When can a patient with severe anemia secondary to bleeding peptic ulcer disease (PUD) be considered for discharge?

Discharge Criteria for Severe Anemia Secondary to Bleeding PUD

Patients with severe anemia from bleeding peptic ulcer disease can be safely discharged when they meet ALL of the following criteria: hemoglobin >100 g/L (10 g/dL), hemodynamic stability (pulse <100 bpm AND systolic BP >100 mmHg), low-risk endoscopic findings (clean ulcer base or flat pigmented spot), age <60 years, minimal or no significant comorbidities, adequate social support, and accessibility to hospital. 1

Risk Stratification Framework

Use the Glasgow-Blatchford Score (GBS) as your primary tool to determine discharge readiness, as it has 99% sensitivity for identifying high-risk patients and is specifically designed to identify patients safe for early discharge. 1 A GBS of 0-1 indicates very low risk and potential for outpatient management. 1

• The Rockall Score can be used post-endoscopy for comprehensive risk assessment, with a score <3 indicating excellent prognosis and very low rebleeding/mortality risk. 1
• Do NOT use AIMS65 for discharge decisions, as it was designed to predict mortality rather than identify low-risk patients for safe discharge, and misclassifies approximately 20% of high-risk patients as low risk. 1

Mandatory Clinical Criteria Before Discharge

Hemodynamic Parameters

• Pulse <100 beats/min AND systolic blood pressure >100 mmHg are both required. 1
• Normalization of lactate and base deficit must be achieved. 2
• Urine output >30 mL/hour sustained for observation period. 2

Hemoglobin Threshold

• Hemoglobin must be >100 g/L (10 g/dL) at time of discharge. 1
• This is distinct from the transfusion threshold of 70-80 g/L (7-8 g/dL) during acute management. 2
• For patients with cardiovascular disease, ensure hemoglobin ≥100 g/L (10 g/dL) before discharge. 1

Endoscopic Findings That Permit Discharge

Low-risk endoscopic stigmata include: 2, 1

• Clean ulcer base (no stigmata of recent hemorrhage)
• Flat pigmented spot
• Normal endoscopy findings
• Mallory-Weiss tear

High-risk findings that PRECLUDE discharge: 2, 1

• Active bleeding from peptic ulcer
• Non-bleeding visible vessel (NBVV)
• Adherent clot
• Any evidence of varices or upper GI malignancy

Post-Endoscopy Observation Period

Observe patients for 4-6 hours post-endoscopy with continuous monitoring of pulse, blood pressure, and urine output to ensure sustained hemodynamic stability. 1, 3 During this period, patients who remain stable can begin oral intake with clear liquids progressing to light diet. 3

Absolute Contraindications to Discharge

Do NOT discharge patients with: 2, 1

• Age >60 years (higher risk category)
• Significant comorbid conditions:
  • Heart failure or recent cardiovascular/cerebrovascular event
  • Chronic alcoholism or active cancer
  • Coronary artery disease or pulmonary disease making them susceptible to adverse effects of anemia 2
• Hemodynamic instability despite resuscitation
• High-risk endoscopic stigmata (active bleeding, NBVV, adherent clot)
• Unsuitable social/family conditions or poor accessibility to emergency care 2
• Patients on anticoagulation with major bleeding require correction of coagulopathy and cardiology consultation before discharge 1

Pre-Discharge Management Requirements

Before discharge, ensure the following are addressed: 1

• Initiate appropriate PPI therapy (typically high-dose for 4-6 weeks)
• Arrange H. pylori testing and eradication therapy if positive
• Counsel regarding NSAID avoidance
• Provide clear instructions for signs of rebleeding (melena, hematemesis, dizziness)
• Ensure follow-up appointment scheduled within 1-2 weeks

Evidence Quality and Clinical Implementation

High-quality RCT evidence demonstrates that early discharge of appropriately selected low-risk patients results in no differences in rebleeding, surgery, or mortality rates while significantly reducing costs (median $340 vs $3,940 for admission). 2 The key is strict adherence to the combined clinical and endoscopic criteria outlined above.

Common pitfall to avoid: Do not discharge patients based on clinical criteria alone without endoscopic risk stratification, as this leads to inconsistent risk assessment and potential adverse outcomes. 1 The combination of validated scoring systems (GBS or Rockall) with endoscopic findings provides the most reliable discharge decision framework.