Raising the threshold for hospital admission and endoscopy in upper gastrointestinal bleeding during the COVID-19 pandemic

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.

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

• 1 Endoscopy activity and COVID-19: BSG and JAG guidance. Updated on: 03 Apr 2020. Accessed: April 8 2020. Available at: https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance
• 2 Gralnek IM, Hassan C, Beilenhoff U. et al. ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic. Accessed: May 9 2020. Available at: https://www.esge.com/esge-and-esgena-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic/
• 3 Barkun AN, Almadi M, Kuipers EJ. et al. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Ann Intern Med 2019; 171: 805-822 DOI: 10.7326/M19-1795.
• 4 Gralnek IM, Dumonceau JM, Kuipers EJ. et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: a1-a46
• 5 Stanley AJ, Laine L, Dalton HR. et al. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ 2017; 356: i6432 DOI: 10.1136/bmj.i6432.
• 6 Stanley AJ, Dalton HR, Blatchford O. et al. Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2011; 34: 470-475 DOI: 10.1111/j.1365-2036.2011.04747.x.

Publication History

Article published online:
23 September 2020