Emergency. 2018; 6 (1): e31 OR I G I N A L RE S E A RC H Full and Modified Glasgow-Blatchford Bleeding Score in Predicting the Outcome of Patients with Acute Upper Gas- trointestinal Bleeding; a Diagnostic Accuracy Study Ali Shahrami1, Saba Ahmadi1∗, Saeed Safari2 1. Emergency Department, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2. Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Received: April 2018; Accepted: May 2018; Published online: 17 May 2018 Abstract: Introduction: Screening of high risk patients and accelerating their treatment measures can reduce the burden of the disease caused by acute upper gastrointestinal (GI) bleeding. This study aimed to compare the full and modified Glasgow-Blatchford Bleeding Score (GBS and mGBS) in prediction of in-hospital outcomes of upper GI bleeding. Methods: In the present retrospective cross-sectional study, the accuracy of GBS and mGBS models were compared in predicting the outcome of patients over 18 years of age with acute upper GI bleeding con- firmed via endoscopy, presenting to the emergency departments of 3 teaching hospitals during 4 years. Results: 330 cases with the mean age of 59.07 ± 19.00 years entered the study (63.60% male). Area under the curve of GBS and mGBS scoring systems were 0.691 and 0.703, respectively, in prediction of re-bleeding (p = 0.219), 0.562 and 0.563 regarding need for surgery (p = 0.978), 0.549 and 0.542 for endoscopic intervention (p = 0.505), and 0.767 and 0.770 regarding blood transfusion (p = 0.753). Area under the ROC curve of GBS scoring system regarding need for hospitalization in intensive care unit (0.589 vs. 0.563; p = 0.035) and mortality (0.597 vs. 0.564; p = 0.011) was better but the superiority was not clinically significant. Conclusion: GBS and mGBS scoring systems have similar accuracy in prediction of the probability of re-bleeding, need for blood transfusion, surgery and endoscopic intervention, hospitalization in intensive care unit, and mortality of patients with acute upper GI bleeding. Keywords: Gastrointestinal hemorrhage; decision support techniques; outcome assessment (Health Care); hospital mor- tality © Copyright (2018) Shahid Beheshti University of Medical Sciences Cite this article as: A Shahrami, Ahmadi S, Safari S. Full and Modified Glasgow-Blatchford Bleeding Score in Predicting the Outcome of Patients with Acute Upper Gastrointestinal Bleeding; a Diagnostic Accuracy Study. Emergency. 2018; 6(1): e31. 1. Introduction U pper gastrointestinal (GI) bleeding is a common cause of visiting the emergency department with a mean incidence of about 100 individuals in each 100000 population per year (1-3). The rate of mortality in these patients has been estimated to be between 2% to 15% and for cases with re-bleeding this rate rises to 10% to 30% (4, 5). Various factors such as age, hemodynamic status, need for blood transfusion, presence of bright blood in vomit or stool, and history of chronic hepatic diseases have been deemed ∗Corresponding Author: Saba Ahmadi; Emergency Department, Shoha- daye Tajrish Hospital, Shahrdari Avenue, Tajrish Square, Tehran, Iran. Tel: +989126057245 Email: ahmadisaba227@yahoo.com related to the prognosis of these patients (6, 7). Patients presenting to the emergency department with com- plaint of upper GI bleeding have a wide range from very low risk to very high risk regarding the risk of re-bleeding and need for surgical and endoscopic interventions. Screening of patients with higher risk and accelerating their diagnos- tic and treatment measures can be a big step towards reduc- ing the burden of the disease, the financial cost, and mortal- ity caused by it. Therefore, by understanding this concept, various studies have been performed with the aim of design- ing and comparing clinical decision rules for scoring of pa- tients regarding the probability of dangerous outcomes oc- curring (8-10). Yet, each of these models has weak and strong points compared to another. One of these clinical decision rules is Glasgow-Blatchford bleeding score (GBS), the modi- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Shahrami et al. 2 fied version of which (mGBS) has been introduced by elim- ination of qualitative factors. This system has moderate to good accuracy in prediction of outcomes such as probabil- ity of re-bleeding and need for interventions like endoscopy, surgery, and blood transfusion (11-13). The preset study has been designed with the aim of comparing the GBS and mGBS in prediction of