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SIG N Scottish Intercollegiate Guidelines Network 105 Management of acute upper and lower gastrointestinal bleeding A national clinical guideline September 2008 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of 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, eg case reports, case series 4 Expert opinion 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 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. NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. This guideline has been assessed for its likely impact on the six equality groups defined by age, disability, gender, race, religion/belief, and sexual orientation. For the full equality and diversity impact assessment report please see the “published guidelines” section of the SIGN website at www.sign.ac.uk/guidelines/published/numlist.html. The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity Officer. Every care is taken to ensure that this publication is correct in every detail at the time of publication. However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site www.sign.ac.uk This document is produced from elemental chlorine-free material and is sourced from sustainable forests Scottish Intercollegiate Guidelines Network Management of acute upper and lower gastrointestinal bleeding A national clinical guideline September 2008 Management of acute upper and lower gastrointestinal bleeding ISBN 978 1 905813 37 7 Published September 2008 SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Elliott House, 8 -10 Hillside Crescent Edinburgh EH7 5EA www.sign.ac.uk CONTENTS Contents 1 Introduction...................................................................................................................... 1 1.1 The need for a guideline.................................................................................................... 1 1.2 Remit of the guideline........................................................................................................ 1 1.3 Definitions......................................................................................................................... 2 1.4 Statement of intent............................................................................................................. 3 2 Assessment and triage........................................................................................................ 4 2.1 Assessing gastrointestinal bleeding in the community......................................................... 4 2.2 Assessing gastrointestinal bleeding in hospital.................................................................... 4 3 Organisation of services.................................................................................................... 10 3.1 Dedicated GI bleeding unit................................................................................................ 10 4 Resuscitation and initial management............................................................................... 12 4.1 Airway, breathing and circulation....................................................................................... 12 4.2 Fluid resuscitation.............................................................................................................. 12 4.3 Early pharmacological management................................................................................... 13 4.4 Early endoscopic intervention............................................................................................ 14 5 Management of non-variceal upper gastrointestinal bleeding............................................ 16 5.1 Risk stratification................................................................................................................ 16 5.2 Endoscopy......................................................................................................................... 16 5.3 Pharmacological therapy.................................................................................................... 19 6 Management of acute variceal upper gastrointestinal bleeding......................................... 26 6.1 Endoscopic therapy for acute variceal haemorrhage........................................................... 27 6.2 Vasoactive drug therapy for acute variceal haemorrhage.................................................... 28 6.3 Antibiotic therapy............................................................................................................... 30 6.4 Balloon tamponade............................................................................................................ 31 6.5 Management of bleeding varices not controlled by endoscopy........................................... 31 7 Prevention of variceal rebleeding...................................................................................... 32 7.1 Vasoactive drug therapy..................................................................................................... 32 7.2 Endoscopic therapy............................................................................................................ 32 7.3 Portosystemic shunts.......................................................................................................... 33 8 Management of lower gastrointestinal bleeding............................................................... 34 8.1 Localising bleeding............................................................................................................ 35 8.2 Interventions...................................................................................................................... 35 Antibiotic prophylaxis Management of acute upper in surgery and lower gastrointestinal bleeding 9 Provision of information.................................................................................................... 37 9.1 Areas of concern to patients............................................................................................... 37 9.2 Sources of further information............................................................................................ 