Excerpt

The incidence of acute upper gastrointestinal haemorrhage in the United Kingdom ranges between 84–172 /100,000/year, equating to 50–70,000 hospital admissions per year. This is therefore a relatively common medical emergency; it is also one that more often affects socially deprived communities.

A recent large UK wide audit showed that the hospital mortality of patients admitted to hospitals in the UK for acute gastrointestinal bleeding is about 7%, rising to approximately 30% in patients who bleed as inpatients. A recent analysis has shown only modest age and co-morbidity corrected mortality decreases in recent years. The audit demonstrated considerable inequities in clinical care; some hospitals provided a comprehensive 24/7 service involving endoscopy, interventional radiology and emergency surgery, whilst others did not provide out of hours endoscopy or interventional radiology. The reported expertise of endoscopists varied widely with approximately 30% being unable to manage bleeding oesophageal varices, yet it is obvious that rotas must be populated by teams trained to deliver all aspects of endoscopic haemostatic therapy.

A guideline is therefore required to demonstrate the clinical utility of the diagnostic and therapeutic steps needed to manage patients, and to stimulate hospitals to develop a structure to enable clinical teams to deliver the optimum service.

The guideline concerns patients who present with haematemesis (vomiting of blood) and/ or melaena (the passage of black, tarry stools). Acute blood loss leads to collapse with low blood pressure, rapid pulse, sweating and pallor. In severe cases poor blood flow to the kidneys leads to acute renal failure and in patients with underlying vascular disease to stroke or myocardial infarction. Elderly patients and those with chronic medical diseases withstand acute gastrointestinal bleeding less well than young fitter patients and have a higher risk of death. Almost all patients who develop acute gastrointestinal bleeding are managed in hospital (rather than in the community), there is no published literature concerning primary care and the guideline is therefore focused upon hospital care.

Contents

• Foreword
• Guideline development group members
• Abbreviations
• Acknowledgments
• 1. Introduction
• 2. Development of the guideline
  • 2.1. What is a NICE clinical guideline?
  • 2.2. Remit
  • 2.3. Who developed this guideline?
  • 2.4. What this guideline covers
  • 2.5. What this guideline does not cover
  • 2.6. Relationships between the guideline and other NICE guidance
• 3. Methods
  • 3.1. Developing the review questions and outcomes
  • 3.2. Searching for evidence
  • 3.3. Evidence of effectiveness
  • 3.4. Evidence of cost-effectiveness
  • 3.5. Developing recommendations
• 4. Guideline summary
  • 4.1. Full list of recommendations
• 5. Risk Assessment (risk scoring)
  • 5.1. Introduction
  • 5.2. Clinical question and methodological introduction
  • 5.3. Clinical evidence review
  • 5.4. Health Economic evidence
  • 5.5. Evidence statements
  • 5.6. Recommendations and link to evidence
• 6. Resuscitation and initial management
  • 6.1. Blood Products
  • 6.2. Terlipressin treatment and treatment duration
• 7. Timing of endoscopy
  • 7.1. Introduction
  • 7.2. Clinical question and methodological introduction
  • 7.3. Clinical evidence review
  • 7.4. Health economic evidence
  • 7.5. Evidence Statements
  • 7.6. Recommendations and link to evidence
• 8. Management of non-variceal bleeding
  • 8.1. Endoscopic combination therapy versus adrenaline injection alone
  • 8.2. Proton pump inhibitor (PPI) treatment
  • 8.3. Treatment options after first or failed endoscopic treatment
• 9. Management of variceal bleeding
  • 9.1. Antibiotic prophylaxis
  • 9.2. Band Ligation
  • 9.3. Transjugular intrahepatic portosystemic shunts [TIPS] and endoscopic treatment
• 10. Control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel
  • 10.1. Introduction
  • 10.2. Clinical question and methodological introduction
  • 10.3. Clinical evidence review
  • 10.4. Health economic evidence
  • 10.5. Evidence Statements
  • 10.6. Recommendations and links to evidence
• 11. Primary prophylaxis for acutely ill patients in critical care
  • 11.1. Introduction
  • 11.2. Clinical question and methodological introduction
  • 11.3. Clinical evidence review
  • 11.4. Health economic evidence
  • 11.5. Evidence statements
  • 11.6. Recommendations and link to evidence
• 12. Information and support for patients and carers
  • 12.1. Introduction
  • 12.2. Clinical question and methodological introduction
  • 12.3. Clinical evidence review
  • 12.4. Health economic evidence review
  • 12.5. Evidence Statements
  • 12.6. Recommendations and link to evidence
• Glossary
• Reference List
• Appendices
  • Appendix A. Scope
  • Appendix B. Declarations of interest
  • Appendix C. Literature Search Strategies
  • Appendix D. Review Protocols
  • Appendix E. Clinical study selection flow charts
  • Appendix F. Evidence tables – clinical studies
  • Appendix G. Economic evidence tables
  • Appendix H. Forest Plots
  • Appendix I. A cost effectiveness model comparing early and late endoscopy in people with acute upper gastrointestinal bleeding
  • Appendix J. Time to endoscopy: statistical analysis of the UK Comparative Audit of Upper Gastrointestinal Bleeding and the use of Blood
  • Appendix K. Excluded Studies
  • Appendix L. Details of Risk scoring analysis and diagnostic meta-analysis plots