PHARMACOLOGICAL THERAPY (COnTd)
ACId SUPPRESSIOn And AGEnTS TO ARREST BLEEdInG
A Antibiotic therapy should be commenced in patients
with chronic liver disease who present with acute upper
A High-dose intravenous proton pump inhibitor therapy (eg,
Scottish Intercollegiate Guidelines Network
omeprazole or pantoprazole 80 mg bolus followed by 8 mg/
hour infusion for 72 hours) should be used in patients with
MAnAGEMEnT OF BLEEdInG VARICES nOT COnTROLLEd BY
major peptic ulcer bleeding (active bleeding or non-bleeding
visible vessel) following endoscopic haemostatic therapy.
C Transjugular intrahepatic portosystemic stent shunting is
COnTInUATIOn OF THERAPY FOR OTHER MEdICAL COndITIOnS
recommended as the treatment of choice for uncontrolled
Medicines known to increase the risk of upper gastrointestinal
complications should, where possible, be given in monotherapy
d Balloon tamponade should be considered as a temporary
and at the lowest effective dose to minimise the risk of upper
salvage treatment for uncontrolled variceal haemorrhage.
PREVEnTIOn OF VARICEAL REBLEEdInG
A Patients with healed bleeding ulcers who test negative for
A Variceal band ligation combined with a beta blocker is
Helicobacter pylori require concomitant proton pump
recommended as secondary prevention for oesophageal
inhibitor therapy at the usual daily dose if nSAIds, aspirin or
COX-2 inhibitors are indicated.
A In patients unsuitable for variceal band ligation, combination
Management of acute upper and
Aspirin and nSAIds should be discontinued when patients
of non-selective beta blocker and nitrate is recommended as
present with peptic ulcer bleeding.
lower gastrointestinal bleeding
secondary prevention for oesophageal variceal haemorrhage.
Once ulcer healing and eradication of Helicobacter
pylori are confirmed, aspirin and nSAIds should only be
prescribed if there is a clear indication.
A Transjugular intrahepatic portosystemic stent shunts should
d Selective serotonin reuptake inhibitors should be used
be considered to prevent oesophageal variceal rebleeding in
with caution in patients who have an increased risk of
patients with contraindications, intolerance to or failure of
gastrointestinal bleeding, especially in patients taking
endoscopic and/or pharmacological therapy.
nSAIds or aspirin. A non-SSRI antidepressant may be an
appropriate choice in such patients.
B Transjugular intrahepatic portosystemic stent shunts should
be considered to prevent gastric variceal rebleeding.
d Oral anticoagulants or corticosteroids should be used with
MAnAGEMEnT OF COLOnIC BLEEdInG
caution in patients at risk from gastrointestinal bleeding,
especially in those taking aspirin or nSAIds.
All patients with rectal bleeding should have a full history
taken, abdominal examination and should undergo digital rectal
MAnAGEMEnT OF VARICEAL UPPER GI BLEEdInG
EndOSCOPIC THERAPY FOR OESOPHAGEAL VARICEAL BLEEdInG
A Patients with confirmed oesophageal variceal haemorrhage
d In patients with massive lower gastrointestinal haemorrhage,
should undergo variceal band ligation.
colonoscopic haemostasis is an effective means of
controlling haemorrhage from active diverticular bleeding
EndOSCOPIC THERAPY FOR GASTRIC VARICEAL BLEEdInG
or post-polypectomy bleeding, when appropriately skilled
B Patients with confirmed gastric variceal haemorrhage should
expertise is available.
have endoscopic therapy, preferably with cyanoacrylate
VASOACTIVE dRUG THERAPY PRIOR TO EndOSCOPY
This Quick Reference Guide provides a summary of the main
A Prior to endoscopic diagnosis, terlipressin should be given to
recommendations in the SIGN guideline on Management of acute
patients suspected of variceal haemorrhage.
upper and lower gastrointestinal bleeding.
Recommendations are graded
to indicate the strength of
VASOACTIVE dRUG THERAPY AFTER EndOSCOPIC dIAGnOSIS
the supporting evidence. Good practice points are provided where
the guideline development group wishes to highlight specific aspects of
A After endoscopic treatment of acute oesophageal variceal
haemorrhage patients should receive vasoactive drug
Details of the evidence supporting these recommendations can be found
Copies of all SIGN guidelines are available
treatment (terlipressin for 48 hours, octreotide, or high-dose
in the full guideline, available on the SIGN website: www.sign.ac.uk
online at www.sign.ac.uk
somatostatin each for three to five days).
