What are the Nice guidelines for managing upper gastrointestinal bleeding?

Management of Upper Gastrointestinal Bleeding: NICE Guidelines

The management of upper gastrointestinal bleeding requires immediate resuscitation for hemodynamically unstable patients, risk stratification using the Glasgow Blatchford Score, and early endoscopy within 24 hours of presentation for diagnosis and therapeutic intervention. 1, 2

Initial Assessment and Resuscitation

• Immediate resuscitation should be initiated for patients with acute UGIB and hemodynamic instability to stabilize blood pressure and restore intravascular volume 1, 2
• Use the Glasgow Blatchford Score (GBS) for pre-endoscopy risk stratification - patients with GBS ≤1 are at very low risk and may not require hospitalization or inpatient endoscopy 1, 3
• Avoid using the AIMS65 prognostic score for identifying very low-risk patients 1
• Consider nasogastric tube placement in selected patients as findings may have prognostic value 1, 2

Blood Transfusion Strategy

• For patients without underlying cardiovascular disease, give blood transfusions when hemoglobin level is <80 g/L 1
• For patients with underlying cardiovascular disease, use a higher hemoglobin threshold for blood transfusion 1
• Avoid over-transfusion as restrictive transfusion strategies have been shown to improve outcomes 2, 4

Pre-Endoscopic Management

• Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists, DOACs) 2
• Pre-endoscopic PPI therapy may be considered to downstage endoscopic lesions but should not delay endoscopy 5
• Promotility agents should not be used routinely before endoscopy 3
• For patients with suspected variceal bleeding, consider antibiotics and vasoactive drugs 4

Endoscopic Management

• Perform early endoscopy (within 24 hours of presentation) after appropriate resuscitation 1, 3
• Develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis 1
• Have trained support staff available on an urgent basis 1

Endoscopic Therapy Based on Stigmata:

• No endoscopic therapy needed for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot) 1
• For clots in ulcer beds, perform targeted irrigation to attempt dislodgement, then treat underlying lesion appropriately 1
• For high-risk stigmata (active bleeding or visible vessel), endoscopic hemostatic therapy is indicated 2
• Use combination therapy (epinephrine injection plus thermal coagulation or mechanical therapy) for actively bleeding ulcers rather than epinephrine injection alone 3

Post-Endoscopic Care

• Administer high-dose PPI therapy for patients who receive endoscopic hemostasis (IV bolus followed by continuous infusion for 72 hours) 2, 4
• Selected patients with low risk for rebleeding based on clinical and endoscopic criteria may be discharged promptly after endoscopy 3
• Test all patients for Helicobacter pylori and provide eradication therapy if positive 2

Management of Recurrent Bleeding

• For persistent bleeding refractory to standard hemostasis, consider topical hemostatic spray/powder or cap-mounted clip 3
• For recurrent bleeding, consider repeat endoscopic therapy, followed by transcatheter angiographic embolization if unsuccessful 3
• Surgery is indicated when angiographic embolization is not available or fails 3

Anticoagulation Management

• In patients requiring ongoing anticoagulation therapy, resume anticoagulation as soon as bleeding is controlled, preferably within 7 days based on thromboembolic risk 3
• Consider the rapid onset of action of DOACs compared to vitamin K antagonists when restarting anticoagulation 3

Common Pitfalls and Caveats

• Routine second-look endoscopy is not recommended 2
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 2
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 2
• Failure to properly risk-stratify patients may lead to unnecessary admissions or premature discharge of high-risk patients 2, 4