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Endoscopy for upper gastrointestinal bleeding: where are we in 2017?
  1. Katy Mary Waddell,
  2. Adrian John Stanley,
  3. Allan John Morris
  1. Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
  1. Correspondence to Dr Allan John Morris, Department of Gastroenterology, Glasgow Royal Infirmary, Castle St, Glasgow G4 0SF, UK; john.morris{at}ggc.scot.nhs.uk

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Background

Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency with an incidence of 103–172 per 100 000 in the UK, equating to approximately 25 000 hospital admissions.1 ,2 The most common causes of UGIB are peptic ulcer disease (36%) and oesophageal varices (11%).3 Endoscopy plays a crucial role in the management of patients with UGIB, yielding diagnosis, calculation of risk assessment scores and prognosis and allowing therapy to be delivered.

A UK audit carried out by the British Society of Gastroenterology (BSG) and the national blood transfusion service in 2007 identified several areas in the management of patients presenting with UGIB that need improvement.4

In recent years, there have been several international guidelines with recommendations on how to optimise the management of UGIB.5–7 Despite this the recent National confidential enquiry in perioperative deaths (NCEPOD) report, ‘Time to get control’ has highlighted ongoing deficiencies in current UK practice.8

Recent developments

Pre-endoscopy care

Risk assessment

National Institute for Health and Care Excellence (NICE) guidelines recommend that all patients should have a Glasgow Blatchford Score (GBS) calculated pre-endoscopy followed by a full Rockall Score post-endoscopy.5 The Rockall Score was initially created to predict risk of rebleeding and mortality and requires endoscopy for full calculation.9 The GBS can be calculated prior to endoscopy and has been shown to predict the need for intervention (blood transfusion, endotherapy and surgery) or death.10 Although a GBS >12 has been suggested to identify patients who would benefit from early endoscopy, risk assessment scores have not yet been proven to accurately predict patients who need emergency or urgent endoscopy.11

Blood transfusion

Recent studies have supported a restrictive transfusion policy in UGIB aiming to transfuse at a haemoglobin threshold of 7–8 g/dL.6 ,7 ,12 ,13 The recent European Society of Gastrointestinal Endoscopy (ESGE) guidelines now recommend …

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