Application and Internal Validation of the Modified Glasgow-Blatchford Score for Early Triage of Acute Upper Gastrointestinal Bleeding

Summary

This retrospective cohort study evaluates the modified Glasgow-Blatchford score for objective early triage of acute upper gastrointestinal bleeding, focusing on low-risk classification, false-negative cases, and clinical safety.

Abstract

Acute upper gastrointestinal bleeding requires early risk stratification to identify patients who may need urgent intervention while avoiding unnecessary hospitalization among low-risk cases. This retrospective single-center cohort study evaluated the modified Glasgow-Blatchford score as an objective triage tool in comparison with the original Glasgow-Blatchford score. A total of 366 consecutive patients with acute upper gastrointestinal bleeding were included. Clinical presentation, initial vital signs, and the earliest laboratory results obtained at presentation were used to calculate both scores. The primary high-risk outcome was a composite of in-hospital blood transfusion, therapeutic endoscopy, surgery, or death. Using a predefined low-risk threshold of ≤1, diagnostic performance was evaluated overall and in variceal and non-variceal subgroups. Overall, 151 of 366 patients (41.26%) met the composite high-risk outcome, and 18 patients (4.92%) died during hospitalization. At the predefined threshold, the modified score showed higher sensitivity, specificity, positive predictive value, negative predictive value, and agreement than the original score, with the greatest gains observed in specificity (45.58% vs. 40.00%) and negative predictive value (98.00% vs. 94.51%). The modified score classified 9 additional patients as low risk and reduced false-negative low-risk classifications from 5 cases to 2 cases. Specificity was also higher in both bleeding-etiology subgroups. Mortality discrimination was more favorable for the modified score, although this finding should be interpreted cautiously because only 18 deaths occurred. These findings suggest that the modified Glasgow–Blatchford score may support a more standardized objective approach to early triage, but the remaining false-negative cases indicate that it should be used as an adjunct to clinical assessment rather than as a stand-alone discharge tool.

Introduction

Acute upper gastrointestinal bleeding refers to hemorrhage arising proximal to the ligament of Treitz and involving the esophagus, stomach, or duodenum¹. Although hospitalization and mortality associated with upper gastrointestinal bleeding have declined over time, acute upper gastrointestinal bleeding remains a common medical emergency and continues to impose substantial clinical burden². Patients commonly present with melena, hematemesis, or both, and the annual incidence remains considerable in adult populations³. Most episodes are non-variceal and are frequently related to peptic ulcer disease, acute gastric mucosal injury, Mallory-Weiss syndrome, stress-related mucosal lesions, or upper gastrointestinal malignancy⁴. In contrast, variceal bleeding remains a particularly severe presentation associated with cirrhosis and portal hypertension and continues to carry substantial early mortality⁵.

Upper gastrointestinal endoscopy remains the standard diagnostic and therapeutic procedure for acute upper gastrointestinal bleeding. However, not all patients require urgent endoscopic therapy, blood transfusion, surgery, or prolonged hospitalization. Early pre-endoscopic risk stratification is therefore central to emergency department triage because it may help identify patients who are likely to require hospital-based intervention while also supporting recognition of patients at very low risk who may not require admission⁶. Several pre-endoscopic scoring systems have been used in this setting, including the Glasgow-Blatchford score, the pre-endoscopic Rockall score, and AIMS65⁷. These tools differ in emphasis. The Glasgow-Blatchford score was originally developed to predict the need for clinical intervention, whereas the pre-endoscopic Rockall score and AIMS65 are more often discussed in relation to broader prognostic assessment and mortality-oriented risk evaluation⁸. Comparative studies have shown that the Glasgow-Blatchford score often performs well for identifying patients who may require treatment, but the practical value of any pre-endoscopic score in emergency care still depends on whether its variables can be obtained rapidly, consistently, and reproducibly during the initial assessment⁹.