38 10 Implementing the guideline............................................................................................... 39 10.1 Resource implications of key recommendations................................................................. 39 10.2 Auditing current practice.................................................................................................... 40 10.3 Advice to NHSScotland from the scottish medicines consortium........................................ 40 11 The evidence base............................................................................................................. 41 11.1 Systematic literature review................................................................................................ 41 11.2 Recommendations for research.......................................................................................... 41 11.3 Review and updating.......................................................................................................... 42 12 Development of the guideline........................................................................................... 43 12.1 Introduction....................................................................................................................... 43 12.2 The guideline development group...................................................................................... 43 12.3 Acknowledgements............................................................................................................ 44 12.4 Consultation and peer review............................................................................................. 44 Abbreviations............................................................................................................................... 46 Annex 1....................................................................................................................................... 47 Annex 2....................................................................................................................................... 51 References................................................................................................................................... 52 INTRODUCTION 1 Introduction 1.1 the need for a guideline Acute gastrointestinal (GI) bleeding (or haemorrhage) is a common major medical emergency, accounting for approximately 7,000 admissions to hospitals in Scotland each year. In a 2007 UK-wide audit, overall mortality of patients admitted with acute GI bleeding was 7%. In contrast the mortality in patients who bled during admissions to hospital for other reasons was 26%.1 In an audit undertaken in the West of Scotland the incidence of acute GI bleeding was higher than that reported elsewhere at 170/100,000 people with a mortality of 8.2%.2 These differences may relate to different case ascertainment in the two audits. Over the last ten years there has been a number of improvements in diagnosis and management. The increased involvement of acute care specialists during resuscitation and follow up, improved diagnostic and therapeutic endoscopy, advances in diagnostic and therapeutic radiology, the use of powerful ulcer healing drugs, more selective and less invasive surgical approaches may all improve outcome for patients. These changes have altered the diagnostic and treatment pathways for patients presenting with non-variceal and variceal upper GI bleeding and those with acute colonic bleeding. There is a need to examine the evidence to clarify which diagnostic and management steps have proven benefit. The major objectives of all involved in the management of bleeding patients are to reduce mortality and the need for major surgery. A secondary objective is to prevent unnecessary hospital admission for patients presenting with bleeding that is not life threatening. 1.2 REMIT of the guideline 1.2.1 overall objectives This guideline provides recommendations based on current evidence for best practice in the management of acute upper and lower GI bleeding. It includes the assessment and management of variceal, non-variceal, and colonic bleeding in adults. The guideline deals with the management of bleeding that is of sufficient severity to lead to emergency admission to hospital. Bleeding of lesser severity is subject to elective investigation and is not considered here. The management of patients under the age of 14 is not covered by this guideline. 1.2.2 target users of the guideline This guideline will be of interest to a range of medical professionals including acute physicians, gastroenterologists, gastrointestinal surgeons, endoscopists, pharmacists, anaesthetists and nurses. It will also be of interest to patients who have suffered from acute GI bleeding and to their carers. 1 Management of acute upper and lower gastrointestinal bleeding 1.3 definitions Upper and lower gastrointestinal bleeding Upper gastrointestinal bleeding (or haemorrhage) is that originating proximal to the ligament of Treitz; in practice from the oesophagus, stomach and duodenum. Lower gastrointestinal bleeding is that originating from the small bowel and colon. This guideline focuses upon upper GI and colonic bleeding since acute small bowel bleeding is uncommon. Haematemesis (and coffee-ground vomitus) Haematemesis is vomiting of blood from the upper gastrointestinal tract or occasionally after swallowing blood from a source in the nasopharynx. Bright red haematemesis usually implies active haemorrhage from the oesophagus, stomach or duodenum. This can lead to circulatory collapse and constitutes a major medical emergency. Patients presenting with haematemesis have a higher mortality than those presenting with melaena alone.2 Coffee-ground vomitus refers to the vomiting of black material which is assumed to be blood. Its presence implies that bleeding has ceased or has been relatively modest. Melaena Melaena is the passage of black tarry stools usually due to acute upper gastrointestinal bleeding but occasionally from bleeding within the small bowel or right side of the colon. Hematochezia Hematochezia is the passage of fresh or altered blood per rectum usually due to colonic bleeding. Occasionally profuse upper gastrointestinal or small bowel bleeding can be responsible. Shock