Gastrointestinal Bleeding: Who Needs Urgent Endoscopic Intervention?

Upper gastrointestinal bleeding (UGIB), a common occurrence, has received a great deal of attention in the clinical literature. UGIB is highly variable in severity and outcome, ranging from clinically insignificant to exsanguinating fatal hemorrhage. Diagnosis of UGIB is generally straightforward with good consensus that resuscitation, circulatory volume replacement and hemodynamic stabilization are the first priorities in management, which may also include intubation, blood transfusion and replacement of clotting factors as needed. Defining the need for and timing of endoscopy has received much less scrutiny. While the ideal might be to provide endoscopy after stabilization, such a practice applied 24 h/day, 7 days/week, would place major burdens on specialist physicians and resource utilization while greatly increasing facility costs. To address these issues, endoscopy within 6, 12, and 24 h of presentation has been advocated, albeit with some defined exceptions. Numerous scoring systems have been proposed to predict prognosis, mortality and the likely need for hospitalization, transfusion, intensive care or surgical intervention [1], but none have been widely adopted. The Glasgow– Blatchford scale [2] is among the most useful, being based on simple clinical findings in the patient prior to endoscopy. Most would agree that a systolic blood pressure (SBP) \100 mmHg, a heart rate (HR) [100/min, or the presence of orthostatic changes, often in the setting of increased bowel sounds, are indicators of a hemorrhage that is severe and ongoing. These signs may however not be present until approximately 30 % of the blood volume has been lost and the patient is about to enter stage III shock, as classified by the American College of Surgeons [3]. Needed are simple methods of quickly identifying the patient who is actively bleeding and in whom endoscopic intervention and therapy would likely arrest hemorrhage and prevent the deterioration that leads to complications such as renal failure, myocardial ischemia or stroke. Development of this kind of score has been attempted with some success, although limited by exclusion of some patient categories, by inclusion of patients up to 12/13 h after presentation, by being positive only when hemorrhage was often advanced, and by ambiguous patient categorization [4, 5]. In this issue of the journal, Iwasaki et al. [6], in a retrospective study of 366 patients with GIB, describe two predictors of active bleeding, identified in the 166 cases that underwent both nasogastric tube aspiration (NGT) and subsequent endoscopy. While the study has a number of shortcomings, nevertheless, in univariate and multivariate analyses, they found two observations, each strongly predictive of endoscopic documentation of active bleeding, namely, a bloody nasogastric aspirate and a HR/SBP ratio C1.4, with the predictive value enhanced when both observations were positive. That the presence of blood in the nasogastric aspirate is highly significant in predicting active or recurrent bleeding is well recognized [4, 5, 7], but despite a wealth of physiologic research on responses to hemorrhage in man and animals, these cardiovascular responses have been understood only superficially by gastroenterologists. In this study a threshold value of HR/ SBP was objectively derived from a receiver operating D. M. McCarthy (&) Raymond G Murphy VA Medical Center, New Mexico Regional VAMC, 1501 San Pedro Blvd. SE, Albuquerque, NM 87108, USA e-mail: denis.mccarthy2@va.gov