Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding

Published:March 30, 2020DOI:https://doi.org/10.1016/j.gie.2020.03.3846

      Background and Aims

      Although upper GI bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3-variable score (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure] ≥1, and blood urea nitrogen/creatinine ≥30 [urea/creatinine≥140]), the Horibe gAstRointestinal BleedING scoRe (HARBINGER), with the 8-variable Glasgow-Blatchford Score (GBS) and 5-variable AIMS65 to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy.


      Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. On presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata.


      Of 1486 enrolled patients, 637 (43%) harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver operating characteristic curve (AUC) for the HARBINGER was .76 (95% confidence interval [CI], .72-.79), which was significantly superior to both the GBS (AUC, .68; 95% CI, .64-.71; P < .001) and the AIMS65 (AUC, .54; 95% CI, .50-.58; P < .001). When the HARBINGER cutoff value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively.


      The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and AIMS65.

      Graphical abstract


      AUC (area under the receiver operating characteristic curve), CI (confidence interval), GBS (Glasgow-Blatchford Score), HARBINGER (Horibe gAstRointestinal BleedING prEdiction scoRe), IDI (integrated discrimination improvement), NRI (net reclassification improvement), UGIB (upper GI bleeding)
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        • Peery A.F.
        • Crockett S.D.
        • Murphy C.C.
        • et al.
        Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.
        Gastroenterology. 2019; 156 (e11): 254-272
        • Laine L.
        • Jensen D.M.
        Management of patients with ulcer bleeding.
        Am J Gastroenterol. 2012; 107 (quiz 61): 345-360
        • Hwang J.H.
        • Fisher D.A.
        • Ben-Menachem T.
        • et al.
        The role of endoscopy in the management of acute non-variceal upper GI bleeding.
        Gastrointest Endosc. 2012; 75: 1132-1138
        • Heldwein W.
        • Schreiner J.
        • Pedrazzoli J.
        • et al.
        Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?.
        Endoscopy. 1989; 21: 258-262
        • Qureshi W.
        • Adler D.G.
        • Davila R.
        • et al.
        ASGE guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005.
        Gastrointest Endosc. 2005; 62: 651-655
        • Sung J.J.
        • Chan F.K.
        • Chen M.
        • et al.
        Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding.
        Gut. 2011; 60: 1170-1177
        • Horibe M.
        • Kaneko T.
        • Yokogawa N.
        • et al.
        A simple scoring system to assess the need for an endoscopic intervention in suspected upper gastrointestinal bleeding: a prospective cohort study.
        Dig Liver Dis. 2016; 48: 1180-1186
        • Gralnek I.M.
        • Dumonceau J.M.
        • Kuipers E.J.
        • et al.
        Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline.
        Endoscopy. 2015; 47: a1-a46
        • Barkun A.N.
        • Almadi M.
        • Kuipers E.J.
        • et al.
        Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the international consensus group.
        Ann Intern Med. 2019; 171: 805-822
        • Horibe M.
        • Ogura Y.
        • Matsuzaki J.
        • et al.
        Absence of high-risk stigmata predicts good prognosis even in severely anemic patients with suspected acute upper gastrointestinal bleeding.
        United Eur Gastroenterol J. 2018; 6: 684-690
        • Greenspoon J.
        • Barkun A.
        • Bardou M.
        • et al.
        Management of patients with nonvariceal upper gastrointestinal bleeding.
        Clin Gastroenterol Hepatol. 2012; 10: 234-239
        • Allower M.
        • Grober U.
        Schockpathogenese und ihre Differentialdiagnose.
        Der Chirurg. 1967; 38: 98-102
        • Lim L.G.
        • Ho K.Y.
        • Chan Y.H.
        • et al.
        Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding.
        Endoscopy. 2011; 43: 300-306
        • Robertson M.
        • Majumdar A.
        • Boyapati R.
        • et al.
        Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems.
        Gastrointest Endosc. 2016; 83: 1151-1160
        • DeLong E.R.
        • DeLong D.M.
        • Clarke-Pearson D.L.
        Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
