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    Glasgow-Blatchford Bleeding Score (GBS)

    Stratifies upper GI bleeding patients who are “low-risk” and candidates for outpatient management.
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    When to Use
    Pearls/Pitfalls
    Why Use
    • Use for adult patients being considered for hospital admission due to upper GI bleeding.
    • Do NOT use in pediatric patients or patients with suspected small bowel or lower GI bleeding.
    • Its use is controversial for patients already admitted, as very few were represented in the original cohort and many of these patients receive endoscopic evaluation.
    • The Glasgow-Blatchford Bleeding Score (GBS) helps identify which patients with upper GI bleeding (UGIB) may be safely discharged from the emergency room.
    • Any of the 9 variables, if present, increase the priority for admission (and likelihood of need for acute intervention).
    • Scores range from 0-23, with higher scores corresponding to increasing acuity and mortality.
    • A score of 0 suggests low risk of complications (0.5%) and these patients may likely not need to be admitted for workup.
    • Scores > 0 do not imply that the patient must be admitted.
    • Clinicians must use their best judgment in assessing whether the patient has heart failure or liver disease. For example, a mild elevation in liver enzymes or steatosis is not considered hepatic failure; likewise, mild diastolic dysfunction was not considered heart failure in the model.
    • History of coffee-ground emesis is NOT counted in the tool as it has a low risk of case fatality (likelihood ratio 0.5).

    Points to keep in mind:

    • Clinicians must use their best judgment in assessing whether the patient has heart failure or liver disease. For example, a mild elevation in liver enzymes or steatosis is not considered hepatic failure; likewise, mild diastolic dysfunction was not considered heart failure in the model.History of coffee-ground emesis is NOT counted in the tool as it has a low risk of case fatality (likelihood ratio 0.5).
    • Its use is controversial for patients already admitted, as very few were represented in the original cohort and many of these patients receive endoscopic evaluation.
    • Variables such as age, creatinine, coagulopathy, mental status, and comorbidities like malignancy or pulmonary disease are not a part of this calculator, although they may impact medical decision making. Other risk assessment tools like the Rockall and AIMS65 scores account for these variables.
    • Easy and quick to calculate.
    • Doesn’t rely on endoscopic findings.
    • Aids in efficient resource utilization.
    • Spares the use of NG lavage.
    • Scores correlate with cost and length of stay, need for blood transfusion, endoscopic treatment, surgery, and mortality.
    • Well-validated in numerous populations.
    • Variables such as age, creatinine, coagulopathy, mental status, and comorbidities like malignancy or pulmonary disease are not a part of this calculator, although they may impact medical decision making. Other risk assessment tools like the Rockall and AIMS65 scores account for these variables.
    • Has been found to be superior to the AIMS65 in predicting need for intervention (transfusion, endoscopic treatment, IR, or surgery) or rebleeding, although the AIMS65 remains a better predictor of mortality (Stanley 2017).
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    Next Steps
    Evidence
    Creator Insights

    Advice

    Once the decision for admission has been made, efforts should focus on stratifying patients into high and low risk categories to determine which patients need ICU admission and urgent endoscopy.

    Management

    Initial management should always focus on hemodynamic resuscitation prior to risk stratification.

    Formula

    Addition of assigned points, as below.

    Facts & Figures

    Glasgow-Blatchford Score
    BUN (mg/dL)
    <18.2 0
    18.2-22.3 +2
    22.4-28 +3
    28-70 +4
    >70 +6
    Hemoglobin (g/dL) for men
    >13 0
    12-13 +1
    10-12 +3
    <10 +6
    Hemoglobin (g/dL) for women
    >12 0
    10-12 +1
    <10 +6
    Systolic blood pressure (mm Hg)
    ≥110 0
    100–109 +1
    90–99 +2
    <90 +3
    Other criteria
    Pulse ≥100 (per min) +1
    Melena present +1
    Presentation with syncope +2
    Liver disease history +2
    Heart failure history +2

    Low risk = Score of 0. Any score higher than 0 is high risk for needing intervention: transfusion, endoscopy, or surgery.

    Evidence Appraisal

    • Originally modeled in a Scottish population in 1997, the Glasgow-Blatchford score is a popular and well validated scoring system for upper GI bleeding.
    • Multiple studies demonstrate better sensitivity than the pre-endoscopy and complete Rockall scores and other validated systems (Pang 2010, Laursen 2012).
    • The AIMS65 Score is a newer and simpler system (albumin, INR >1.5, altered mental status, systolic BP <90, age = 65) derived from a much larger population database. It is designed to predict mortality (Saltzman 2011).
    • The modified GBS performs similarly and takes into account only pulse, blood pressure, BUN, and hemoglobin (Cheng 2012).
    • Although the original study concluded that only scores of 0 were safe for discharge, multiple subsequent trials including Stanley et al (2017) have shown that GBS scores of 1 are also low risk.

    Literature

    Other References

    Research PaperStanley AJ, et. al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. The Lancet. 2009; 373( 9657): 42-7.Research PaperSrygley FD, et al. Does this patient have a severe upper gastrointestinal bleed?. JAMA 307.10 (2012): 1072-1079.Research PaperBlatchford O, Davidson LA, Murray WR, Blatchford M, Pell J. Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study. BMJ. 1997 Aug 30;315(7107):510-4.Research PaperPang SH, Ching JY, Lau JY, et al. Comparing the Blatchford and pre-endoscopic Rockall score in predicting the need for endoscopic therapy in patients with upper GI hemorrhage. Gastrointest Endosc. 2010 Jun;71(7):1134-40.Research PaperLaursen SB, Hansen JM, Schaffalitzky de Muckadell OB. The Glasgow Blatchford score is the most accurate assessment of patients with upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol. 2012 Oct;10(10):1130-1135.Research PaperSaltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc. 2011 Dec;74(6):1215-24.Research PaperCheng DW, Lu YW, Teller T, et al. A modified Glasgow Blatchford Score improves risk stratification in upper gastrointestinal bleed: a prospective comparison of scoring systems. Aliment Pharmacol Ther. 2012 Oct;36(8):782-9.Research PaperStanley AJ, Laine L, Dalton HR, Ngu JH, Schultz M, Abazi R, Zakko L, Thornton S, Wilkinson K, Khor CJ, Murray IA, Laursen SB; International Gastrointestinal Bleeding Consortium. Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study. BMJ. 2017 Jan 4;356:i6432. doi: 10.1136/bmj.i6432.
    Dr. Oliver Blatchford

    About the Creator

    Oliver Blatchford, MD, PhD, MPH, is a consultant in public health medicine working at NHS Health Protection Scotland. He is also honorary senior lecturer in public health at the University of Glasgow. Dr. Blatchford is the specialist lead for tuberculosis control and researches causes of healthcare associated infection (HAI).

    To view Dr. Oliver Blatchford's publications, visit PubMed

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