Acute management of gastrointestinal haemorrhage

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:

1. NICE (August 2016). Acute Upper GI bleeding.