Discharge Deemed Safe for Select Upper GI Bleeders

SAN DIEGO – A Glasgow-Blatchford bleeding score of zero identifies a subset of upper GI bleeders who can be sent home from the ED and safely managed as outpatients, according to gastroenterologist Dr. Derek Patel at the annual meeting of the Society of Hospital Medicine.

"Less than 1% of patients you send home with a Blatchford score of zero will require" therapeutic endoscopy, transfusion, or surgery. A zero score is "a reasonable predictor for not requiring therapeutic intervention," said Dr. Patel, associate clinical professor of medicine at the University of California, San Diego.

The scale was specifically designed to predict who’ll need intervention for upper GI bleeding. A score of zero translates to a blood urea nitrogen (BUN) below 18.2 mg/dL; hemoglobin of at least 13 g/dL for men and 12 g/dL for women; systolic blood pressure above 109 mmHg; pulse below 100 bpm; no melena at presentation; and no syncope, liver disease, or heart failure.

In a Hong Kong study with 1,087 upper-GI bleed patients undergoing endoscopy within 24 hours of hospital admission, none of the 50 who met those requirements turned out to need therapeutic intervention (Gastrointest. Endosc. 2010;71:1134-40).

Another study found a zero score to be 99.6% sensitive for not needing intervention, with a negative likelihood ratio of 0.02. That’s "probably about as good as it gets for predicting which upper GI bleed patients will not require therapeutic intervention," Dr. Patel said (JAMA 2012;307:1072-9).

Typically, people with an upper GI bleed, regardless of their Blatchford score, are admitted from the ED and evaluated by endoscopy within 24 hours. "Most of those patients will have clean-based ulcers or nothing that needs intervention. We’ll give them a [proton-pump inhibitor], shake their hands, and send them home the next day," he said.

The alternative is to send zero-score patients home instead of admitting them. "Maybe you are going to pick off 20% of your upper-GI bleed population. This has a pretty big financial impact as well as an impact on hospital utilization." However, physicians may be wary of the approach because, for now, "none of the major GI societies in their guidelines for upper GI bleeds even mention the potential of sending patients home," Dr. Patel said.

But British researchers recently found the approach works. Of about 560 people presenting with upper-GI bleeds, 123 had zero scores; 84 were sent home and managed as outpatients without complications (Lancet 2009;373:42-7).

It’s a different situation for acute, significant, lower GI-bleeds. "Data are lacking to support outpatient management," Dr. Patel noted.

Dr. Patel said he has no disclosures.

SAN DIEGO – A Glasgow-Blatchford bleeding score of zero identifies a subset of upper GI bleeders who can be sent home from the ED and safely managed as outpatients, according to gastroenterologist Dr. Derek Patel at the annual meeting of the Society of Hospital Medicine.

"Less than 1% of patients you send home with a Blatchford score of zero will require" therapeutic endoscopy, transfusion, or surgery. A zero score is "a reasonable predictor for not requiring therapeutic intervention," said Dr. Patel, associate clinical professor of medicine at the University of California, San Diego.

The scale was specifically designed to predict who’ll need intervention for upper GI bleeding. A score of zero translates to a blood urea nitrogen (BUN) below 18.2 mg/dL; hemoglobin of at least 13 g/dL for men and 12 g/dL for women; systolic blood pressure above 109 mmHg; pulse below 100 bpm; no melena at presentation; and no syncope, liver disease, or heart failure.

In a Hong Kong study with 1,087 upper-GI bleed patients undergoing endoscopy within 24 hours of hospital admission, none of the 50 who met those requirements turned out to need therapeutic intervention (Gastrointest. Endosc. 2010;71:1134-40).

Another study found a zero score to be 99.6% sensitive for not needing intervention, with a negative likelihood ratio of 0.02. That’s "probably about as good as it gets for predicting which upper GI bleed patients will not require therapeutic intervention," Dr. Patel said (JAMA 2012;307:1072-9).

Typically, people with an upper GI bleed, regardless of their Blatchford score, are admitted from the ED and evaluated by endoscopy within 24 hours. "Most of those patients will have clean-based ulcers or nothing that needs intervention. We’ll give them a [proton-pump inhibitor], shake their hands, and send them home the next day," he said.

The alternative is to send zero-score patients home instead of admitting them. "Maybe you are going to pick off 20% of your upper-GI bleed population. This has a pretty big financial impact as well as an impact on hospital utilization." However, physicians may be wary of the approach because, for now, "none of the major GI societies in their guidelines for upper GI bleeds even mention the potential of sending patients home," Dr. Patel said.

But British researchers recently found the approach works. Of about 560 people presenting with upper-GI bleeds, 123 had zero scores; 84 were sent home and managed as outpatients without complications (Lancet 2009;373:42-7).

It’s a different situation for acute, significant, lower GI-bleeds. "Data are lacking to support outpatient management," Dr. Patel noted.

Dr. Patel said he has no disclosures.

SAN DIEGO – A Glasgow-Blatchford bleeding score of zero identifies a subset of upper GI bleeders who can be sent home from the ED and safely managed as outpatients, according to gastroenterologist Dr. Derek Patel at the annual meeting of the Society of Hospital Medicine.

"Less than 1% of patients you send home with a Blatchford score of zero will require" therapeutic endoscopy, transfusion, or surgery. A zero score is "a reasonable predictor for not requiring therapeutic intervention," said Dr. Patel, associate clinical professor of medicine at the University of California, San Diego.

The scale was specifically designed to predict who’ll need intervention for upper GI bleeding. A score of zero translates to a blood urea nitrogen (BUN) below 18.2 mg/dL; hemoglobin of at least 13 g/dL for men and 12 g/dL for women; systolic blood pressure above 109 mmHg; pulse below 100 bpm; no melena at presentation; and no syncope, liver disease, or heart failure.

In a Hong Kong study with 1,087 upper-GI bleed patients undergoing endoscopy within 24 hours of hospital admission, none of the 50 who met those requirements turned out to need therapeutic intervention (Gastrointest. Endosc. 2010;71:1134-40).

Another study found a zero score to be 99.6% sensitive for not needing intervention, with a negative likelihood ratio of 0.02. That’s "probably about as good as it gets for predicting which upper GI bleed patients will not require therapeutic intervention," Dr. Patel said (JAMA 2012;307:1072-9).

Typically, people with an upper GI bleed, regardless of their Blatchford score, are admitted from the ED and evaluated by endoscopy within 24 hours. "Most of those patients will have clean-based ulcers or nothing that needs intervention. We’ll give them a [proton-pump inhibitor], shake their hands, and send them home the next day," he said.

The alternative is to send zero-score patients home instead of admitting them. "Maybe you are going to pick off 20% of your upper-GI bleed population. This has a pretty big financial impact as well as an impact on hospital utilization." However, physicians may be wary of the approach because, for now, "none of the major GI societies in their guidelines for upper GI bleeds even mention the potential of sending patients home," Dr. Patel said.

But British researchers recently found the approach works. Of about 560 people presenting with upper-GI bleeds, 123 had zero scores; 84 were sent home and managed as outpatients without complications (Lancet 2009;373:42-7).

It’s a different situation for acute, significant, lower GI-bleeds. "Data are lacking to support outpatient management," Dr. Patel noted.

Dr. Patel said he has no disclosures.