Endoscopy 2020; 52(10): 930-931
DOI: 10.1055/a-1202-1374
Letter to the editor

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

Stig B. Laursen
1  Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
,
Ian M. Gralnek
2  Ellen and Pinchas Mamber Institute of Gastroenterology, Emek Medical Center, Afula, Israel
,
Adrian J. Stanley
3  Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, United Kingdom
› Author Affiliations
 

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.


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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.


Corresponding author

S.B. Laursen, MD
Department of Medical Gastroenterology, Odense University Hospital
29 Søndre Boulevard, 5000 Odense C
Denmark   
Fax: +45-66-111328   

Publication History

Publication Date:
23 September 2020 (online)

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