低风险性上消化道出血患者的门诊处理：

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多中心验证和前瞩性评价。
Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.
低风险性上消化道出血患者的门诊处理：多中心验证和前瞩性评价。
出处：Lancet   2009  Jan  373(9657) :42-7
作者：Stanley AJ;Ashley D;Dalton HR;Mowat C;Gaya DR;Thompson E;Warshow U;Groome M;Cahill A;Benson G;Blatchford O;Murray W
PMID：19091393

BACKGROUND: Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals. METHODS: Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients. FINDINGS: Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001). INTERPRETATION: The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

背景：上消化道出血是一种常见的入院病因。虽然这种疾病的大多数风险评分系统要结合内镜表现，Glasgow- Blatchford出血评分（GBS）是基于简单的临床与实验室变量;以0分标志可能需要门诊处理的低风险患者。我们的目的是依据非入院的低风险个体的这一得分，对GBS进行评估，然后再对有效性进行评估。方法：我们的研究由英国四所医院承担。我们对表现为上消化道出血的患者计算GBS和入院（内窥镜检查前）与Rockall完全（内窥镜检查后）评分。我们采用接收器工作特性（ROC）曲线，对这些得分预测必需临床干预或死亡的能力进行比较。然后，我们对两个医院G引入BS评分以避免低风险患者的入院进行了前瞻性评估。结果：在676例表现上消化道出血的患者中，我们确定了105例（ 16 ％ ）GBS得分为0的患者。对于需要干预或死亡的预测，GBS（ ROC曲线下面积为0.90 [ 95 ％ CI，0.88-0.93 ] ）明显优于Rockall完全评分（ 0.81 [ 0.77-0.84 ] ），这反过来又优于Rockall入院评分（ 0.70 [ 0.65-0.75 ] ）。当引入到临床实践中， 123例（ 22 ％ ）上消化道出血患者被列入低风险，其中84例（ 68 ％ ）作为无不良反应事件的门诊患者处理。被接收入院的此条件下的个体比例也有所下降（96％－71％，P<0.00001）。阐述：GBS确定了许多前往综合性医院就医的表现为上消化道出血的患者，这些患者可作为门诊患者安全地进行处理。这评分降低了此条件下患者的入院，使得住院患者资源的利用更为恰当。

专家评价：
Ian Beales
University of East Anglia, United Kingdom
Gastroenterology &amp; Hepatology
Changes Clinical Practice: These data support those published in the original report on the Glasgow-Blatchford Score (GBS) for gastrointestinal (GI) haemorrhage and show that non-admission without gastroscopy is an appropriate management strategy in the low-risk patients (with low GBS)
This paper confirms that a policy of non-admission without endoscopy for patients presenting with upper GI haemorrhage and a low GBS is safe and effective. This will help the initial triage of patients and enhance effective use of resources.
Upper GI bleeding remains and important cause of presentation to gastroenetrologists and emergency departments. Previous systems of risk stratification have been described. Of these, the Rockall score is the most widely used and validated {1,2}. Whilst this is useful for comparing outcomes in hospitalized patients, the score is much less useful in accurately detecting those at lowest risk (usually defined as those requiring endoscopic therapy or transfusion or dying) from their GI bleeding. Accurate detection of this group would facilitate an outpatient-based strategy avoiding admissions. The GBS was reported as more accurate in detecting these low-risk patients {3-5}. This is the important subsequent validation study. The key finding was that a GBS of zero was not associated with any requirement for subsequent transfusion or endoscopic therapy and not associated with any subsequent risk of dying related to the GI haemorrhage. Patients were safely managed without admission, and follow-up endoscopy was not mandatory. Only 40% of those offered outpatient endoscopy did attend (in these, no malignant disease, varices or ulcers were found). Follow up of those that did not have endoscopy showed no recurrent admissions with GI haemorrhage within 6 months. This study provides essential support for a conservative policy of non-admission and non-endoscopy in these lowest risk patients. These data are consistent with other studies showing a 100% negative predictive rate for re-bleeding, intervention or death {4,5}. A GBS of zero comprises urea <6.5mmol/L, haemoglobin >130g/L (men) or >120g/L (women), systolic blood pressure >110mmHg, pulse <100/min, absence of melaena, syncope, cardiac failure or liver disease. Age is not a feature of the GBS.
John Inadomi
with Ma Somsouk
San Francisco General Hospital, United States of America
Gastroenterology &amp; Hepatology
According to this study, the Glasgow-Blatchford bleeding score (GBS) can accurately identify patients with upper gastrointestinal hemorrhage who can be managed safely as outpatients, which is expected to reduce utilization of medical resources.
Upper gastrointestinal hemorrhage is a frequent cause of admission to the hospital. However, many patients do not need endoscopic treatment, surgery or blood transfusion and therefore could be managed without hospitalization. Accurate identification of patients who could be safely managed as outpatients is lacking. Moreover, most risk-scoring systems incorporate findings at endoscopy, which generally requires hospital admission. The GBS score is based on several simple clinical and laboratory variables and not on endoscopic findings. The investigators evaluated the performance of the GBS score against the Rockall score, which incorporates both endoscopic and non-endoscopic criteria for risk stratification. In phase one of the study, consecutive patients from four hospitals in the United Kingdom were retrospectively and prospectively reviewed to evaluate the performance of the prognostic models. 105 out of 676 (16%) of the subjects had a GBS score of 0; none of these patients had an adverse outcome, that is, need for clinical intervention (blood transfusion, endoscopic treatment or surgery) or death. The Rockall score, by both pre-endoscopy and post-endoscopy criteria, was less predictive, with 32 out of 184 (17%) of patients with the lowest score dying or still requiring intervention. In phase two, physicians at two hospitals were notified if patients in the emergency room had a GBS score of zero. 123 out of 491 (22%) patients presenting with upper gastrointestinal hemorrhage were identified as low risk with a GBS score of 0. Of these 123 subjects, 84 subjects were managed as outpatients without any events. It is unclear why the remaining 39 patients were hospitalized, although some subjects had alcohol withdrawal and others had poor social circumstances precluding discharge. Before introduction of the GBS risk stratification system, only 6% of patients identified as being low risk (GBS=0) were managed as outpatients. After introduction, 68% of low risk patients were managed as outpatients. GBS identifies subjects at low risk for requiring interventions provided during hospital admission. These patients have normal blood urea nitrogen and hemoglobin, systolic blood pressure =/>110mmHg, pulse <100 beats per minute and absence of melena, syncope, cardiac failure or liver disease. Implementation of a process by which patients are triaged using GBS may reduce resource expenditure without compromising patient safety. Future studies will be necessary to determine whether the scoring system could be safely expanded to GBS of 1 or 2, since the need for clinical intervention in such patients is still quite low at 2%.