Note from the Scottish Intercollegiate Guidelines Network (SIGN) and National Guideline Clearinghouse (NGC): In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the full-text guideline document.
The grades of recommendations (A–D) and levels of evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) are defined at the end of the "Major Recommendations" field.
Assessment and Triage
Assessing Gastrointestinal Bleeding in Hospital
D - All patients presenting with acute upper gastrointestinal bleeding should have an initial (pre-endoscopic) Rockall score calculated. Patients with a Rockall score of 0 should be considered for non-admission or early discharge with outpatient follow up.
D - In patients with initial (pre-endoscopic) Rockall score >0 endoscopy is recommended for a full assessment of bleeding risk.
D - Patients with a full (post-endoscopic) Rockall score <3 have a low risk of rebleeding or death and should be considered for early discharge and outpatient follow up.
D - The Rockall score should be taken into account with other clinical factors in assigning patients to different levels of care. It should not be used in isolation to assign patients to high dependency care.
Organisation of Services
Dedicated Gastrointestinal (GI) Bleeding Unit
D - Patients with acute upper gastrointestinal haemorrhage should be admitted, assessed and managed in a dedicated gastrointestinal bleeding unit.
Resuscitation and Initial Management
Fluid Resuscitation
Initial Resuscitation
D -
- Shocked patients should receive prompt volume replacement.
- Red cell transfusion should be considered after loss of 30% of the circulating volume.
Colloid and Crystalloid Fluids
B - Either colloid or crystalloid solutions may be used to achieve volume restoration prior to administering blood products.
Early Pharmacological Management
A - Proton pump inhibitors should not be used prior to diagnosis by endoscopy in patients presenting with acute upper gastrointestinal bleeding.
Early Endoscopic Intervention
Timing of Endoscopy
Acute Lower Gastrointestinal Bleeding
C - Early endoscopic examination should be undertaken within 24 hours of initial presentation, where possible.
Management of Non-Variceal Upper Gastrointestinal Bleeding
Endoscopy
D - Endoscopic therapy should only be delivered to actively bleeding lesions, non-bleeding visible vessels and, when technically possible, to ulcers with an adherent blood clot.
Combination Therapies
A - Combinations of endoscopic therapy comprising an injection of at least 13 ml of 1:10,000 adrenaline coupled with either a thermal or mechanical treatment are recommended in preference to single modalities.
Repeat Endoscopy
B - Endoscopy and endo-therapy should be repeated within 24 hours when initial endoscopic treatment was considered sub-optimal (because of difficult access, poor visualisation, technical difficulties) or in patients in whom rebleeding is likely to be life threatening.
Rebleeding Following Endoscopic Therapy
D - Non-variceal upper gastrointestinal haemorrhage not controlled by endoscopy should be treated by repeat endoscopic treatment, selective arterial embolisation or surgery.
Pharmacological Therapy
Helicobacter Pylori (H. pylori)
Testing for H. pylori
A - Patients with peptic ulcer bleeding should be tested for H. pylori (with biopsy methods or urea breath test) and a one week course of eradication therapy prescribed for those who test positive. A further three weeks ulcer healing treatment should be given.
A - In non-non-steroidal anti-inflammatory (NSAID) users, maintenance antisecretory therapy should not be continued after successful healing of the ulcer and H. pylori eradication.
B - Biopsy samples to test for presence of H. pylori should be taken at initial endoscopy prior to commencing proton pump inhibitor therapy. Biopsy specimens should be histologically assessed when the rapid urease test is negative.
Acid Suppression and Agents to Arrest Bleeding
Acid Suppression
A - High-dose intravenous proton pump inhibitor therapy (e.g., omeprazole or pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours) should be used in patients with major peptic ulcer bleeding (active bleeding or non-bleeding visible vessel following endoscopic haemostatic therapy.
Continuation of Therapy for Other Medical Conditions
Cyclo-oxygenase 2 (COX-2) Inhibitors
A - Patients with healed bleeding ulcers who test negative for H. pylori require concomitant proton pump inhibitor therapy at the usual daily dose if NSAIDs, aspirin or COX-2 inhibitors are indicated.
Aspirin and Clopidogrel
A -
- Aspirin and NSAIDs should be discontinued when patients present with peptic ulcer bleeding.