The Glasgow-Blatchford score incorporates blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, melena, syncope, liver disease, and heart failure¹⁰. This structure gives the score clear clinical relevance, but several components depend on symptom reporting, prior history ascertainment, documentation quality, or clinician judgment. In time-sensitive emergency settings, these factors may reduce scoring consistency across evaluators and may limit workflow standardization. To address this concern, previous investigators proposed a modified Glasgow-Blatchford score based on objective variables only¹¹. From a practical perspective, such an approach may be particularly useful in early triage settings in which rapid data capture, reproducibility, and reduced inter-observer variability are important. At the same time, any simplification of the original score must still preserve adequate safety for low-risk classification, because greater objectivity is not clinically meaningful if discrimination becomes insufficient for routine use.

The concept of the modified Glasgow-Blatchford score is therefore not new. However, its role in routine emergency department triage remains incompletely characterized in real-world cohorts, particularly when it is compared directly with the original Glasgow-Blatchford score under the same operational outcome framework and low-risk threshold. This gap is clinically important because a more objective score may improve implementation consistency, but its value depends on whether this simplification preserves clinically acceptable identification of low-risk patients and acceptable discrimination of high-risk outcomes. Existing literature has described the modified score, yet further cohort-based validation remains necessary to clarify its practical applicability, its likely constraints, and its performance in contemporary emergency department workflow rather than under purely conceptual comparison alone.

Accordingly, the present study was designed as a single-center retrospective internal validation and application analysis rather than as a new score-development study. Clinical presentation, initial vital signs, and the earliest laboratory findings recorded at presentation were used to calculate both the original Glasgow-Blatchford score and the modified Glasgow-Blatchford score. No recalibration or threshold optimization was performed. Instead, a predefined low-risk threshold of 1 or less was used for comparative analysis to evaluate whether the modified score could support a more standardized and objective approach to early triage of acute upper gastrointestinal bleeding in routine emergency department practice.

Protocol

This retrospective study was conducted in accordance with institutional requirements and the Declaration of Helsinki. Ethics approval was obtained from the Research Ethics Committee of Qinghai Provincial People’s Hospital (Approval No. [2023]-045; approved on May 18, 2023) before the record review was initiated. All patient identifiers were removed before analysis, and only de-identified data were used for score reconstruction and statistical evaluation.

Study design and study period

A single-center retrospective cohort study was conducted to evaluate the modified Glasgow-Blatchford score for early risk stratification in acute upper gastrointestinal bleeding. Consecutive eligible admissions between January 2023 and January 2025 were identified from the hospital information system and electronic medical record system. The study was positioned as an internal validation and application analysis rather than as a new score-development study or a threshold-recalibration study.

Patient screening and eligibility criteria

Hospitalized patients during the study period were screened for eligibility by reviewing admission records and emergency department documentation. Patients were included if they were 18 to 80 years of age and had presented within the preceding 24 h with overt acute upper gastrointestinal bleeding, defined as hematemesis and/or melena. Patients were excluded if gastrointestinal bleeding developed after hospitalization for another primary condition, if pregnancy was documented, if acute lower gastrointestinal bleeding was confirmed, or if any variables required to calculate the original Glasgow-Blatchford score or the modified Glasgow-Blatchford score were missing from presentation. A screening log was maintained during case review to document the total number of screened patients, exclusions by reason, the number excluded because of incomplete score variables, and the final analytic cohort size. Cohort derivation is summarized in Figure 1.

Data collection and variable definitions

Demographic variables, including age and sex, were extracted from admission registration records. Presenting symptoms and signs were abstracted from the first emergency department assessment note, including hematemesis, melena, syncope, and hematochezia. The first recorded vital signs, specifically systolic blood pressure and heart rate, were extracted from the emergency department triage record in order to reflect the earliest clinically available pre-endoscopic assessment. Comorbidities required for the original Glasgow-Blatchford score, specifically liver disease and heart failure, were recorded according to the documented medical history and admission assessment. Laboratory variables were extracted from the earliest blood sample obtained at presentation. Hemoglobin and blood urea nitrogen were used for score calculation. Albumin, when available, was recorded as a baseline descriptive variable only and was not included in the original Glasgow-Blatchford score, the modified Glasgow-Blatchford score, or the primary comparative analysis.

