hemoglobin level, hemodynamic instability, and presence of melena, liver disease, or cardiac failure; urea and syncope were not recorded) were calculated. Logistic regression was used to assess the association between an mBRS of 1 or less with HRS and with rebleeding and mortality.
  
  
  RESULTS
  The mean (SD) age of the patients was 66 (17) years, with 62% men and a mean of 2.5 comorbidities. Of the 1860 patients with 30-day rebleeding data, 334 (18.0%) rebled; 5.3% died. The mBRS was 0 in 3% and 1 or less in 9.8% of patients; HRS were seen in 31.0% of patients. An mBRS of 1 or less was associated with lower rebleeding (5% vs 19%; P<.001) and mortality (0.5% vs 5.8%; P=.003), and was significant in multivariate analysis for rebleeding (odds ratio, 0.24; 95% confidence interval, 0.12-0.48) and mortality (odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The HRS were less frequent when the mBRS was 1 or less (16.9% vs 32.7%; odds ratio, 0.4; 95% confidence interval, 0.3-0.6). Patients with a low mBRS with HRS had a low rebleeding rate (3.3%) and a lower apparent benefit from endoscopic therapy.
  
  
  CONCLUSIONS
  An mBRS of 1 or less identifies approximately 10% of patients with gastrointestinal tract bleeding with a low likelihood of having HRS and a low risk of adverse outcomes. A prospective randomized study is required to examine whether this subgroup of patients presenting after hours could be discharged safely from emergency departments with arrangements for (urgent) outpatient endoscopy.
authors.affiliation: Departments of Medicine and Biometry, Bioinformatics and Epidemiology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA. romagnuo@musc.edu
authors.forename: Joseph
authors.initials: J
authors.lastname: Romagnuolo
authors.forename: Alan N
authors.initials: AN
authors.lastname: Barkun
authors.forename: Robert
authors.initials: R
authors.lastname: Enns
authors.forename: David
authors.initials: D
authors.lastname: Armstrong
authors.forename: Jamie
authors.initials: J
authors.lastname: Gregor
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016099:Endoscopy, Gastrointestinal; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000473:pathology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000209:etiology* / Q000401:mortality; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012008:Recurrence; D012307:Risk Factors