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Acute upper gastrointestinal bleeding

Short Text

The management of acute upper gastrointestinal bleeding

Introduction

This pathway covers risk assessment and management of adults and young people (16 years and older) with acute upper gastrointestinal bleeding.
Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate. Almost all people who develop acute upper gastrointestinal bleeding are treated in hospital and this pathway therefore focuses on hospital care. The most common causes of upper gastrointestinal bleeding are peptic ulcer and oesophago-gastric varices.
Endoscopy is the primary diagnostic investigation in patients with acute upper gastrointestinal bleeding but it has not always been clear whether urgent endoscopy is cost effective as well as clinically valuable. Endoscopy aids diagnosis, yields information that helps predict outcome and most importantly allows treatments to be delivered that can stop bleeding and reduce the risk of re-bleeding.
Drugs may have a complementary role in reducing gastric acid secretion and portal vein pressure. Not every patient responds to endoscopic and drug treatments; emergency surgery and a range of radiological procedures may be needed to control bleeding.

Source guidance

The NICE guidance that was used to create the pathway.
Acute upper gastrointestinal bleeding. NICE clinical guideline 141 (2012)

Quality standards

Quality statements

Risk assessment

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with acute upper gastrointestinal bleeding receive a risk assessment using a validated risk score.

Rationale

The prognosis for people with acute upper gastrointestinal bleeding can vary so it is important to carry out a risk assessment using a validated risk score. This can inform the best course of further treatment, and in some instances can identify people for whom early discharge or outpatient endoscopy are appropriate.

Quality measures

Structure
Evidence of local arrangements to ensure that people with acute upper gastrointestinal bleeding receive a risk assessment using a validated risk score.
Data source: Local data collection.
Process
Proportion of people with acute upper gastrointestinal bleeding who receive a risk assessment using a validated risk score.
Numerator – the number of people in the denominator who receive a risk assessment using a validated risk score.
Denominator – the number of people with acute upper gastrointestinal bleeding.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: initial management (NICE clinical guideline 141). The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) asks, 'Does your hospital routinely calculate and document a risk score (for example, Rockall or Blatchford scores) for patients with suspected upper GI bleeding?'

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with acute upper gastrointestinal bleeding to receive a risk assessment using a validated risk score.
Healthcare practitioners give people with acute upper gastrointestinal bleeding a risk assessment using a validated risk score.
Commissioners ensure that they commission services that give people with acute upper gastrointestinal bleeding a risk assessment using a validated risk score.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding have an assessment of their risk of more bleeding or complications, using an accepted scoring system.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendations 1.1.1 (key priority for implementation) and 1.1.2.

Definitions of terms used in this quality statement

Risk assessment NICE clinical guideline 141 recommendations 1.1.1 and 1.1.2 suggest the following approach for risk assessment:
Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding:
  • the Blatchford score at first assessment, and
  • the full Rockall score after endoscopy.
Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.

Immediate endoscopy for people who are haemodynamically unstable

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with severe acute upper gastrointestinal bleeding who are haemodynamically unstable are given an endoscopy within 2 hours of optimal resuscitation.

Rationale

In most cases, endoscopy diagnoses the cause of bleeding, provides information about the likely prognosis and facilitates delivery of a range of haemostatic therapies. People who are haemodynamically unstable should be given an endoscopy within 2 hours of optimal resuscitation because their condition means they need urgent investigation and treatment.

Quality measures

Structure
Evidence of local arrangements to ensure that people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable are given an endoscopy within 2 hours of optimal resuscitation.
Data source: Local data collection.
Process
Proportion of people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable who receive endoscopy within 2 hours of optimal resuscitation.
Numerator – the number of people in the denominator who receive endoscopy within 2 hours of optimal resuscitation.
Denominator – the number of people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: initial management (NICE clinical guideline 141).

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable to be given an endoscopy within 2 hours of optimal resuscitation.
Healthcare practitioners perform an endoscopy within 2 hours of optimal resuscitation in people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.
Commissioners ensure that they commission services that give an endoscopy within 2 hours of optimal resuscitation to people with severe acute upper gastrointestinal bleeding who are haemodynamically unstable.