If serial laboratory measurements were available at 0 h, 6 h, and 24 h, only the earliest presentation-time values were used for score calculation. Likewise, if repeated vital signs were recorded during emergency department observation, only the first arrival values were used. This rule was applied uniformly across all cases so that both scores reflected the same early triage time point. The collected variables, source documents, and extraction time points are summarized in Table 1. Hospital-course variables were extracted from the full electronic medical record, including red blood cell transfusion, endoscopic management, surgery, discharge status, and all-cause in-hospital death. Bleeding etiology was classified as variceal or non-variceal according to the endoscopy report when available. If endoscopic confirmation was unavailable, the treating team’s documented discharge diagnosis was used, and the same classification rule was applied consistently across all patients.

GBS and mGBS calculation

The original Glasgow-Blatchford score was calculated from blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, melena, syncope, liver disease, and heart failure according to the standard scoring criteria shown in Table 2. The total score range was 0 to 23. The modified Glasgow-Blatchford score was calculated by retaining objective presentation-time variables only, including blood urea nitrogen, hemoglobin, systolic blood pressure, and heart rate, according to the modified scoring criteria shown in Table 3. The total score range was 0 to 16.

Both scores were reconstructed retrospectively from the same presentation-time data source for each patient, using the first recorded arrival vital signs and the earliest presentation-time laboratory values, following the workflow summarized in Figure 2. For comparative analysis, a low-risk threshold of 1 or less was applied to both scores. For the original Glasgow-Blatchford score, this threshold was consistent with guideline-supported identification of very-low-risk patients. For the modified Glasgow-Blatchford score, the same threshold was used as a predefined comparative rule to permit direct comparison with the original score and was not recalibrated within the present cohort. Both the original and modified Glasgow-Blatchford scores were calculated retrospectively after chart abstraction. Neither score guided transfusion, endoscopy, surgery, admission level, nor discharge decisions during real-time clinical care.

Outcome definition and adjudication

The primary high-risk outcome was defined as in-hospital intervention and/or all-cause in-hospital death. Intervention was defined as red blood cell transfusion, therapeutic endoscopic hemostasis, or surgery during the index hospitalization. Diagnostic endoscopy without hemostatic treatment was not classified as an intervention outcome. Transfusion status was adjudicated directly from the inpatient record. During the study period, transfusion decisions were made by the treating clinicians according to institutional practice and the patient’s clinical condition rather than by study investigators. These decisions were based on hemoglobin level, ongoing bleeding status, hemodynamic stability, and relevant comorbid conditions as documented in the medical record.

Endoscopy timing and procedure type were abstracted from the endoscopy report and procedure record. Endoscopy was generally performed after initial stabilization when clinically indicated. Only therapeutic endoscopic procedures involving active hemostatic treatment were classified as intervention outcomes. Surgical intervention was confirmed from the operative and hospitalization records. Patients were assigned to the high-risk outcome group if any intervention was performed and/or in-hospital death occurred. Patients were assigned to the low-risk outcome group if no intervention was performed, and survival to discharge was documented. The same outcome definition was applied to the overall cohort and to the variceal and non-variceal subgroup analyses.

Statistical analysis

Continuous variables were summarized as mean ± standard deviation when normally distributed and as median with interquartile range when non-normally distributed. Categorical variables were summarized as n (%). Between-group comparisons were performed using the independent-samples t test for normally distributed continuous variables, the rank-sum test for non-normally distributed continuous variables, and the chi-square test or Fisher exact test for categorical variables, as appropriate.

At the predefined threshold of 1 or less, sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for both scores together with 95% confidence intervals. Absolute false-negative counts and false-positive counts were also recorded. Agreement between score-based classification and observed clinical outcomes was assessed using Cohen’s kappa with 95% confidence intervals. Receiver operating characteristic curves were generated for both scores for the primary composite outcome and for in-hospital mortality. The area under the curve with 95% confidence intervals was calculated, and the areas under the correlated receiver operating characteristic curves were compared using the DeLong method. Comparative analyses of paired sensitivity and specificity were performed using McNemar testing, and exact P values were reported. Calibration was assessed by comparing observed and predicted event frequencies across score levels and by visual inspection of calibration plots. Decision curve analysis was performed to compare the net clinical benefit of the two scores across clinically relevant threshold probabilities. Prespecified subgroup analyses were conducted for variceal and non-variceal bleeding using the same outcome definition, threshold rule, and performance metrics. Because the number of mortality events and the size of the variceal subgroup were limited, these analyses were interpreted cautiously. A sensitivity analysis using alternative modified Glasgow-Blatchford score cutoffs was also performed. The corresponding comparative performance figures are presented in Figure 3.