        Biometrics. 1988; 44: 837-845
        • Pencina M.J.
        • D'Agostino Sr., R.B.
        • D'Agostino Jr., R.B.
        • et al.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27 (discussion 207-12): 157-172
        • Liang P.S.
        • Saltzman J.R.
        A national survey on the initial management of upper gastrointestinal bleeding.
        J Clin Gastroenterol. 2014; 48: e93-e98
        • Cipolletta L.
        • Bianco M.A.
        • Rotondano G.
        • et al.
        Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial.
        Gastrointest Endosc. 2002; 55: 1-5
        • Lee J.G.
        • Turnipseed S.
        • Romano P.S.
        • et al.
        Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.
        Gastrointest Endosc. 1999; 50: 755-761
        • Blatchford O.
        • Murray W.R.
        • Blatchford M.
        A risk score to predict need for treatment for upper-gastrointestinal haemorrhage.
        Lancet. 2000; 356: 1318-1321
        • Saltzman J.R.
        • Tabak Y.P.
        • Hyett B.H.
        • et al.
        A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding.
        Gastrointest Endosc. 2011; 74: 1215-1224
        • Stanley A.J.
        • Ashley D.
        • Dalton H.R.
        • et al.
        Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.
        Lancet. 2009; 373: 42-47
        • Stanley A.J.
        • Laine L.
        • Dalton H.R.
        • et al.
        Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.
        BMJ. 2017; 356: i6432
        • Park S.M.
        • Yeum S.C.
        • Kim B.W.
        • et al.
        Comparison of AIMS65 score and other scoring systems for predicting clinical outcomes in Koreans with nonvariceal upper gastrointestinal bleeding.
        Gut Liver. 2016; 10: 526-531
        • Barkun A.N.
        • Bardou M.
        • Kuipers E.J.
        • et al.
        International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.
        Ann Intern Med. 2010; 152: 101-113
        • Hyett B.H.
        • Abougergi M.S.
        • Charpentier J.P.
        • et al.
        The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding.
        Gastrointest Endosc. 2013; 77: 551-557
        • Villanueva C.
        • Colomo A.
        • Bosch A.
        • et al.
        Transfusion strategies for acute upper gastrointestinal bleeding.
        N Engl J Med. 2013; 368: 11-21
        • Odutayo A.
        • Desborough M.J.
        • Trivella M.
        • et al.
        Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials.
        Lancet Gastroenterol Hepatol. 2017; 2: 354-360
        • Laine L.
        Risk assessment tools for gastrointestinal bleeding.
        Clin Gastroenterol Hepatol. 2016; 14: 1571-1573
        • Ko I.G.
        • Kim S.E.
        • Chang B.S.
        • et al.
        Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding.
        BMC Gastroenterol. 2017; 17: 159
        • Barkun A.
        • Sabbah S.
        • Enns R.
        • et al.
        The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.
        Am J Gastroenterol. 2004; 99: 1238-1246
        • Cho S.H.
        • Lee Y.S.
        • Kim Y.J.
        • et al.
        Outcomes and role of urgent endoscopy in high-risk patients with acute nonvariceal gastrointestinal bleeding.
        Clin Gastroenterol Hepatol. 2018; 16: 370-377
        • Laursen S.B.
        • Leontiadis G.I.
        • Stanley A.J.
        • et al.
        Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study.
        Gastrointest Endosc. 2017; 85: 936-944
        • Bagin V.
        • Tarasov E.
        • Astafyeva M.
        • et al.
        Quick SOFA vs Rockall preendoscopy scores for risk assessment in patients with nonvariceal upper gastrointestinal bleeding: a retrospective cohort study.
        Int J Emerg Med. 2019; 12: 10
        • Redondo-Cerezo E.
        • Vadillo-Calles F.
        • Stanley A.J.
        • et al.
        MAP(ASH): A new scoring system for the prediction of intervention and mortality in upper gastrointestinal bleeding.
        J Gastroenterol Hepatol. 2020; 35: 82-89
        • Nguyen-Tat M.
        • Cornelius C.
        • Hoffman A.
        • et al.
        The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding.
        Z Gastroenterol. 2018; 56: 479-487
        • Shung D.L.
        • Au B.
        • Taylor R.A.
        • et al.
        Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding.
        Gastroenterology. 2020; 158: 160-167

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