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Acute upper gastrointestinal bleeding
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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
Effective interventions library
Successful effective interventions library details
Implementation
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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:
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
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
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeControlling 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.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeResuscitation 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
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeRisk 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.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeEndoscopy
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.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeManaging 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.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeManaging 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.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeGastric 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.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-singleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeOesophageal 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).
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-singleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePreventing bleeding in acutely ill patients in the Acutely ill patients in hospital pathway
View the 'Preventing bleeding in acutely ill patients' nodePaths in this pathway
Pathway created: June 2012 Last updated: February 2013
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