Quality statement 5: Treatment of non-variceal bleeding after first or failed endoscopic treatment

Quality statement

People with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment.

Rationale

Sometimes endoscopic therapy is technically difficult and the endoscopist cannot achieve or secure haemostasis, or bleeding recurs despite full or maximal endoscopic treatment. One additional therapeutic option is interventional radiology (embolisation), which can identify and treat the bleeding point. This can be preferable to surgery, because postoperative mortality is high for this group of patients, most of whom are extremely ill at the time of surgery.

Quality measures

Structure

Evidence of local arrangements to ensure that people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment (embolisation).

Data source: Local data collection.

Process

Proportion of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable who receive interventional radiology treatment (embolisation).

Numerator – the number of people in the denominator who receive interventional radiology treatment (embolisation).

Denominator – the number of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.

Data source: Local data collection. Contained in NICE audit support for Acute upper gastrointestinal bleeding: non-variceal (NICE clinical guideline 141). The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) shows the proportion of people having either surgery or radiological intervention.

What the quality statement means for service providers, healthcare practitioners, and commissioners

Service providers ensure that systems are in place for people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable to be given interventional radiology treatment.

Healthcare practitioners give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.

Commissioners ensure that they commission services that give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.

What the quality statement means for patients, service users and carers

People with acute upper gastrointestinal bleeding from the stomach or duodenum who continue to bleed or re-bleed after endoscopic treatment and whose blood pressure or pulse is unstable are given interventional radiology treatment. A long narrow plastic tube called a catheter is inserted into an artery in the groin and, under X-ray guidance, is then steered to the site of bleeding. After a small injection of X-ray dye to confirm that the tube is in the right place, the bleeding artery is blocked off to stop the bleeding. A CT scan may be needed beforehand to guide treatment if endoscopy has not identified the site of bleeding.

Source guidance

  • Acute upper gastrointestinal bleeding: management (NICE clinical guideline 141), recommendation 1.4.7 (key priority for implementation).

Definitions of terms used in this quality statement

NICE clinical guideline 141 recommendation 1.4.7 states that if interventional radiology is not promptly available people should be referred urgently for surgery.