Risk Stratification of Upper Gastrointestinal Bleeding
Singleton Ambulatory Care and Minor Injuries Unit
(MIU)
Prepared by: Dr Chris Johns-Singleton MIU Lead GP
Background
Upper gastrointestinal heamorrhage (UGIH) is a common medical emergency with an
incidence of about 100 per 100 000 adults per annum in the UK. The clinical severity
ranges from insignificant bleeds to catastrophic exsanguinations. Hospital admission
is generally regarded as obligatory, although a substantial proportion of patients are at
very low risk of re-bleeding or death. Early identification of “low risk” patients may
permit safe outpatient management and lead to major resource savings. Scoring
systems that are usually based on clinical and endoscopic data have been successful in
predicting patients at high risk of re-bleeding and death. NICE are due to publish
guidance on Upper GI heamorrhage in July 2012. SIGN however have produced
guidelines for both upper and lower GI bleeding.
http://www.sign.ac.uk/pdf/sign105.pdf
Singleton Hospital is undergoing transformational change moving towards provision
of services on an ambulatory basis. There are plans to consider adopting a Portsmouth
model with acute GPs from MIU taking calls for admission from Swansea Primary
Care colleagues. Where appropriate patients will be assessed, investigated and
discharged back to the community by the acute GP service. During operational hours
the service would
• Receives community requests (GP and where appropriate downgraded ambulance
service request) for adult medical admissions
• Identifies needs of both patient and carer, and seeks to address them in the most
expedient manner
• Supports the Intermediate Care Team with the development of alternatives to acute
hospital admission
This model promotes choice and ownership within each episode of urgent care. It
provides a responsive service and ensures:
• The patient’s choice is always an informed one,
• Decisions are made with them, rather than for them, about where the most
appropriate care can be provided and,
• Risk management plans are discussed and agreed upon. It also provides an
opportunity for GPs and hospital Physicians to challenge traditional ways of working,
and to build relationships enhanced by mutual respect, trust, and an understanding of
each other’s strengths and weaknesses.
One of the areas of care the Plymouth model has focused on is risk stratification of
upper GI haemorrhage.
The Rockall scoring system was principally designed to predict death based on a
combination of clinical and endoscopic findings. One prospective study which
validated the initial (pre-endoscopic) Rockall score confirmed a mortality of less than
1% in patients with a score of 0 or 1, including one death in the score 0 group,
emphasising that no predictive score is totally reliable for the individual.
The Glasgow Blatchford Score (GBS) is a pre-endoscopic risk assessment tool for
patients presenting with upper gastrointestinal haemorrhage (UGIH). It can predict
need for intervention or death and identifies low risk patients suitable for out-patient
management. There are no published data assessing its use in variceal haemorrhage.
Most commonly an upper gastrointestinal bleed is a result of:


chronic peptic ulcer:
o duodenal ulcer (40%)
o gastric ulcer (20%)
acute peptic ulcer (30%)
Less commonly:


Mallory-Weiss syndrome
gastric erosions
Rarely, the following causes will be found:












oesophageal / gastric varices, e.g. in portal hypertension
erosive oesophagitis, e.g. due to a hiatus hernia
duodenitis
gastric carcinoma
bleeding diathesis
hereditary haemorrhagic telangiectasia
pseudoxanthoma elasticum
Ehlers-Danlos syndrome
pseudohaematemesis
small bowel disease, e.g. a very rare tumour
pancreatitis
haemobilia, i.e. bleeding from the gall bladder or biliary tree
Glasgow-Blachford Score
The score is calculated using the table below:
Glasgow-Blatchford Score
Admission risk marker Score component value
Blood Urea
≥6·5 <8·0
2
≥8·0 <10·0
3
≥10·0 <25·0
4
≥25
6
Haemoglobin (g/L) for men
≥12.0 <13.0
1
≥10.0 <12.0
3
<10.0
6
Haemoglobin (g/L) for women
≥10.0 <12.0
1
<10.0
6
Systolic blood pressure (mm Hg)
100–109
1
90–99
2
<90
3
Other markers
Pulse ≥100 (per min)
1
Presentation with melaena 1
Presentation with syncope 2
Hepatic disease
2
Cardiac failure
2
In the validation group, scores of 6 or more were associated with a greater than 50%
risk of needing an intervention.
Score
Score is equal to "0" if the following are all present:

Hemoglobin level >12.9 g/dL (men) or >11.9 g/dL (women)

Systolic blood pressure >109 mm Hg

Pulse <100/minute

Blood urea level <6.5 mg/dL

No meleana or syncope

No past or present liver disease or heart failure
Exclusion criteria for outpatient management of GI bleeding
Singleton Minor Injuries Unit incorporating clinical from the
Rockall scoring system.

Non ambulatory patients

Major comorbidity, cardiac failure, ischaemic heart disease, renal failure,
liver failure or disseminated malignancy.

Age 70 or above.

Geographically unsuitable accommodation or living alone
Pre endoscopic therapy
Pre-endoscopic therapy with high-dose PPI may reduce the numbers of
patients who require endoscopic therapy, but there is no evidence that it alters
important clinical outcomes and there is insufficient evidence to support this
practice. Proton pump inhibitors should not be used prior to diagnosis by endoscopy
in patients presenting with acute upper gastrointestinal bleeding considered for
outpatient management.
Endoscopy Timing
Endoscopy is an effective intervention for acute GI bleeding. The optimal timing of
endoscopy has not been clearly established and there is no consistent definition of an
“early” or “delayed” procedure. Early endoscopy for the purposes of ambulatory
management in Singleton should be considered as within 7 days if score is equal to
zero.
SINGLETON MIU UPPER GI BLEED RISK
STRATIFICATION
GP/Down Graded Ambulance Referral
(History)
Haemodynamically Unstable/Shocked
Haemodynamically Stable
Does not fit
criteria for OPD
Management
Fits criteria for possible
Ambulatory OPD
Management. GB
MIU Assessment
Glasgow Blachford
Score (GBS)
Modified GBS Score ‘0’ and
agrees to OPD Management
Referred to SAU
Modified GBS Score
above ‘0’ or not
agreeable to OPD
Management
Initial Management from MIU and
booked for URGENT OPD Endoscopy
Morriston Hospital