Acute upper gastrointestinal bleeding in over 16s: management – NICE guideline

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This National Institute for Health and Care Excellence (NICE) guideline covers how upper gastrointestinal bleeding can be effectively managed in adults and young people aged 16 years and older. It aims to identify which diagnostic and therapeutic steps are useful so hospitals can develop a structure in which clinical teams can deliver an optimum service for people who develop this condition.

Key recommendations

Risk assessment

  • Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding:
    • Blatchford score at first assessment, and
    • 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.

Acute upper gastrointestinal bleeding is a common medical emergency that has a 10% hospital mortality rate. Despite changes in management, mortality has not significantly improved over the past 50 years.

Elderly patients and people with chronic medical diseases withstand acute upper gastrointestinal bleeding less well than younger, fitter patients, and have a higher risk of death. Almost all people who develop acute upper gastrointestinal bleeding are treated in hospital and the guideline therefore focuses on hospital care. The most common causes are peptic ulcer and oesophago-gastric varices.

This guideline aims to identify which diagnostic and therapeutic steps are useful in managing acute upper gastrointestinal bleeding. This should enable hospitals to develop a structure in which clinical teams can deliver an optimum service for people who develop this condition.

You can read the guideline on NICE's website.