In this study, VSF during emergency endoscopy and rebleeding within 30 days after first endoscopy were defined as indicators for transfer to higher medical institutions. Hence, the presence of comorbidities extracted as the independent risk factor for these indicators may be important for rapid triage of patients requiring transfer. Most patients with VSF or rebleeding have peptic ulcers, diverticular bleeding, and ischemic enteritis with comorbidities, possibly because they have more severe hemorrhage, resulting in lower systolic and diastolic blood pressure, tachycardia, and increased respiratory rate. When faced with VSF and uncontrollable bleeding despite appropriate hemostatic treatments during emergency endoscopy, it is critically important to both understand and stabilize the patient’s general conditions and to make a clinical decision regarding transfer of urgent patients to higher medical institutions. Many studies have examined the severity of upper and lower gastrointestinal bleeding and predictive tools for proper acute triage settings. The Glasgow-Blatchford Score (GBS), which is designed to predict the need for a blood transfusion, intervention to control bleeding, rebleeding, or death, and AIMS65, which aims to predict all-cause mortality, are scoring systems for treatment and emergency transfer priorities for patients with upper GI bleeding [3, 4]. The cohort study by Horibe et al. [5] advocates the Horibe gAstRointestinal BleedING scoRe (HARBINGER), a score of 3 variables (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure ≥1], and blood urea nitrogen/creatinine ≥30) that is superior to the GBS and AIMS65 in terms of simplicity and accuracy as a triage tool to identify patients with upper GI bleeding who require hospitalization and emergency endoscopy. Patients with a HARBINGER ≥1 are identified as candidates for hospitalization. In our study, it was found that all cases of upper GI bleeding with VSF during emergency endoscopy corresponded to the shock index (heart rate/systolic blood pressure ≥1), suggesting that the decision to set VSF as a criterion for transferring to higher medical institutions was valid. Rebleeding acts as a sign of instability, and emergency transfer should be considered for patients with high-risk upper GI bleeding. The location on the lesser curvature of the stomach or on the posterior or superior wall of the duodenum, size over 2 cm in diameter, and presence of high-risk lesions (spurting, oozing blood, nonbleeding visible vessel, and an adherent clot) have been reported as endoscopic predictors of increased risk of GI rebleeding [6]. On the other hand, clinical predictors of GI rebleeding include comorbidity, anemia (low hemoglobin levels), need for transfusion, finding of fresh red blood during a rectal examination or during nasogastric suction or vomiting, melena, advanced age (older than 65 years), syncope or hemodynamic instability, and deterioration of overall health [6].
With regard to LGIB, Strate et al. [7] reported the following seven clinical risk factors associated with severe LGIB (defined as continuous and/or recurrent bleeding): tachycardia, low systolic blood pressure, syncope, nontender abdominal examination, bleeding per rectum within the first 4 h of medical assessment, use of aspirin, and more than two active comorbidities. Patients with 3 or more of these risk factors are at a high risk of severe bleeding. Furthermore, Aoki et al. [8] described a predictive model of severe LGIB (NOBLADS score), i.e., NSAID use, no diarrhea, no abdominal tenderness, systolic blood pressure ≤ 100 mmHg, albumin level < 3.0 g/dL nonaspirin antiplatelet drug use, Charlson comorbidity index score ≥ 2, and syncope. These studies suggest that hemodynamic instability and comorbidities are important factors associated with the severity and rebleeding of upper and lower GI bleeding. Moreover, in lower GI bleeding, the use of antithrombotic medication is associated with increased severity. Chong et al. [9] reported that patients taking aspirin were 2.6 times more likely to develop severe lower GI bleeding. Many private facilities, such as ours, do not have an on-site laboratory and cannot perform blood tests on the same day. Thus, it is necessary to triage patients who need urgent hospitalization with the minimum necessary information. In private facilities, extracting low-risk patients from among those with GI bleeding may prevent unnecessary transfers, reduce medical costs, and efficiently utilize medical resources.
The present study had several limitations. This was a single-center retrospective study with a small number of cases. In addition, well-known rebleeding risk factors may have been taken into consideration when deciding whether to transfer patients after endoscopy. Moreover, as our facility is a private clinic, the number of critically severe cases was small, and options for endoscopic treatment were limited. We will continue to accumulate cases and strive to establish optimal transfer standards for emergency patients with GI bleeding who are at high risk of sudden changes in their physical condition.