Hemostasis during emergency endoscopy has become easier than before with the advancement of instruments, and a high success rate has been maintained [17, 18]. However, spontaneous hemostasis may occur during emergency endoscopy, and endoscopic hemostasis is not necessary in all cases .
In cases of suspected acute gastrointestinal bleeding, early risk stratification to identify high-risk patients is important and is associated with the timing and need for subsequent endoscopy. In an international multicenter prospective study of more than 3,000 patients, the GBS was the best predictor of the need for hospital-based intervention or death. In an international multicenter prospective study of more than 3,000 patients, GBS was the best predictor of the need for hospital-based intervention or death . A GBS score of 7 or higher indicated the need for endoscopic intervention. Another report showed that a GBS of 12 points or higher had a 90% specificity for predicting in-hospital mortality, and that a delay in endoscopy significantly increased the number of deaths in patients with a GBS of 12 points or higher . GBS was useful for endoscopic intervention  and hemostatic treatment  among conventional scores. The GBS score correlates with therapeutic intervention and lethality as the score increases, but the actual score at which therapeutic intervention should be performed has not been determined. A systematic review of 16 reports confirmed that the GBS was better than other cutoff points and risk scores at identifying low-risk patients, but had very low specificity . Therefore, it is difficult to accurately assess the risk of patients with upper gastrointestinal bleeding to determine what cases should be promptly endoscoped and treated .
Therefore, we conducted this study to examine the association between each existing score and the need for endoscopic or other hemostatic treatment. The GBS was found to be the most useful in predicting hemostatic treatment, as previously reported. However, there are many items in the GBS, and it is difficult to assess accurately in emergency medicine because it includes subjective factors such as fainting and the presence of cardiac and hepatic diseases. In addition, it is difficult to define cardiac and hepatic diseases, and it is a difficult question whether to include even minor diseases. In addition, it is difficult to define cardiac and hepatic diseases.
From our study, the factors associated with endoscopic treatment were hematemesis, heart rate (>100 beats/min), Hb (Hemoglobin: 10.0 g/dl or less), blood pressure (Blood pressure: 100 mmHg or less), BUN (Blood urea BUN (Blood urea nitrogen: 22.4 mg/dl or higher). Hematemesis can be observed from the surroundings and can be easily and objectively assessed by examining the oral cavity and perioral area. Therefore, the above five factors are all objective indicators. The measurement of each clinical index is simple and can be performed in actual clinical situations requiring emergency. Based on the above predictors and the partial regression coefficients, we proposed a new score with a total of 6 points, 2 points for BUN and 1 point for each of the other factors, and named this score the HB score, using the initial letters of each factor. The HB score can be used as a useful index compared to GBS and Modified GBS. The HB score has a cutoff value of 3 points, which is the maximum value based on the Youden index, as a guideline for hemostatic treatment. However, considering the clinical aspects, a score of 2 or higher, which has a certain degree of sensitivity, should be considered as an indication for urgent endoscopy and should be a subject for further study. Although the HB score is inferior to the AIMS65, it is also an excellent predictor of subsequent death.
There are, of course, some limitations to this study. First, it was an analysis of cases from a single institution. Also, patients with esophageal varices were not analyzed, so our conclusions cannot be applied to all patients with suspected upper gastrointestinal bleeding. However, there are few data on the use of scoring systems in patients with variceal bleeding, and the predictive power is low. In this study, we did not uniformly administer PPIs between the time of our consultation and the endoscopic intervention, although patients were taking PPIs regularly. North American and European guidelines suggest the use of high-dose PPIs before endoscopy as basic therapy to reduce the incidence of peptic ulcer [24-26]. Patients receiving PPIs prior to endoscopic intervention were significantly less likely to develop adverse outcomes and had significantly lower rates of rebleeding, upper gastrointestinal surgery, mortality, and length of hospital stay compared with patients who did not receive PPIs [27-29]. Potassium-competitive acid blockers (P-CABs) were approved in Japan in 2015, the first in the world. P-CABs do not require acid activation, are stable in acidic environments, and accumulate in secretory tubules in high density. This may be an issue for further study.
In this study, the primary endpoint was the presence or absence of hemostatic treatment in patients who underwent emergency endoscopy within 6 hours of presentation. A prospective observational study in Korea evaluated mortality and rebleeding rate 28 days after hospitalization in adult patients with GBS 7 or higher NVUGIB who underwent endoscopy within 6 hours of emergency department visit and those who underwent endoscopy within 6-48 hours. The mortality rate was significantly lower in the group that underwent endoscopy within 6 hours, but there was no difference in rebleeding between the two groups . Another report examined whether emergency upper gastrointestinal endoscopy within 6 hours improved all-cause mortality at 30 days compared with early endoscopy within 6 to 24 hours in patients with stable upper gastrointestinal hemorrhage without persistent hemorrhage (GBS 12 points or higher). However, it was reported that there was no significant difference in all-cause mortality between the two groups . There is controversy about when endoscopy should be performed in patients with suspected acute upper gastrointestinal bleeding . Even if the new score can predict hemostatic therapy such as endoscopic treatment and mortality, it remains to be determined when therapeutic intervention can improve important clinical outcomes such as death.
Shung et al. validated a machine-learning model for hemostatic treatment requiring hospitalization and 30-day mortality in patients with upper gastrointestinal bleeding using a 24-item index that included demographics, comorbidities, medications, clinical characteristics, and blood sampling results. It showed higher AUC, sensitivity, and specificity than the conventional GBS and AIMS65 scores . However, it requires many items and a detailed interview, and patients themselves often do not remember their medications and comorbidities accurately, so it is not suitable for urgent care at present. However, with the development of AI and digitalization, for more efficient collection of medical information, the Shung et al. score with higher sensitivity and specificity using more indicators may become necessary in the future.