Comparison of pre-endoscopic risk scores for identifying high-risk Forrest lesions in emergency department patients with suspected upper gastrointestinal bleeding.
TL;DR
In patients undergoing endoscopy for suspected upper gastrointestinal bleeding, CHAMPS showed stronger discrimination for high-risk Forrest findings than the other evaluated scores, and should be considered complementary to existing pre-endoscopic UGIB risk stratification rather than a replacement for established risk scores.
Abstract
Background
Early risk stratification in suspected upper gastrointestinal bleeding may help guide admission decisions, monitoring, and timing of endoscopy in the emergency department. Although several pre-endoscopic scores are widely used, their ability to predict high-risk endoscopic findings remains incompletely defined. This study aimed to compare the performance of established pre-endoscopic upper gastrointestinal bleeding scores and anticoagulation-related bleeding risk scores for predicting high-risk Forrest findings.
Methods
This prospective multicentre cohort study included adult patients who underwent upper gastrointestinal endoscopy for suspected upper gastrointestinal bleeding. The primary outcome was high-risk endoscopic findings, defined as Forrest Ia-IIb. Low-risk findings were defined as Forrest IIc-III. We compared the performance of CHAMPS, Glasgow-Blatchford score, AIMS65, pre-endoscopic Rockall, HAS-BLED, ATRIA, ORBIT, VTE-BLEED, and HEMORR₂HAGES using receiver operating characteristic analysis. Multivariable logistic regression, calibration assessment, 10-fold cross-validated modelling, and Brier score were used to evaluate incremental discriminatory contribution beyond a baseline clinical model.
Results
A total of 571 patients were included, of whom 199 patients (34.9%) had high-risk Forrest findings. Patients with high-risk findings were older and had greater haemodynamic instability, lower haemoglobin, higher blood urea nitrogen, greater transfusion requirement, higher intensive care unit admission, and higher mortality than those with low-risk findings. Among all evaluated scores, CHAMPS had the best overall performance for predicting high-risk endoscopic findings, with an AUC of 0.889 (95% CI: 0.860-0.916). At the optimal cut-off of ≥2, CHAMPS achieved 72.9% sensitivity, 94.9% specificity, 88.4% positive predictive value, and 86.7% negative predictive value. CHAMPS significantly outperformed the Glasgow-Blatchford score (AUC 0.831; p = 0.001). In multivariable analysis, lower haemoglobin, higher blood urea nitrogen, lower systolic blood pressure, higher heart rate, and older age were independently associated with high-risk Forrest findings. Adding CHAMPS to the baseline clinical model produced the greatest incremental improvement, increasing the cross-validated AUC from 0.804 to 0.898 and reducing the Brier score from 0.165 to 0.109. CHAMPS remained the best-performing score in both anticoagulated and non-anticoagulated patients.
Conclusion
In patients undergoing endoscopy for suspected upper gastrointestinal bleeding, CHAMPS showed stronger discrimination for high-risk Forrest findings than the other evaluated scores. Prediction of high-risk endoscopic stigmata should be considered complementary to existing pre-endoscopic UGIB risk stratification rather than a replacement for established risk scores. Conventional upper gastrointestinal bleeding scores remained clinically useful, whereas anticoagulation-related bleeding risk scores showed more limited value for acute endoscopic risk prediction. Additional validation in different emergency department settings is needed before broader clinical use.