What are the criteria for assessing severity of upper gastrointestinal (GI) conditions?

Criteria for Assessing Severity of Upper Gastrointestinal Bleeding

Use the Blatchford score to identify low-risk patients who do not require urgent intervention; a score of 0 has a likelihood ratio of 0.02 for severe bleeding requiring urgent management. 1

Clinical Risk Stratification

High-Risk Features Indicating Severe Bleeding

Hemodynamic instability is the most critical indicator of severe upper GI bleeding requiring immediate intervention. The following features significantly increase the likelihood of severe bleeding requiring urgent endoscopic or interventional therapy:

• Tachycardia (heart rate >100 bpm) increases the likelihood of severe UGIB (LR 4.9; 95% CI, 3.2-7.6) 1
• Hypotension (systolic BP <100 mmHg) or orthostatic changes indicate significant blood loss 2
• Nasogastric lavage with red blood (not just coffee grounds) increases likelihood of severe bleeding (LR 3.1; 95% CI, 1.2-14.0) 1
• Hemoglobin <8 g/dL substantially increases likelihood of severe bleeding requiring intervention (LR range 4.5-6.2) 1
• Bright red blood in nasogastric aspirate is an independent predictor of rebleeding and poor outcomes 2

Laboratory Markers of Severity

• Blood urea nitrogen to creatinine ratio >30 increases likelihood of UGIB (LR 7.5; 95% CI, 2.8-12.0) and suggests significant bleeding 1
• Hematocrit decrease ≥6% or transfusion requirement >2 units packed red blood cells merits ICU admission 2
• Coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) increases bleeding severity and requires correction 2

Validated Risk Scoring Systems

Blatchford Score (Preferred for Initial Triage)

A Blatchford score of 0 effectively rules out the need for urgent intervention (LR 0.02; 95% CI, 0-0.05), allowing safe outpatient management 1. This score incorporates:

• Blood urea nitrogen level
• Hemoglobin concentration
• Systolic blood pressure
• Heart rate
• Presence of melena or syncope
• Hepatic disease or cardiac failure

Patients with Oakland score ≤8 points who are hemodynamically stable can be managed with urgent outpatient investigation rather than admission 2.

Endoscopic Severity Criteria

Forrest Classification for Peptic Ulcer Bleeding

The Forrest classification should be used to document endoscopic findings and predict rebleeding risk 3:

• Forrest Ia/Ib (active arterial spurting or oozing): Highest risk, requires immediate endoscopic therapy
• Forrest IIa (visible vessel): High risk, requires endoscopic therapy
• Forrest IIb (adherent clot): Moderate risk
• Forrest IIc (flat pigmented spot): Low risk
• Forrest III (clean-based ulcer): Lowest risk (comprised 52% of all ulcers in multicenter data) 4

Standardized Documentation Requirements

At minimum, photodocument the following anatomic landmarks: lower esophagus/cardia with squamocolumnar junction, gastroesophageal junction/fundus in retroflexion, body and antrum in anterograde view, incisura in retroflexion, and distal extent in duodenum 3.

Mortality and Morbidity Indicators

Upper GI bleeding carries mortality rates as high as 14% despite declining incidence, with 100 episodes per 100,000 admissions annually in the United States 3.

Features Associated with Increased Mortality

• Hemodynamic instability at presentation requiring vasopressor support 2
• Active bleeding on endoscopy (Forrest Ia/Ib) 3
• Rebleeding after initial hemostasis (predicted by bright red blood in NG aspirate) 2
• Significant comorbidities including liver disease, renal failure, or cardiovascular disease 2
• Advanced age and male gender are associated with worse outcomes 4

Common Etiologies by Severity

Ulcer disease accounts for 32.7% of nonvariceal UGIB, followed by erosions (18.8%) 4. Among ulcers:

• Gastric ulcers are more common than duodenal ulcers (54.4% vs 37.1%) 4
• Inpatient procedures more commonly identify ulcers and Mallory-Weiss tears, while outpatient ulcers are more likely clean-based 4
• Dieulafoy lesions account for 1-2% of acute UGIB but are underrecognized and can cause severe bleeding 3

Critical Pitfalls to Avoid

• Never assume lower GI source based solely on hematochezia: up to 15% of apparent lower GI bleeds originate from upper GI sources 2
• Do not delay resuscitation while pursuing diagnostic tests: stabilization always takes precedence 2
• Avoid assuming benign disease in patients with hemodynamic instability: these patients require ICU admission and urgent endoscopy within 24 hours 5, 2
• Do not overlook the need for correction of coagulopathy before endoscopic intervention in anticoagulated patients 2

Timing of Endoscopy Based on Severity

• Hemodynamically unstable patients: Proceed directly to CT angiography if endoscopy cannot be performed safely, followed by visceral angiography if needed 5, 2
• Stable patients with high-risk features: Upper endoscopy within 24 hours of presentation after hemodynamic stabilization 5, 2
• Low-risk patients (Blatchford score 0): Can be managed with outpatient endoscopy 1