Post written by Masayasu Horibe, MD, PhD, from the Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan, and the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

Our study validates a recently developed simple scoring system in patients with suspected upper GI bleeding, called the Horibe gAstRointestinal BleedING prEdiction scoRe (HARBINGER). This system was incepted in 2016. In the present study, we prospectively validated the HARBINGER in almost 1500 patients. When compared with the Glasgow Blatchford Score (GBS) and the AIMS65, the HARBINGER is significantly more accurate in predicting the presence of endoscopic high-risk stigmata upon endoscopy.

In a recent American College of Physicians guideline (Annals of Internal Medicine, 2019), the general recommendation was that all patients with acute non-variceal upper GI bleeding should undergo endoscopy within 24 hours of presentation. However, performing an urgent endoscopy within 24 hours for all suspected upper GI bleed patients can be challenging due to the limited health-care resources. On the other hand, concerns have always been raised regarding “early” endoscopy in GI bleed patients.

Therefore, we have to carefully triage patients who require an urgent endoscopic intervention. According to international consensus statements, the presence of high-risk stigmata during the endoscopy indicates the need for therapeutic intervention. Moreover, there is data to suggest that patients who do not need urgent endoscopy can be treated as outpatients even if they require a blood transfusion. Therefore, when it comes to making a decision whether to scope or not, predicting the presence of high-risk stigmata is a very meaningful outcome with solid implications for patients.

We propose that patients with HARBINGER of 0 could be outpatients, those with 1 should be admitted for observation without the need for urgent endoscopy, and those with 2 or 3 require urgent endoscopy after optimal resuscitation. Although endoscopic hemostasis improves the outcome in patients with high-risk stigmata, whether urgent endoscopic hemostasis could improve the mortality is unclear. A randomized clinical trial allocating patients according to their HARBINGER may answer that question.

It is difficult to determine exactly non-variceal or variceal bleeding before the endoscopy. Although the treatment strategy after endoscopic diagnosis of non-variceal or variceal must be addressed by each disease, the pre-endoscopic triage strategy must be considered as a suspected upper gastrointestinal bleeding that includes both. We included patients with suspected upper gastrointestinal bleeding in this study.

The fact that hemoglobin is not included in the index is a feature of HARBINGER. The low value of hemoglobin is not a surrogate of endoscopic urgency, as it can also be caused by chronic disease. Indeed, furthermore, we were not interested in a score that predicted the need for a blood transfusion, given that this need is readily dictated by a certain hemoglobin cut-off (depending on comorbidities) or vital signs. There is not much yield of developing a score that predicts such a need.

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