Acute upper gastrointestinal bleeding in over 16s: management

This guideline covers how upper gastrointestinal bleeding can be effectively managed in adults and young people aged 16 years and older. It aims to identify which diagnostic and therapeutic steps are useful so hospitals can develop a structure in which clinical teams can deliver an optimum service for people who develop this condition.

# Introduction
Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate. Despite changes in management, mortality has not significantly improved over the past 50 years.
Elderly patients and people with chronic medical diseases withstand acute upper gastrointestinal bleeding less well than younger, fitter patients, and have a higher risk of death. Almost all people who develop acute upper gastrointestinal bleeding are treated in hospital and the guideline therefore focuses on hospital care. The most common causes 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.
This guideline aims to identify which diagnostic and therapeutic steps are useful in managing acute upper gastrointestinal bleeding. This should enable hospitals to develop a structure in which clinical teams can deliver an optimum service for people who develop this condition.
The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions made with individual patients.# Recommendations
The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.
People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# 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.

# 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 are actively bleeding and have a prothrombin time (or international normalised ratio) or activated partial thromboplastin time greater than 1.5 times normal. If a patient's fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well.
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.

# Timing of 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.

# Management of 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.

# Management of variceal bleeding
Offer terlipressin 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.At 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.
Offer prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.

## Oesophageal varices
Use band ligation in patients with upper gastrointestinal bleeding from oesophageal varices.
Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.

## 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.

# Control of bleeding and prevention of 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  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.

# Primary prophylaxis for acutely ill patients in critical care
Offer acid-suppression therapy (H2-receptor antagonists or proton pump inhibitors) for primary prevention of upper gastrointestinal bleeding in acutely ill patients admitted to critical care. If possible, use the oral form of the drug.As of August 2016, only the H2-receptor antagonists ranitidine and cimetidine are licensed for prophylaxis of gastrointestinal bleeding in acutely ill patients. The proton pump inhibitors omeprazole, esomeprazole, lansoprazole, pantoprazole and rabeprazole are not licensed for prophylaxis of gastrointestinal bleeding in acutely ill patients. The use of proton pump inhibitors or H2-receptor antagonists other than ranitidine and cimetidine for this indication would be off label.
Review the ongoing need for acid-suppression drugs for primary prevention of upper gastrointestinal bleeding in acutely ill patients when they recover or are discharged from critical care.

# Information and support for patients and carers
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.