NICE consults on draft recommendations to improve the management of upper gastrointestinal bleeding
In draft guidance published today (Tuesday 13 December) NICE, the healthcare guidance body, has identified a number of key areas for improvement in the management of acute upper gastrointestinal bleeding.
Each year in the UK acute upper gastrointestinal bleeding results in 50-70,000 hospital admissions, making it the most common emergency managed by gastroenterologists in the UK. Usually caused by peptic ulcers, which can bleed as the ulcer erodes into an underlying artery, or oesophago-gastric varices (dilated veins in the oesophagus, often the result of portal hypertension secondary to liver cirrhosis), upper gastrointestinal tract bleeding is estimated to account for 5000 deaths per year in the UK. In 2007 a major audit described a mortality of 7% in patients admitted to hospital with upper gastrointestinal bleeding, rising to 26% for patients already admitted to hospital who subsequently developed the problem.
The guideline identifies a number of key priorities for implementation, including:
- Do not offer blood transfusion to patients with acute upper gastrointestinal bleeding who have a haemoglobin level of more than 0.8 g/litre, unless there is another indication for transfusion.
- Offer endoscopy within 24 hours of admission to patients with upper gastrointestinal bleeding. Units seeing more than 330 cases a year should offer daily endoscopy lists. Units seeing fewer than 330 cases should choose between daily endoscopy lists and alternative strategies (such as networks) according to local circumstances.
- Perform urgent endoscopy in unstable patients with severe acute upper gastrointestinal bleeding.
- Offer interventional radiology if this is promptly available to patients who re-bleed despite endoscopic treatment. Refer urgently for surgery if interventional radiology is not available.
- Consider using transjugular intrahepatic portosystemic shunts (TIPS) for oesophageal, gastric or ectopic variceal bleeding if initial endoscopic treatment has not controlled upper gastrointestinal bleeding.
Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE said: "Despite changes in how upper gastrointestinal tract bleeding is managed, including the use of endoscopy for diagnosis, to provide prognostic information and as a means to stop active bleeding and prevent re-bleeding, mortality has not improved much over the past 50 years. Although this is partly due to the aging population meaning more people are at higher risk of a poor outcome, there is also evidence that compliance with standards of care, such as the use of blood products, deployment of investigations and management, is variable at best. For example, we know that some hospitals provide a comprehensive 24/7 service involving endoscopy, interventional radiology and emergency surgery, while others do not. The reported expertise of endoscopists varies widely with approximately 30% being unable to manage bleeding oesophageal varices. A national guideline is therefore needed on the management of acute upper gastrointestinal bleeding to address the uncertainties and variability in practice in primary and secondary care."
The draft guideline also addresses risk assessment, initial management, timing of endoscopy, controlling bleeding and preventing re-bleeding, and information and support for patients.
Notes to Editors
About the clinical guideline
1. The draft recommendations will be available on the NICE website from Tuesday 13 December 2011 to Tuesday 14 February 2012 at http://guidance.nice.org.uk/CG/Wave21/1.
2. Final guideline is expected to be published in July 2012.
3. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health
4. NICE produces guidance in three areas of health:
- public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
- health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
- clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS
5. NICE produces standards for patient care:
- quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
- Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients
6. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.
This page was last updated: 12 December 2011