Seek expert advice and consult local guidelines.
Risk assessment
- following formal risk assessment scores should be used for all patients with acute upper gastrointestinal bleeding:
- the Blatchford score at first assessment,
- and the full Rockall score after endoscopy
- if a pre-endoscopy Blatchford score of 0 then consider early discharge
Timing of endoscopy
- unstable patients with severe acute upper gastrointestinal bleeding should be offered an endoscopy immediately after resuscitation
- all other patients with upper gastrointestinal bleeding should be offered an endoscopy within 24 hours of admission
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 10^9/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
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
Management of non-variceal bleeding
- adrenaline should not be used 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
- interventional radiology should be offered to unstable patients who re-bleed after endoscopic treatment
- refer urgently for surgery if interventional radiology is not promptly available
Management of variceal bleeding
- terlipressin should be offered 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
- prophylactic antibiotic therapy should be offered 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
- endoscopic injection of N-butyl-2-cyanoacrylate should be offered to patients with upper gastrointestinal bleeding from gastric varices
- TIPS should be offered if bleeding from gastric varices is not controlled by endoscopic injection of N-butyl-2-cyanoacrylate
Reference:
- NICE (August 2016). Acute Upper GI bleeding.