in-hospital outcomes of patients presenting to emergency department with symptoms of upper GI bleed- ing. 2. Methods 2.1. Study design and setting In the present retrospective cross-sectional study, the di- agnostic accuracy of GBS and mGBS models in predicting the outcome of patients with acute upper GI bleeding, pre- senting to the emergency departments of 3 teaching hos- pitals (Imam Hossein, Shohadaye Tajrish, and Taleghani), Tehran, Iran, from spring 2011 to winter 2016 (4 years) were compared. The researchers adhered to the ethical princi- ples of clinical researches and kept patient data confidential. Methodology of the study was approved by the ethics com- mittee of Shahid Beheshti University of Medical Sciences. 2.2. Participants All patients over 18 years of age visiting the mentioned emer- gency departments with symptoms of upper GI bleeding (hematemesis, coffee ground vomit, melena, hematochezia) whose bleeding was confirmed via endoscopy were included via census sampling method. Incomplete medical profile, unavailability of data needed for calculation of score, and the outcome of the patient not being known were among the ex- clusion criteria. 2.3. Data gathering Demographic data (age, sex), vital signs on admission (blood pressure, heart rate), clinical symptom on admission (syn- cope, melena, coffee ground vomit, hematochezia), history of illnesses (GI bleeding, hepatic disease, cardiac disease), history of consuming anti-coagulation drugs or platelet ag- gregation inhibitors, laboratory findings (hemoglobin and blood urea nitrogen levels), and finally, outcome of the pa- tients were extracted from their clinical profile and gath- ered using a pre-designed checklist. The evaluated out- comes in the present study included: in-hospital mortal- ity, re-bleeding in the present hospitalization duration, need for blood transfusion, hospitalization in intensive care unit (ICU), and need for an intervention, either endoscopic, sur- gical or radiologic. A senior emergency medicine resident was in charge of extracting and gathering data of the patients from their clinical profiles. Blood transfusion in these pa- tients had been done based on the decision of the in-charge Appendixl 1: Calculation of GBS score Variable Score Heart rate (/min) ≥ 100 1 Systolic blood pressure (mmHg) 100 – 109 1 90 - 99 2 Less than 90 3 Blood urea nitrogen (mg/dl) 19 – 22.4 2 22.4 – 28 3 28 – 70 4 ≥ 70 6 Hemoglobin (male) (gr/dl) 12 – 13 1 10 – 12 3 Less than 10 6 Hemoglobin (female) (gr/dl) 10 – 12 1 Less than 10 6 History of chronic disease Hepatic 2 Cardiac 2 Symptom Melena 1 Syncope 2 physician. 2.4. Calculating patients’ scores in the 2 men- tioned models The method of calculating the scores of the patients based on GBS model is summarized in appendix 1. In mGBS model, only the scores of quantitative variables of GBS model are considered and the scores of the qualitative variables (his- tory of cardiac and hepatic diseases as well as melena and syncope symptoms) are eliminated from calculations. There- fore, the ranges of obtainable scores in GBS and mGBS mod- els are 0 to 23 and 0 to 16, respectively. In the present study, the score ranges of (0–3), (4–7), (8–11), and (12–23) were con- sidered as the first to 4th quartiles of GBS system, respec- tively, and (0–1), (2–6), (7–9), and (10–16) were the first to 4th quartiles of mGBS system, respectively. subsectionStatistical analysis After entering data to a de- signed excel sheet, they were analyzed using SPSS 21 and STATA 11 statistical software. To report the findings, fre- quency and percentage or mean ± standard deviation were used. In addition, for evaluating the agreement rate between the 2 models in predicting the patients in need of at least one intervention (endoscopic, surgical, radiologic, or blood transfusion) Kappa coefficient was calculated. Comparison of the area under the receiver operating characteristic (ROC) curve was used for comparing the accuracy of the 2 models in predicting the mentioned outcomes. In this study, the area This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 3 Emergency. 