What the quality statement means for patients, service users and carers

People with severe acute upper gastrointestinal bleeding whose blood pressure and/or pulse is unstable are given an endoscopy (a procedure using a narrow, flexible tube that is swallowed and has a very small camera at its tip) within 2 hours of being resuscitated.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.3.1 (key priority for implementation).

Definitions of terms used in this quality statement

2 hour timeframe Derived from expert consensus.
Haemodynamically unstable People who are haemodynamically unstable are those with active bleeding whose blood pressure or pulse cannot be normalised or who need rapid intravenous fluids to maintain haemodynamic stability.
Endoscopy is associated with complications. These are uncommon when it is used for diagnosis in relatively fit people, but are relatively common in people who are actively bleeding, and may be life threatening in people with comorbidities whose condition is unstable.
The full guideline Acute upper gastrointestinal bleeding: management states that, whenever possible, endoscopy should not be undertaken until cardiovascular stability is achieved. However, it is recognised that for people who are haemodynamically unstable it will not be possible to achieve full resuscitation, therefore attempts should be made to optimally resuscitate before endoscopy to minimise the risk of complications. The risks of endoscopy for people whose condition is unstable should be balanced against the risks of delaying endoscopy.
Clinical judgement should be used to determine whether people who are haemodynamically unstable have achieved their optimal level of resuscitation.

Endoscopy within 24 hours for people who are haemodynamically stable

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable are given an endoscopy within 24 hours of admission.

Rationale

In most cases, endoscopy diagnoses the cause of bleeding, provides information about the likely prognosis and facilitates delivery of a range of haemostatic therapies. People admitted to hospital who are haemodynamically stable should be given an endoscopy within 24 hours of admission. This will help to avoid re-bleeding, and can reduce the length of their hospital stay.

Quality measures

Structure
Evidence of local arrangements to ensure that people admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable are given an endoscopy within 24 hours of admission.
Data source: Local data collection.
Process
Proportion of people admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable who receive endoscopy within 24 hours of admission.
Numerator – the number of people in the denominator who receive endoscopy within 24 hours of admission.
Denominator – the number of people admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: initial management (NICE clinical guideline 141).
Outcome
Length of hospital stay for people with acute upper gastrointestinal bleeding who are haemodynamically stable.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable to be given an endoscopy within 24 hours of admission.
Healthcare practitioners perform endoscopy within 24 hours of hospital admission in people with acute upper gastrointestinal bleeding who are haemodynamically stable.
Commissioners ensure that they commission services that give an endoscopy within 24 hours of hospital admission to people with acute upper gastrointestinal bleeding who are haemodynamically stable.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding whose blood pressure and pulse are stable and who are admitted to hospital are given an endoscopy (a procedure using a narrow, flexible tube that is swallowed and has a very small camera at its tip) within 24 hours of admission.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.3.2 (key priority for implementation).

Definitions of terms used in this quality statement

Haemodynamically stable People who are haemodynamically stable have stabilised blood pressure and pulse.

Endoscopic treatment for non-variceal bleeding

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage are offered endoscopic treatments (combination or a mechanical method).

Rationale

Endoscopic treatment of non-variceal acute upper gastrointestinal bleeding can control active bleeding, reduce the rate of re-bleeding and the need for blood transfusion.

Quality measures

Structure
Evidence of local arrangements to ensure that people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage are offered endoscopic treatments (combination or a mechanical method).
Data source: Local data collection.
Process
Proportion of people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage who receive endoscopic treatments (combination or a mechanical method).
Numerator – the number of people in the denominator who receive endoscopic treatments (combination or a mechanical method).
Denominator – the number of people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: non-variceal (NICE clinical guideline 141). The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) asks 'Were any therapeutic endoscopic procedures undertaken?'
Outcome
a) Proportion of people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage who have uncontrolled bleeding or re-bleeding within 48 hours.
Data source: Local data collection.
b) Proportion of people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage who need rescue therapies.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage to be offered endoscopic treatments (combination or a mechanical method).
Healthcare practitioners offer endoscopic treatments (combination or a mechanical method) to people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage.
Commissioners ensure that they commission services that offer endoscopic treatments (combination or a mechanical method) to people with non-variceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding caused by stomach or duodenal ulcers are offered treatment using an endoscope (a narrow, flexible tube that is swallowed and has a very small camera at its tip).

