What scoring system can be used to determine readiness for discharge in a patient with an upper gastrointestinal (GI) bleed?

Risk Stratification Scores for Upper GI Bleed Discharge Readiness

The Glasgow Blatchford Score (GBS) is the preferred prognostic tool for determining discharge readiness after upper GI bleeding, with a score of 0-1 identifying patients at very low risk who can be safely discharged without hospitalization or inpatient endoscopy. 1, 2

Primary Scoring System: Glasgow Blatchford Score

The GBS should be used as the primary risk stratification tool because it has superior sensitivity (99%) for identifying high-risk patients, meaning it misclassifies ≤1% of high-risk patients as low risk. 1, 2

GBS Components (Pre-Endoscopy)

The GBS includes only clinical and laboratory data available at presentation: 1, 2

• Hemoglobin level
• Blood urea nitrogen level
• Pulse rate
• Systolic blood pressure
• Presence of syncope
• Presence of melena
• Evidence of hepatic disease
• Evidence of cardiac failure

GBS Discharge Threshold

• A GBS score of ≤1 identifies patients at very low risk for rebleeding or mortality who may be safely discharged without hospitalization or inpatient endoscopy 2
• This threshold has excellent sensitivity (98.6%) for detecting high-risk patients 2
• Implementation of GBS-based early discharge reduces hospital admissions and healthcare costs without increasing adverse outcomes 1, 3

Alternative Scoring System: Rockall Score

The Rockall Score exists in two forms and has different utility: 1, 2

Pre-Endoscopic Rockall Score

• Has good sensitivity (93-96%) but may misclassify 4-7% of high-risk patients as low risk 1, 2
• Due to this lower sensitivity compared to GBS, international consensus groups could not make a firm recommendation for or against its use for discharge decisions 1

Complete (Post-Endoscopic) Rockall Score

• Requires endoscopic findings and is used post-endoscopy for comprehensive risk stratification 4, 2
• A complete Rockall score <3 indicates excellent prognosis with very low rebleeding and mortality risk 4
• Better discriminative ability for predicting mortality than rebleeding 1, 2
• Variables include age, shock parameters, comorbidities, endoscopic diagnosis, and stigmata of recent hemorrhage 4

Scoring System NOT Recommended: AIMS65

The AIMS65 score should NOT be used for discharge decisions because it was designed to identify high-risk patients for death rather than low-risk patients for safe discharge. 1, 2

• Even at low cutoff values, AIMS65 misclassifies approximately 20% of high-risk patients as low risk 1
• Has lower sensitivity (78-82%) for identifying high-risk patients compared to GBS 1

Additional Discharge Criteria Beyond Scoring

Clinical Parameters Required for Discharge

Beyond a low GBS score, patients must meet these criteria: 4

• Hemoglobin >100 g/L (10 g/dL) 4
• Normal vital signs: pulse <100 beats/min AND systolic blood pressure >100 mmHg 4
• Age <60 years (in most cases) 4
• Minimal or no comorbid conditions 4

Endoscopic Findings Permitting Discharge

Low-risk endoscopic findings that permit discharge include: 4

• Normal upper GI endoscopy
• Mallory-Weiss tear
• Peptic ulcer with clean base (no stigmata of recent hemorrhage)
• No evidence of varices or upper GI malignancy

Post-Endoscopy Observation

• A stabilization period of 4-6 hours post-endoscopy is necessary, during which pulse, blood pressure, and urine output are continuously monitored 4

High-Risk Findings That Preclude Discharge

Patients with these findings must be hospitalized: 4

• Age >60 years with other risk factors
• Pulse >100 beats/min
• Systolic blood pressure <100 mmHg
• Hemoglobin <100 g/L (10 g/dL)
• Significant comorbid medical diseases
• High-risk endoscopic findings: active bleeding from peptic ulcer, non-bleeding visible vessel, or adherent clot

Practical Implementation Considerations

When deciding on early discharge, consider these contextual factors: 1

• Urban versus rural environment
• Access to hospital or ambulance services
• Access to out-of-hours endoscopy
• Patient preferences regarding diagnostic certainty versus avoiding hospitalization
• Adequate social support and accessibility to hospital 4

Common Pitfalls to Avoid

• Do not use clinical judgment alone without a standardized scoring system, as this cannot be standardized and may lead to inconsistent risk assessment 1
• Do not discharge patients based solely on a low risk score without confirming hemodynamic stability and appropriate hemoglobin levels 4
• Do not use AIMS65 for discharge decisions, as its high false-negative rate makes it unsafe for this purpose 1
• Ensure appropriate therapy is initiated before discharge, including proton pump inhibitor therapy, H. pylori eradication when indicated, and NSAID counseling 4