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.
Methods
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.
Results
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.
Conclusions
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

Graphical Abstract
Abbreviations:
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)To read this article in full you will need to make a payment
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References
- Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.Gastroenterology. 2019; 156 (e11): 254-272
- Management of patients with ulcer bleeding.Am J Gastroenterol. 2012; 107 (quiz 61): 345-360
- The role of endoscopy in the management of acute non-variceal upper GI bleeding.Gastrointest Endosc. 2012; 75: 1132-1138
- Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?.Endoscopy. 1989; 21: 258-262
- ASGE guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005.Gastrointest Endosc. 2005; 62: 651-655
- Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding.Gut. 2011; 60: 1170-1177
- 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
- Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline.Endoscopy. 2015; 47: a1-a46
- Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the international consensus group.Ann Intern Med. 2019; 171: 805-822
- 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
- Management of patients with nonvariceal upper gastrointestinal bleeding.Clin Gastroenterol Hepatol. 2012; 10: 234-239
- Schockpathogenese und ihre Differentialdiagnose.Der Chirurg. 1967; 38: 98-102
- Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding.Endoscopy. 2011; 43: 300-306
- 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
- Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.Biometrics. 1988; 44: 837-845
- 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
- A national survey on the initial management of upper gastrointestinal bleeding.J Clin Gastroenterol. 2014; 48: e93-e98
- Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial.Gastrointest Endosc. 2002; 55: 1-5
- Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.Gastrointest Endosc. 1999; 50: 755-761
- A risk score to predict need for treatment for upper-gastrointestinal haemorrhage.Lancet. 2000; 356: 1318-1321
- 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
- Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.Lancet. 2009; 373: 42-47
- Comparison of risk scoring systems for patients presenting with upper gastrointestinal bleeding: international multicentre prospective study.BMJ. 2017; 356: i6432
- 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
- International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.Ann Intern Med. 2010; 152: 101-113
- The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding.Gastrointest Endosc. 2013; 77: 551-557
- Transfusion strategies for acute upper gastrointestinal bleeding.N Engl J Med. 2013; 368: 11-21
- 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
- Risk assessment tools for gastrointestinal bleeding.Clin Gastroenterol Hepatol. 2016; 14: 1571-1573
- Evaluation of scoring systems without endoscopic findings for predicting outcomes in patients with upper gastrointestinal bleeding.BMC Gastroenterol. 2017; 17: 159
- 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
- Outcomes and role of urgent endoscopy in high-risk patients with acute nonvariceal gastrointestinal bleeding.Clin Gastroenterol Hepatol. 2018; 16: 370-377
- Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study.Gastrointest Endosc. 2017; 85: 936-944
- 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
- MAP(ASH): A new scoring system for the prediction of intervention and mortality in upper gastrointestinal bleeding.J Gastroenterol Hepatol. 2020; 35: 82-89
- The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding.Z Gastroenterol. 2018; 56: 479-487
- Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding.Gastroenterology. 2020; 158: 160-167
Article info
Publication history
Published online: March 30, 2020
Accepted:
March 19,
2020
Received:
November 5,
2019
Footnotes
DISCLOSURE: All authors disclosed no financial relationships. Dr Horibe received research support for this study from the Japanese Society for Abdominal Emergency Medicine.
See CME section; p. 754.
Identification
Copyright
© 2020 by the American Society for Gastrointestinal Endoscopy
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