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendations 1.4.1 and 1.4.2 (key priorities for implementation).

Definitions of terms used in this quality statement

NICE clinical guideline 141 recommendation 1.4.1 states: do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding.
NICE clinical guideline 141 recommendation 1.4.2 recommends using 1 of the following endoscopic treatments:
  • a mechanical method (for example, clips) with or without adrenaline
  • thermal coagulation with adrenaline
  • fibrin or thrombin with adrenaline.
The full guideline Acute upper gastrointestinal bleeding: management concludes that each of these approaches can control active bleeding, reduce the rate of re-bleeding and need for blood transfusion compared with not receiving endoscopic therapy. Trials have failed to show superiority of any single approach.

Treatment of non-variceal bleeding after first or failed endoscopic treatment

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment.

Rationale

Sometimes endoscopic therapy is technically difficult and the endoscopist cannot achieve or secure haemostasis, or bleeding recurs despite full or maximal endoscopic treatment. One additional therapeutic option is interventional radiology (embolisation), which can identify and treat the bleeding point. This can be preferable to surgery, because postoperative mortality is high for this group of patients, most of whom are extremely ill at the time of surgery.

Quality measures

Structure
Evidence of local arrangements to ensure that people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment (embolisation).
Data source: Local data collection.
Process
Proportion of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable who receive interventional radiology treatment (embolisation).
Numerator – the number of people in the denominator who receive interventional radiology treatment (embolisation).
Denominator – the number of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.
Data source: Local data collection. Contained in NICE audit support for Acute upper GI bleeding: non-variceal (NICE clinical guideline 141). The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) shows the proportion of people having either surgery or radiological intervention.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable to be given interventional radiology treatment.
Healthcare practitioners give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.
Commissioners ensure that they commission services that give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding from the stomach or duodenum who continue to bleed or re-bleed after endoscopic treatment and whose blood pressure or pulse is unstable are given interventional radiology treatment. A long narrow plastic tube called a catheter is inserted into an artery in the groin and, under X-ray guidance, is then steered to the site of bleeding. After a small injection of X-ray dye to confirm that the tube is in the right place, the bleeding artery is blocked off to stop the bleeding. A CT scan may be needed beforehand to guide treatment if endoscopy has not identified the site of bleeding.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.4.7 (key priority for implementation).

Definitions of terms used in this quality statement

NICE clinical guideline 141 recommendation 1.4.7 states that if interventional radiology is not promptly available people should be referred urgently for surgery.

Prophylactic antibiotic therapy for variceal bleeding

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with suspected or confirmed variceal acute upper gastrointestinal bleeding are given antibiotic therapy at presentation.

Rationale

People with variceal acute upper gastrointestinal bleeding are prone to infection. Infection has adverse effects on renal function and commonly precipitates hepatorenal failure, characterised by oliguria, sodium and fluid retention and death. Early antibiotic therapy reduces these risks.

Quality measures

Structure
Evidence of local arrangements to ensure that people with suspected or confirmed variceal acute upper gastrointestinal bleeding are given antibiotic therapy at presentation.
Data source: Local data collection.
Process
Proportion of people with suspected or confirmed variceal acute upper gastrointestinal bleeding who receive antibiotic therapy at presentation.
Numerator – the number of people in the denominator who receive antibiotic therapy at presentation.
Denominator – the number of people with suspected or confirmed variceal acute upper gastrointestinal bleeding at presentation.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: variceal (NICE clinical guideline 141).
Outcome
Rates of sepsis in people with suspected or confirmed variceal acute upper gastrointestinal bleeding.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with suspected or confirmed variceal acute upper gastrointestinal bleeding to be given antibiotic therapy at presentation.
Healthcare practitioners give antibiotic therapy at presentation to people with suspected or confirmed variceal acute upper gastrointestinal bleeding.
Commissioners ensure that they commission services that give antibiotic therapy at presentation to people with suspected or confirmed variceal acute upper gastrointestinal bleeding.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding known or suspected to be caused by enlarged veins are given antibiotics when they first see a healthcare professional.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.5.2 (key priority for implementation).