- Once ulcer healing and eradication of H. pylori are confirmed, aspirin and NSAIDs should only be prescribed if there is a clear indication.
Selective Serotonin Reuptake Inhibitors
D - Selective serotonin reuptake inhibitors should be used with caution in patients who have an increased risk of gastrointestinal bleeding, especially in patients taking NSAIDs or aspirin. A non-selective serotonin reuptake inhibitor (SSRI) antidepressant may be an appropriate choice in such patients.
Anticoagulants, Corticosteroids
D - Oral anticoagulants or corticosteroids should be used with caution in patients at risk from gastrointestinal bleeding, especially in those taking aspirin or NSAIDs.
Management of Acute Variceal Upper Gastrointestinal Bleeding
Endoscopic Therapy for Acute Variceal Haemorrhage
Oesophageal Varices
A - Patients with confirmed oesophageal variceal haemorrhage should undergo variceal band ligation.
Gastric Varices
B - Patients with confirmed gastric variceal haemorrhage should have endoscopic therapy, preferably with cyanoacrylate injection.
Vasoactive Drug Therapy for Acute Variceal Haemorrhage
Vasoactive Drug Therapy Prior to Endoscopy
A - Prior to endoscopic diagnosis, terlipressin should be given to patients suspected of variceal haemorrhage.
Vasoactive Drug Therapy After Endoscopic Diagnosis of Acute Variceal Haemorrhage
A - After endoscopic treatment of acute oesophageal variceal haemorrhage patients should receive vasoactive drug treatment (terlipressin for 48 hours, octreotide, or high-dose somatostatin each for three to five days).
Antibiotic Therapy
A - Antibiotic therapy should be commenced in patients with chronic liver disease who present with acute upper gastrointestinal haemorrhage.
Management of Bleeding Varices Not Controlled by Endoscopy
C - Transjugular intrahepatic portosystemic stent shunting is recommended as the treatment of choice for uncontrolled variceal haemorrhage.
D - Balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage.
Prevention of Variceal Rebleeding
Endoscopic Therapy
Oesophageal Varices
A - Variceal band ligation combined with a beta blocker is recommended as secondary prevention for oesophageal variceal haemorrhage.
A - In patients unsuitable for variceal band ligation combination of non-selective beta blocker and nitrate is recommended as secondary prevention for oesophageal variceal haemorrhage.
Portosystemic Shunts
Oesophageal Varices
A - Transjugular intrahepatic portosystemic stent shunts should be considered to prevent oesophageal variceal rebleeding in patients with contraindications, intolerance to or failure of endoscopic and/or pharmacological therapy.
Gastric Varices
B - Transjugular intrahepatic portosystemic stent shunts should be considered to prevent gastric variceal rebleeding.
Management of Lower Gastrointestinal Bleeding
Localising Bleeding
D - The cause and site of massive lower gastrointestinal haemorrhage should be determined following the early use of colonoscopy and use of computed tomography scanning, computed tomography angiography or digital subtraction angiography.
D - Nuclear scintigraphy should be considered to assist in localisation of bleeding in patients with significant recent haemorrhage.
Interventions
Colonoscopic Haemostatic Techniques
D - In patients with massive lower gastrointestinal haemorrhage, colonoscopic haemostasis is an effective means of controlling haemorrhage from active diverticular bleeding or post-polypectomy bleeding, when appropriately skilled expertise is available.
Embolisation
D - In patients with massive lower gastrointestinal haemorrhage, if colonoscopy fails to define site of bleeding and control haemorrhage, angiographic transarterial embolisation is recommended as an effective means of controlling haemorrhage.
Surgery
D - Localised segmental intestinal resection or subtotal colectomy is recommended for the management of colonic haemorrhage uncontrolled by other techniques.
Definitions:
Grades of Recommendation
Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation.
A At least one meta-analysis, systematic review, or randomised controlled trial (RCT) rated as 1++ and directly applicable to the target population; or
A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias
1-: Meta-analyses, systematic reviews, or RCTs with a high risk of bias
2++: High quality systematic reviews of case control or cohort studies
High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal
2+: Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal
2-: Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal
3: Non-analytic studies (e.g., case reports, case series)
4: Expert opinion