ASSESSInG GI BLEEdInG In HOSPITAL
POST-EndOSCOPIC RISK ASSESSMEnT
PRE-EndOSCOPIC RISK ASSESSMEnT
d Patients with a full (post-endoscopic) Rockall score <3 have
C Early endoscopic examination should be undertaken within
a low risk of rebleeding or death and should be considered
24 hours of initial presentation, where possible.
d All patients presenting with acute upper gastrointestinal
for early discharge and outpatient follow up.
bleeding should have an initial (pre-endoscopic) Rockall
MAnAGEMEnT OF nOn-VARICEAL UPPER GI BLEEdInG
score calculated. Patients with a Rockall score of 0 should
be considered for non-admission or early discharge with
outpatient follow up.
d Endoscopic therapy should only be delivered to actively
d In patients with initial (pre-endoscopic) Rockall score >0
bleeding lesions, non-bleeding visible vessels and, when
endoscopy is recommended for a full assessment of bleeding
technically possible, to ulcers with an adherent blood clot.
A Combinations of endoscopic therapy comprising an injection
ACUTE UPPER GASTROInTESTInAL BLEEdInG – InITIAL
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.
Consider for discharge or non-admission with outpatient follow up if:
B Endoscopy and endo-therapy should be repeated within 24
hours when initial endoscopic treatment was considered
no evidence of haemodynamic disturbance (systolic blood
sub-optimal (because of difficult access, poor visualisation,
pressure ≥100 mm Hg, pulse<100 beats per minute), and;
technical difficulties) or in patients in whom rebleeding is
no significant comorbidity (especially liver disease, cardiac
likely to be life threatening.
REBLEEdInG FOLLOWInG EndOSCOPIC THERAPY
not a current inpatient (or transfer), and;
no witnessed haematemesis or haematochezia.
d non-variceal upper gastrointestinal haemorrhage not
controlled by endoscopy should be treated by repeat
Consider for admission and early endoscopy (and calculation of full
endoscopic treatment, selective arterial embolisation or
Rockall score) if:
or full sc
age ≥60 years (all patients who are aged >70 years should be
witnessed haematemesis or haematochezia (suspected continued
A Patients with peptic ulcer bleeding should be tested for
Helicobacter pylori (with biopsy methods or urea breath test)
haemodynamic disturbance (systolic blood pressure
and a one week course of eradication therapy prescribed for
*SBP - systolic blood pressure *SRH - Stigmata of recent haemorrhage
<100 mm Hg, pulse ≥100 beats per minute), or;
those who test positive. A further three weeks ulcer healing
Maximum additive score prior to diagnosis = 7
treatment should be given.
Maximum additive score after diagnosis = 11.
A In non-nSAId users, maintenance antisecretory therapy
ORGAnISATIOn OF SERVICES
should not be continued after successful healing of the ulcer
ACUTE LOWER GASTROInTESTInAL BLEEdInG – InITIAL
and Helicobacter pylori eradication.
dEdICATEd GI BLEEdInG UnIT
B Biopsy samples to test for presence of Helicobacter pylori
Consider for discharge or non-admission with outpatient follow up if:
d Patients with acute upper gastrointestinal haemorrhage
should be taken at initial endoscopy prior to commencing
should be admitted, assessed and managed in a dedicated
proton pump inhibitor therapy. Biopsy specimens should be
gastrointestinal bleeding unit.
histologically assessed when the rapid urease test is negative.
no evidence of haemodynamic disturbance, and;
Successful Helicobacter pylori eradication should be
no evidence of gross rectal bleeding, and;
RESUSCITATIOn And InITIAL MAnAGEMEnT
confirmed by breath test or biopsy to minimise the risk of
an obvious anorectal source of bleeding on rectal examination/
Second line treatment should be prescribed in the case of
Shocked patients should receive prompt volume
Consider for admission if:
Red cell transfusion should be considered after loss of
Helicobacter pylori testing to confirm successful eradication
30% of the circulating volume.
should only be taken after proton pump inhibitor and
antibiotic therapy has been completed and discontinued.
evidence of gross rectal bleeding, or;
EARLY PHARMACOLOGICAL MAnAGEMEnT
Follow up endoscopy should be performed to confirm healing
A Proton pump inhibitors should not be used prior to diagnosis
of gastric ulcers if there is suspicion of malignancy.
by endoscopy in patients presenting with acute upper
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