Management of variceal bleeding using transjugular intrahepatic portosystemic shunts (TIPS)

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with uncontrolled acute upper gastrointestinal bleeding from varices are given transjugular intrahepatic portosystemic shunts (TIPS).

Rationale

In some cases variceal bleeding cannot be controlled with endoscopic treatment. In these instances, TIPS can be used to stop the bleeding.

Quality measures

Structure
Evidence of local arrangements to ensure that people with uncontrolled acute upper gastrointestinal bleeding from varices are given TIPS.
Data source: Local data collection.
Process
The proportion of people with uncontrolled acute upper gastrointestinal bleeding from varices who receive TIPS.
Numerator – the number of people in the denominator who receive TIPS.
Denominator – the number of people with uncontrolled acute upper gastrointestinal bleeding from varices.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: variceal (NICE clinical guideline 141).

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with uncontrolled acute upper gastrointestinal bleeding from varices to be given TIPS.
Healthcare practitioners perform TIPS in people with uncontrolled acute upper gastrointestinal bleeding from varices.
Commissioners ensure that they commission services that give TIPS to people with uncontrolled acute upper gastrointestinal bleeding from varices.

What the quality statement means for patients, service users and carers

People with uncontrolled acute upper gastrointestinal bleeding caused by enlarged veins are given a procedure called transjugular intrahepatic portosystemic shunts (also called TIPS). In a TIPS procedure the veins feeding into the liver and those draining it are connected so that the blood flow is redirected and the pressure in the enlarged veins is lowered.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.5.4 (key priority for implementation) and 1.5.6.

Definitions of terms used in this quality statement

Transjugular intrahepatic portosystemic shunts (TIPS) In a TIPS procedure the veins feeding into the liver and those draining it are connected so that the blood flow is redirected and the pressure in the enlarged veins is lowered.
Before using TIPS, attempts should first be made to stop bleeding using the alternative methods described in quality statements 7 and 8. NICE clinical guideline 141 recommendations 1.5.4 and 1.5.6 state:
  • Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.
  • Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate.

N-butyl-2-cyanoacrylate for gastric variceal bleeding

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with acute upper gastrointestinal bleeding from gastric varices are given an endoscopic injection of N-butyl-2-cyanoacrylate.

Rationale

Endoscopic injection of N-butyl-2-cyanoacrylate can obliterate gastric varices, whereas attempts at banding are likely to be unsuccessful for these varices.

Quality measures

Structure
Evidence of local arrangements to ensure that people with acute upper gastrointestinal bleeding from gastric varices are given an endoscopic injection of N-butyl-2-cyanoacrylate.
Data source: Local data collection.
Process
Proportion of people with acute upper gastrointestinal bleeding from gastric varices who receive endoscopic injection of N-butyl-2-cyanoacrylate.
Numerator – the number of people in the denominator who receive endoscopic injection of N-butyl-2-cyanoacrylate.
Denominator – the number of people with acute upper gastrointestinal bleeding from gastric varices.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: initial management (NICE clinical guideline 141).
Outcome
Rates of uncontrolled bleeding in people with acute upper gastrointestinal bleeding from gastric varices.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with acute upper gastrointestinal bleeding from gastric varices to be given an endoscopic injection of N-butyl-2-cyanoacrylate.
Healthcare practitioners give an endoscopic injection of N-butyl-2-cyanoacrylate to people with acute upper gastrointestinal bleeding from gastric varices.
Commissioners ensure that they commission services that give an endoscopic injection of N-butyl-2-cyanoacrylate to people with upper gastrointestinal bleeding from gastric varices.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding caused by enlarged veins in the stomach are given an injection of N-butyl-2-cyanoacrylate, a substance that helps to stop the bleeding. This injection is given using an endoscope (a narrow, flexible tube with a camera at its tip).

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.5.5.

Band ligation for oesophageal variceal bleeding

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with acute upper gastrointestinal bleeding from oesophageal varices are given band ligation.

Rationale

The use of bands for oesophageal bleeding will stop the bleeding and has significant benefits over the alternative of injection sclerotherapy. The benefits include: improved mortality and a reduction in re-bleeding, numbers of additional procedures needed to control bleeding, total units of blood transfused and number of sessions of treatment needed to eradicate varices.