2018; 6 (1): e31 Table 1: Baseline characteristics of the studied patients Variable Rates Sex Male 210 (63.6) Female 120 (36.4) Age (year) 20 – 39.9 63 (19.1) 40 – 59.9 91 (27.6) > 60 176 (53.3) Symptoms on admission Systolic blood pressure (mmHg) 107.2 ± 22.8 Diastolic blood pressure (mmHg) 71.6 ± 12.4 Heart rate (/min) 94.8 ± 16.7 Blood Hemoglobin (gr/dl) 9.6 ± 2.4 Blood urea nitrogen (mg/dl) 37.6 ± 32.5 Symptom on admission Syncope 47 (14.2) Melena 236 (71.5) hematemesis 140 (42.4) Coffee ground vomit 59 (17.9) Drug history Yes 135 (40.9) No 195 (59.1) History of gastrointestinal bleeding Yes 77 (23.3) No 253 (76.7) History of cardiac disease Yes 101 (30.6) No 229 (69.4) History of hepatic disease Yes 7 (2.1) No 323 (97.9) The rates are reported as either frequency (%) or mean ± standard deviation. under the curve of 90-100 was considered as excellent, 80-90 as good, 70-80 as moderate, 60-70 as weak and 50-60 as poor. In all analyses, level of significance was considered to be 0.05. 3. Results 3.1. Baseline characteristics 400 patients who had presented to the emergency depart- ment with complaint of upper GI bleeding were evaluated. 70 (17.5%) cases were excluded from the study due to missing data or lost to follow-up. In the end, 330 individuals with the mean age of 59.07 ± 19.00 (19 – 95) years entered the study (63.60% male). Table 1 depicts the baseline characteristics of the studied patients. Most of the patients (53.3%) were in the over 60 years age group and their most common symptom on admission to emergency department was melena (71.5%). 3.2. Outcomes 178 patients had needed at least one of the interventions of blood transfusion, endoscopy, or surgery. Frequency of need for the mentioned interventions was 137 (41.5%) cases of need for blood transfusion, 84 (25.5%) cases of need for endoscopic intervention, and 17 (5.2%) cases of need for surgery (some of the patients needed more than one inter- vention). None of the patients had undergone radiologic in- tervention. 49 (14.8%) patients were hospitalized in the ICU and 281 (85.2%) were hospitalized in the gastroenterology department. In the end, 90 (27.3%) patients were affected with re-bleeding and 55 (16.7%) patients had died. 3.3. Comparing the accuracy of the 2 models Mean GBS and mGBS scores of the patients were 9.95 ± 4.22 (0 – 19) and 8.29 ± 3.77 (0 – 16), respectively. Table 2 shows the frequency of patients in various quartiles of GBS and mGBS scores and indicates the need for at least 1 interven- tion in each quartile (kappa = 0.752, p <0.001). There was a significant correlation between higher quartile of both GBS (r = 0.416, p < 0.0001) and mGBS (r = 0.422, p < 0.0001), and increase in need for at least one intervention. Area under the curves of GBS and mGBS scoring systems in prediction of re-bleeding (p = 0.219), need for surgery (p = 0.978), en- doscopic intervention (p = 0.505), and blood transfusion (p = 0.753) were not significantly different. However, although area under the ROC curve of GBS scoring system was signif- icantly higher regarding need for hospitalization in ICU (p = 0.035) and mortality (p = 0.011), the difference was not clini- cally significant. The highest accuracy of both models was in prediction of need for blood transfusion and re-bleeding. 4. Discussion Based on the present study findings, GBS and mGBS scoring systems have similar accuracy in prediction of the probabil- ity of re-bleeding, need for blood transfusion, surgical inter- vention, and endoscopic intervention in patients with acute upper GI bleeding. Regarding prediction of need for hospi- talization in ICU and in-hospital mortality, although the dif- ference between the 2 models was statistically significant, it was not clinically important. The overall accuracy of the 2 models in predicting the mentioned outcomes was weak and the highest accuracy belonged to predicting the probability of re-bleeding and need for blood transfusion, which were in the moderate range (70-80). Stanley et al. in 2011 compared GBS and Rockall systems in predicting the outcome of patients with acute upper GI bleeding and pointed out the superiority of GBS system regarding prediction of need for surgery intervention, en- doscopy, and blood transfusion (9). Balaban et al. in a study titled "Predictors for in-hospital mortality and need for clin- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com A. Shahrami et al. 4 Table 2: Frequency of patients in various quartiles of GBS and mGBS scores and the rate of need for at least 1 intervention in each quartile Quartile1 GBS frequency (%) P mGBS frequency (%) P Frequency Need for intervention2 Frequency Need for interven- tion First 31 (9.4) 3 (9.6) 21 (6.4) 1 (4.7) Second 50 (15.2) 8 (16.0) 0.0001 73 (22.1) 17 (23.2) 0.0001 Third 113 (34.2) 74 (65.4) 85 (25.8) 55 (64.7) Fourth 136 (41.2) 93 (68.3) 151 (45.8) 105 (69.6) 1: Score ranges of (0 – 3), (4 – 7), (8 – 11), and (12 – 23), were considered as 1st to 4th quartiles of GBS system, respectively, and (0–1), (2–6), (7–9), and (10–16) were considered the first to 4th quartiles of mGBS system, respectively. 