Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

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.

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

  • 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.

  • 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 prophylactic antibiotic therapy at presentation to patients with suspected or confirmed variceal bleeding.

  • Consider transjugular intrahepatic portosystemic shunts (TIPS) if bleeding from oesophageal varices is not controlled by band ligation.

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.

  • National Institute for Health and Care Excellence (NICE)