Quality measures

Structure
Evidence of local arrangements to ensure that people with acute upper gastrointestinal bleeding from oesophageal varices are given band ligation.
Data source: Local data collection.
Process
Proportion of people with acute upper gastrointestinal bleeding from oesophageal varices who receive band ligation.
Numerator – the number of people in the denominator who receive band ligation.
Denominator – the number of people with acute upper gastrointestinal bleeding from oesophageal varices.
Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: variceal (NICE clinical guideline 141). The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) shows the number of endoscopic therapeutic procedures, which includes banding.
Outcome
Rates of uncontrolled bleeding in people with upper gastrointestinal bleeding from oesophageal varices.
Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with acute upper gastrointestinal bleeding from oesophageal varices to be given band ligation.
Healthcare practitioners perform band ligation in people with acute upper gastrointestinal bleeding from oesophageal varices.
Commissioners ensure that they commission services that give band ligation to people with acute upper gastrointestinal bleeding from oesophageal varices.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding caused by enlarged veins in the oesophagus (gullet) are given band ligation, a type of elastic band that helps to stop the bleeding.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141) recommendation 1.5.3.

Continuation on low-dose aspirin

This quality statement is taken from the acute upper gastrointestinal bleeding quality standard. The quality standard defines clinical best practice for acute upper gastrointestinal bleeding and should be read in full.

Quality statement

People with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved are advised to continue on low-dose aspirin.

Rationale

Aspirin can cause gastrointestinal ulcers to form and cause pre-existing ulcers to bleed. Clinicians have therefore withheld aspirin at the time of acute gastrointestinal bleeding. However, the antiplatelet effects of aspirin persist for at least 7 days after discontinuation. This means that people with acute upper gastrointestinal bleeding who are already taking low-dose aspirin to prevent further vascular events should be advised to continue taking aspirin if their bleeding has stabilised so that the benefit of taking aspirin can be maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that people with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved are advised to continue on low-dose aspirin.
Data source: Local data collection.
Process
Proportion of people with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved who are advised to continue on low-dose aspirin.
Numerator – the number of people in the denominator who are advised to continue on low-dose aspirin.
Denominator – the number of people with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved.
Data source: Local data collection. The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) records the drugs taken by people who have acute upper gastrointestinal bleeding.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place to advise people with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved to continue on low-dose aspirin.
Healthcare practitioners advise people with acute upper gastrointestinal bleeding, who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved, to continue on low-dose aspirin.
Commissioners ensure that they commission services that advise people with acute upper gastrointestinal bleeding who take aspirin for secondary prevention of vascular events and in whom haemostasis has been achieved to continue on low-dose aspirin.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding who have had a stroke or heart attack, and are taking aspirin to prevent another, are advised to continue on aspirin when their bleeding has stabilised.

Source guidance

Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141) recommendation 1.6.1.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on acute upper gastrointestinal bleeding
NICE has also written a document for the public explaining its quality standard for acute upper gastrointestinal bleeding.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.

Updates to this pathway

29 July 2013 Quality standard added to the pathway
22 February 2013 Minor maintenance updates.
20 June 2012 Link to main shared learning page for this topic added.
21 August 2012 Link to Acutely ill patients in hospital pathway added.

Supporting information

Glossary

Transjugular intrahepatic portosystemic shunts

Adult or young person (aged 16 or older) with upper gastrointestinal bleeding

Adult or young person (16 years and older) with upper gastrointestinal bleeding

Information and support

Information and support

Information and support

Establish good communication between clinical staff and patients and their family and carers at the time of presentation, throughout their time in hospital and following discharge. This should include:
  • giving verbal information that is recorded in medical records
  • different members of clinical teams providing consistent information
  • providing written information where appropriate
  • ensuring patients and their families and carers receive consistent information.

Source guidance

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Controlling bleeding and preventing re-bleeding in patients on NSAIDs, aspirin or clopidogrel

Controlling bleeding and preventing re-bleeding in patients on NSAIDs, aspirin or clopidogrel

Controlling bleeding and preventing re-bleeding in patients on NSAIDs, aspirin or clopidogrel

Continue low-dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding in whom haemostasis has been achieved.
Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors) during the acute phase in patients presenting with upper gastrointestinal bleeding.
Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) in patients with upper gastrointestinal bleeding with the appropriate specialist (for example, a cardiologist or a stroke specialist) and with the patient.