2: Need for at least one of endoscopic, surgical, and radiologic interventions, and blood transfusion. ical intervention in upper GI bleeding" showed that Rock- all and Blatchford models are good predictors for screening more critically ill patients with weaker outcome (14). Com- parison of GBS and AIMS65was also indicative of the superi- ority of GBS in detection of patients with high risk and those in need of blood transfusion and other interventions (12). Laursen et al. in 2012 in a prospective study to compare the scales GBS, EGBS, Rockall, Baylor, and cedars-Sinai cen- ter index regarding prediction of the need for hospital inter- vention, 30-day mortality, early discharge, and re-bleeding showed that GBS determines the need for hospital interven- tion and outpatient visit accurately (15). In contrast, the re- sults of a study on comparison of various scoring systems for patients with non-varicose upper GI bleeding showed that none of the existing systems have proper accuracy in predict- ing the probability of re-bleeding (16). A one-year prospective cohort in 2012 estimated the effi- ciency of GBS and mGBS in prediction of patient outcome to be the same (17). The results of a study by Quach et al. in 2014 in Vietnam was also indicative of the similar efficacy of the 2 mentioned scoring systems in predicting the need for clinical intervention in patients with upper GI bleeding (18). Findings of the present study was similar to Quach and Cheng studies and indicated the similar accuracy of GBS and mGBS systems in predicting outcomes such as need for clin- ical interventions as well as prediction of mortality and need for blood transfusion. However, in this study, the power of the 2 models in prediction of need for hospitalization in ICU was also evaluated, which showed the similar and low accu- racy of both models. The overall accuracy of the models in this study was esti- mated a little lower than previous studies, which might be due to the limitations of this study or the differences in clin- ical decision-making in the studied hospitals. Another rea- son for the low accuracy of models in the present study might be the type of patients evaluated. In this study, only patients whose bleeding was confirmed via endoscopy and were therefore hospitalized were included and thus, a large number of patients who have probably been discharged from emergency department with a very low or low risk have been eliminated and this factor has affected the screening perfor- mance characteristics of the test. It seems that for determin- ing the best clinical decision rule in predicting the outcome of patients with acute upper GI bleeding, more comprehen- sive studies and performing a systematic review and if possi- ble, a meta-analysis are needed. 5. Limitation Small sample size, retrospective design, and probability of selection bias might be among the most important limita- tions of the present study. Additionally, since selection of pa- tients in need of intervention in various hospitals was based on the in-charge physician’s opinion and not a determined standard, therefore this may cause errors in selection of pa- tients. 6. Conclusion Based on the findings of the present study, GBS and mGBS scoring systems have similar accuracy in prediction of the probability of re-bleeding, need for blood transfusion, sur- gical intervention, and endoscopic intervention in patients with acute upper GI bleeding. Regarding prediction of need for hospitalization in ICU and in-hospital mortality, although the difference between the 2 models was statistically signifi- cant, it was not clinically considerable. The overall accuracy of the 2 models in predicting the mentioned outcomes was weak and the highest accuracy of the models belonged to predicting the probability of re-bleeding and need for blood transfusion, which were in the moderate range (70-80). 7. Appendix 7.1. Acknowledgements Hereby, the authors thank all the staff of medical profile archiving units of the studied hospitals for their cooperation in retrieving the clinical profiles of the patients. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 5 Emergency. 2018; 6 (1): e31 7.2. Author contribution All the authors meet the standard criteria of authorship con- tribution based on the recommendations of the international committee of medical journal editors. 