ABSTRACT
Objective: During the COVID-19 pandemic, we extended the low-risk threshold for patients not requiring inpatient endoscopy for upper gastrointestinal bleeding (UGIB) from Glasgow Blatchford Score (GBS) 0-1 to GBS 0-3. We studied the safety and efficacy of this change. Methods: Between 1 April 2020 and 30 June 2020 we prospectively collected data on consecutive unselected patients with UGIB at five large Scottish hospitals. Primary outcomes were length of stay, 30-day mortality and rebleeding. We compared the results with prospective prepandemic descriptive data. Results: 397 patients were included, and 284 index endoscopies were performed. 26.4% of patients had endoscopic intervention at index endoscopy. 30-day all-cause mortality was 13.1% (53/397), and 33.3% (23/69) for pre-existing inpatients. Bleeding-related mortality was 5% (20/397). 30-day rebleeding rate was 6.3% (25/397). 84 patients had GBS 0-3, of whom 19 underwent inpatient endoscopy, 0 had rebleeding and 2 died. Compared with prepandemic data in three centres, there was a fall in mean number of UGIB presentations per week (19 vs 27.8; p=0.004), higher mean GBS (8.3 vs 6.5; p<0.001) with fewer GBS 0-3 presentations (21.5% vs 33.3%; p=0.003) and higher all-cause mortality (12.2% vs 6.8%; p=0.02). Predictors of mortality were cirrhosis, pre-existing inpatient status, age >70 and confirmed COVID-19. 14 patients were COVID-19 positive, 5 died but none from UGIB. Conclusion: During the pandemic when services were under severe pressure, extending the low-risk threshold for UGIB inpatient endoscopy to GBS 0-3 appears safe. The higher mortality of patients with UGIB during the pandemic is likely due to presentation of a fewer low-risk patients.
ABSTRACT
IntroductionIn light of the COVID-19 pandemic, speciality groups have recommended down-scaling endoscopy (OGD) provision to true emergencies only. Following review of a large UK study on Upper Gastrointestinal Bleeding (UGIB), we extended the threshold for patients not requiring inpatient OGD from Glasgow Blatchford Score (GBS) 0-1 to GBS 0-3. We studied the safety and efficacy of this change in practice.MethodsOver 3 months (01/04/20 – 30/06/20), we prospectively collected data on consecutive unselected patients with UGIB at 5 large Scottish hospitals. All patients were followed up for 30 days. Data collected included patient characteristics, referral source, GBS, COVID-19 status, endoscopic findings and interventions, length of stay, rebleeding and mortality. We compared data with pre-pandemic prospective data on UGIB available in 3 of the centres.Results397 patients were included. 69 (17.3%) were pre-existing inpatients. 288 (72.5%) patients received OGD. 36.5% patients had endoscopic intervention at index OGD. Mean length of stay was 7 days. Overall 30-day all-cause mortality rate was 13.1% (53/397) and 33.3% (23/69) for pre-existing inpatients. Bleeding related mortality was 5% (20/397). Overall 30-day rebleeding rate was 6.3% (25/397). On comparison with pre-pandemic data in 3 centres, there was a fall in mean number of UGIB presentations per week (26 vs 19;p=0.004) and a lower proportion of GBS 0-3 presentations (33.3% vs 21.5% p=0.003) during the pandemic, with a rise in mean GBS (6.5 vs 8.3;p<0.001) and all-cause mortality (6.8% vs 12.2% p=0.02). On logistic regression analysis, predictors of all-cause mortality were: cirrhosis, GBS >9, pre-existing inpatient status, age >70, and confirmed COVID-19. 84 (21.2%) patients had GBS 0-3, of whom 19 (22.6%) received inpatient OGD due to clinical concern, with endotherapy used once. Of all GBS 0-3 patients, none had rebleeding, none represented requiring OGD at a later date, and one died due to sepsis. 82 patients were clinically suspected to have COVID-19 at presentation, but only 14 were confirmed on testing. The 30-day all-cause mortality in this group was 20.7% (17/82), and 35.7% in the 14 confirmed cases.ConclusionDuring periods of severe pressure from COVID-19, extending the low-risk threshold for inpatient endoscopy in acute UGIB to GBS 0-3 appears safe. The higher GBS and mortality of patients with UGIB during the pandemic is likely due to non-presentation of lower risk patients as a secondary effect.