Quality standards

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Source guidance

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Resuscitation and initial management

Resuscitation and initial management

Resuscitation and initial management

Transfuse patients with massive bleeding with blood, platelets and clotting factors in line with local protocols for managing massive bleeding.
Base decisions on blood transfusion on the full clinical picture, recognising that over-transfusion may be as damaging as under-transfusion.
Do not offer platelet transfusion to patients who are not actively bleeding and are haemodynamically stable.
Offer platelet transfusion to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre.
Offer fresh frozen plasma to patients who have either:
  • a fibrinogen level of less than 1 g/litre, or
  • a prothrombin time (international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal.
Offer prothrombin complex concentrate to patients who are taking warfarin and actively bleeding.
Treat patients who are taking warfarin and whose upper gastrointestinal bleeding has stopped in line with local warfarin protocols.
Do not use recombinant factor Vlla except when all other methods have failed.

Implementation tools

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Source guidance

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Risk assessment

Risk assessment

Risk assessment

Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding:
  • the Blatchford score at first assessment, and
  • the full Rockall score after endoscopy.
Consider early discharge for patients with a pre-endoscopy Blatchford score of 0.

Quality standards

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Implementation tools

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Source guidance

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Endoscopy

Endoscopy

Endoscopy

Offer endoscopy to unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation.
Offer endoscopy within 24 hours of admission to all other patients with upper gastrointestinal bleeding.
Units seeing more than 330 cases a year should offer daily endoscopy lists. Units seeing fewer than 330 cases a year should arrange their service according to local circumstances.

Quality standards

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Implementation tools

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Source guidance

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Managing non-variceal bleeding

Managing non-variceal bleeding

Managing non-variceal bleeding

Endoscopic treatment

Do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal upper gastrointestinal bleeding.
For the endoscopic treatment of non-variceal upper gastrointestinal bleeding, use one of the following:
  • a mechanical method (for example, clips) with or without adrenaline
  • thermal coagulation with adrenaline
  • fibrin or thrombin with adrenaline.

Proton pump inhibitors

Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.
Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy.

Treatment after first or failed endoscopic treatment

Consider a repeat endoscopy, with treatment as appropriate, for all patients at high risk of re-bleeding, particularly if there is doubt about adequate haemostasis at the first endoscopy.
Offer a repeat endoscopy to patients who re-bleed with a view to further endoscopic treatment or emergency surgery.
Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment. Refer urgently for surgery if interventional radiology is not promptly available.

Quality standards

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Implementation tools

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Source guidance

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Managing variceal bleeding

Managing variceal bleeding

Managing variceal bleeding

Offer terlipressinAt the time of publication (June 2012), terlipressin was indicated for the treatment of bleeding from oesophageal varices, with a maximum duration of treatment of 72 hours (3 days). Prescribers should consult the relevant summary of product characteristics. Informed consent for off-label use of terlipressin should be obtained and documented. to patients with suspected variceal bleeding at presentation. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use.
Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.

Quality standards

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Implementation tools

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Source guidance

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Gastric varices

Gastric varices

Gastric varices

Offer endoscopic injection of N-butyl-2-cyanoacrylate to patients with upper gastrointestinal bleeding from gastric varices.
Offer TIPS if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate.

Quality standards

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Implementation tools

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Source guidance

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Oesophageal varices

Oesophageal varices

Oesophageal varices

Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices.
Consider TIPS if bleeding from oesophageal varices is not controlled by band ligation.
NICE has produced guidance on stent insertion for bleeding oesophageal varices (NICE interventional procedure guidance 392).

Quality standards

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Implementation tools

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Source guidance

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Preventing bleeding in acutely ill patients in the Acutely ill patients in hospital pathway

View the 'Preventing bleeding in acutely ill patients' node

Paths in this pathway

Pathway created: June 2012 Last updated: July 2013

Copyright © 2014 National Institute for Health and Care Excellence. All Rights Reserved.

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