7.3. Funding/Support No funds have been received. 7.4. Conflict of interest There are none. References 1. Lassen A, Hallas J, De Muckadell OB. Complicated and uncomplicated peptic ulcers in a Danish county 1993– 2002: a population-based cohort study. The American journal of gastroenterology. 2006;101(5):945. 2. Van Leerdam M, Vreeburg E, Rauws E, Geraedts A, Ti- jssen J, Reitsma J, et al. Acute upper GI bleeding: did anything change?: Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. The American journal of gastroenterology. 2003;98(7):1494-9. 3. Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993–2003. Clinical Gastroenterology and Hep- atology. 2006;4(12):1459-66. e1. 4. Van Leerdam M. Epidemiology of acute upper gastroin- testinal bleeding. Best Practice & Research Clinical Gas- troenterology. 2008;22(2):209-24. 5. Tramer MR, Moore RA, Reynolds DJM, McQuay HJ. Quantitative estimation of rare adverse events which fol- low a biological progression: a new model applied to chronic NSAID use. Pain. 2000;85(1-2):169-82. 6. Lim C, Vani D, Shah S, Everett S, Rembacken B. The out- come of suspected upper gastrointestinal bleeding with 24-hour access to upper gastrointestinal endoscopy: a prospective cohort study. Endoscopy. 2006;38(06):581-5. 7. Kolkman J, Meuwissen S. A review on treatment of bleed- ing peptic ulcer: a collaborative task of gastroenterologist and surgeon. Scandinavian Journal of Gastroenterology. 1996;31(sup218):16-25. 8. Camellini L, Merighi A, Pagnini C, Azzolini F, Guazzetti S, Scarcelli A, et al. Comparison of three different risk scor- ing systems in non-variceal upper gastrointestinal bleed- ing. Digestive and liver disease. 2004;36(4):271-7. 9. Stanley AJ, Dalton HR, Blatchford O, Ashley D, Mowat C, Cahill A, et al. Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage. Al- imentary pharmacology & therapeutics. 2011;34(4):470- 5. 10. Enns RA, Gagnon YM, Barkun AN, Armstrong D, Gregor JC, Fedorak RN, et al. Validation of the Rockall scoring system for outcomes from non-variceal upper gastroin- testinal bleeding in a Canadian setting. World journal of gastroenterology: WJG. 2006;12(48):7779. 11. Cheng D, Lu Y, Teller T, Sekhon H, Wu B. A modified Glas- gow Blatchford Score improves risk stratification in up- per gastrointestinal bleed: a prospective comparison of scoring systems. Alimentary pharmacology & therapeu- tics. 2012;36(8):782-9. 12. Yaka E, Yilmaz S, Ozgur Dogan N, Pekdemir M. Com- parison of the Glasgow-Blatchford and AIMS65 scoring systems for risk stratification in upper gastrointestinal bleeding in the emergency department. Academic Emer- gency Medicine. 2015;22(1):22-30. 13. Quach DT, Dao NH, Dinh MC, Nguyen CH, Ho LX, Nguyen N-DT, et al. The performance of a modified Glas- gow Blatchford score in predicting clinical interventions in patients with acute nonvariceal upper gastrointestinal bleeding: a Vietnamese prospective multicenter cohort study. Gut and liver. 2016;10(3):375. 14. Balaban DV, Strambu V, Florea BG, Cazan AR, Bratucu M, Jinga M. Predictors for in-hospital mortality and need for clinical intervention in upper GI bleeding: a 5-year ob- servational study. Chirurgia (Bucharest, Romania : 1990). 2014;109(1):48-54. 15. Laursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate as- sessment of patients with upper gastrointestinal hemor- rhage. Clinical gastroenterology and hepatology : the of- ficial clinical practice journal of the American Gastroen- terological Association. 2012;10(10):1130-5.e1. 16. Yang HM, Jeon SW, Jung JT, Lee DW, Ha CY, Park KS, et al. Comparison of scoring systems for nonvariceal upper gastrointestinal bleeding: a multicenter prospective co- hort study. Journal of gastroenterology and hepatology. 2016;31(1):119-25. 17. Cheng DW, Lu YW, Teller T, Sekhon HK, Wu BU. A mod- ified Glasgow Blatchford Score improves risk stratifica- tion in upper gastrointestinal bleed: a prospective com- parison of scoring systems. Aliment Pharmacol Ther. 2012;36(8):782-9. 18. Quach DT, Dao NH, Dinh MC, Nguyen CH, Ho LX, Nguyen NT, et al. The Performance of a Modified Glas- gow Blatchford Score in Predicting Clinical Interventions in Patients with Acute Nonvariceal Upper Gastrointesti- nal Bleeding: A Vietnamese Prospective Multicenter Co- hort Study. Gut Liver. 2015. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Introduction Methods Results Discussion Limitation Conclusion Appendix References