Results

Patient flow and baseline characteristics

A total of 402 patients presented to the emergency department with acute upper gastrointestinal bleeding during the study period. After application of the eligibility criteria, 366 patients were included in the final analysis, as shown in Figure 1. Baseline demographic and clinical characteristics of the overall cohort and the outcome groups are summarized in Table 4.

Discussion

Acute upper gastrointestinal bleeding remains a clinically heterogeneous emergency in which differences in physiological severity, bleeding etiology, comorbidity burden, and treatment response can lead to substantial variation in short-term management and outcome¹². Even though resuscitation strategies, pharmacologic therapy, and endoscopic hemostasis have advanced, clinically meaningful intervention burden and early mortality remain common, particularly in patients with cirrhosis, hemodynamic com...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Automated hematology analyzer	Sysmex	XN-1000	Representative analyzer used for complete blood count testing, including hemoglobin measurement.
Bedside patient monitor	Philips	MX450	Representative model: IntelliVue MX450; may be used as an alternative monitor for bedside physiologic assessment.
Blood transfusion record system	Institution-specific	N/A	Used to confirm packed red blood cell transfusion events during hospitalization.
Case screening log	Institution-specific	N/A	Used to document screened, excluded, and included patients for cohort derivation and flow diagram construction.
Clinical chemistry analyzer	Roche Diagnostics	cobas c 311	Representative analyzer used for serum biochemistry testing, including blood urea nitrogen-related assays.
Decision curve analysis package	CRAN	rmda	Used for decision curve analysis; report the exact installed package version used in the final analysis environment.
Electronic medical record (EMR) system	Institution-specific	N/A	Used to extract demographic characteristics, presenting symptoms, comorbidities, admission records, and in-hospital outcomes.
Endoscopy reporting system	Institution-specific	N/A	Used to confirm therapeutic endoscopy and classify bleeding etiology.
Hospital information system (HIS)	Institution-specific	N/A	Used for retrospective identification of eligible emergency department and inpatient cases with acute upper gastrointestinal bleeding.
Laboratory information system (LIS)	Institution-specific	N/A	Used to retrieve the earliest available laboratory results at presentation, including hemoglobin and blood urea nitrogen.
ROC analysis package	CRAN	pROC version 1.19.0.1	Used for ROC curve generation, area under the curve estimation, confidence interval calculation, and ROC comparison.
Score calculation worksheet	Institution-specific	N/A	Used to calculate Glasgow-Blatchford Score and modified Glasgow-Blatchford Score from extracted clinical variables.
Spreadsheet software	Microsoft	N/A	Used for initial data collation, variable checking, and preparation of the analysis dataset.
Statistical analysis software	IBM	SPSS Statistics 26.0	Used for descriptive statistics, contingency table analysis, and comparison of diagnostic performance metrics.
Statistical computing environment	R Foundation for Statistical Computing	R version 4.5.3	Used for ROC analysis, confidence interval estimation, and supplementary statistical analyses.
Surgical record system	Institution-specific	N/A	Used to confirm bleeding-related surgical intervention during hospitalization.
Urea/BUN reagent	Roche Diagnostics	5171873190	UREAL Urea/BUN reagent for cobas c systems; representative reagent for blood urea nitrogen measurement.
Video gastroscope	Olympus	GIF-HQ190	Representative upper gastrointestinal endoscope used for diagnostic and therapeutic endoscopy.
Video system center	Olympus	CV-190	Representative endoscopy processor compatible with the EVIS EXERA III workflow.
Vital signs monitor	Baxter (Welch Allyn)	CSM	Representative model: Connex Spot Monitor; used for recording triage vital signs, including systolic blood pressure and heart rate.