Shock is circulatory insufficiency resulting in inadequate oxygen delivery leading to global hypoperfusion and tissue hypoxia. In the context of GI bleeding shock is most likely to be hypovolaemic (due to inadequate circulating volume from acute blood loss). The shocked, hypovolaemic patient generally exhibits one or more of the following signs or symptoms: ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ ƒƒ a rapid pulse (tachycardia) anxiety or confusion a high respiratory rate (tachypnoea) cool clammy skin low urine output (oliguria) low blood pressure (hypotension). It is important to remember that a patient with normal blood pressure may still be shocked and require resuscitation. Varices Varices are abnormal distended veins usually in the oesophagus (oesophageal varices) and less frequently in the stomach (gastric varices) or other sites (ectopic varices) usually occurring as a consequence of liver disease. Bleeding is characteristically severe and may be life threatening. The size of the varices and their propensity to bleed is directly related to the portal pressure, which, in the majority of cases, is directly related to the severity of underlying liver disease. Large varices with red spots are at highest risk of rupture. Endoscopy Endoscopy is the visualisation of the inside of the gastrointestinal tract using telescopes. Examination of the upper gastrointestinal tract (oesophagus, stomach and duodenum) is known as gastroscopy or upper gastrointestinal endoscopy. Examination of the colon (large bowel) is called colonoscopy. Triage Triage is a system of initial assessment and management whereby a group of patients is classified according to the seriousness of their injuries or illnesses so that treatment priorities can be allocated between them. 2 INTRODUCTION 1.4 Statement of intent This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken. 1.4.1 additional advice to nhsscotland from NHS quality improvement scotland and the scottish medicines consortium NHS QIS processes multiple technology appraisals (MTAs) for NHSScotland that have been produced by the National Institute for Health and Clinical Excellence (NICE) in England and Wales. The Scottish Medicines Consortium (SMC) provides advice to NHS Boards and their Area Drug and Therapeutics Committees about the status of all newly licensed medicines and any major new indications for established products. SMC advice and NHS QIS validated NICE MTAs relevant to this guideline are summarised in the section on implementation. 3 Management of acute upper and lower gastrointestinal bleeding 2 Assessment and triage 2.1 assessing gastrointestinal bleeding in the community The assessment of GI bleeding from any cause in the community involves the identification of patients who require urgent admission, patients who require to be referred for outpatient assessment and patients who can be managed at home without involvement of hospital services. No studies were identified that were undertaken in primary care settings to address optimal referral practice. The decision to refer must be based upon clinical experience, common sense and extrapolation of guidance derived from risk assessment studies undertaken in secondary care settings. 2.2 assessing gastrointestinal bleeding in hospital The purpose of this section is to assist individual units to develop guidelines and protocols based on available evidence which are suitable for their local circumstances. Patients referred to hospital are initially assessed in a variety of settings including emergency departments, acute assessment units, gastroenterology departments, dedicated GI bleeding units or surgical wards. Acute GI bleeding is a medical emergency. Initial triage and assessment are generic with emphasis on identifying the sick patient with life threatening haemodynamic compromise and initiating appropriate resuscitation (see section 4.2). Certain clinical features associated with GI bleeding have been studied in attempts to identify patients at increased risk of morbidity and death. Although acute upper and lower GI bleeding are distinct entities, the site of bleeding is not always immediately apparent; for example, 15% of patients with severe haematochezia have a source of bleeding in the upper GI tract.3 Despite this, the literature on upper and lower GI bleeding is largely separate and this section on assessment is similarly subdivided. 2.2.1 risk factors associated with poor outcome Acute upper gastrointestinal bleeding There is a lack of good quality studies on the initial assessment of patients with acute upper GI bleeding (UGIB). Limited evidence is available from cohort and case series which identify risk factors associated with poor outcome (variously defined) but usually without formal scoring. Studies confirm an extremely high fatality in inpatients of 42%.4,5 3 The following factors are associated with a poor outcome, defined in terms of severity of bleed, uncontrolled bleeding, rebleeding, need for intervention and mortality. These factors should be taken into account when determining the need for admission or suitability for discharge. ƒƒ Age - mortality due to UGIB increases with age across all age groups. Odds ratio (OR) for mortality is from 1.8 to 3 for age >60 years (compared to patients aged 45-59 years), and from 4.5 to 12 for age>75 years (compared to patients ≤75 years).2,4,6 ƒƒ Comorbidity - the absence of significant comorbidity is associated with mortality as low as 4%.2,4,6,7 Even one comorbidity almost doubles mortality (OR 1.8) and the presence of cardiac failure (OR 1.8) or malignancy (OR 3.8) significantly worsens prognosis. ƒƒ Liver disease - cirrhosis is associated with a doubling of mortality and much higher risk of interventions such as endoscopic haemostasis or transfusion.8 The overall mortality of patients presenting with varices is 14%.1 ƒƒ Inpatients have approximately a threefold increased risk of death compared to patients newly admitted with GI bleeding. This is due to the presence of comorbidities in established inpatients rather than increased severity of bleeding.4,5 ƒƒ Initial shock (hypotension and tachycardia) is associated with increased mortality (OR 3.8) and need for intervention.2,4,7 4 3 23 3 3 2