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Upper GI bleeding mortality rates remain unacceptably high — international expert

The mortality rate in upper GI patients remains at approximately 10 per cent, not having changed significantly in the last 20 years, a leading expert in the field, Dr John Morris, Consultant Gastroenterologist, Glasgow Royal Infirmary, UK, told the ISG Winter Meeting.

Upper GI bleeding is one of the major emergencies gastroenterologists deal with in their daily practice, he noted. However, UK audits carried out by the British Society of Gastroenterology (BSG), the national blood transfusion service and other bodies identified several areas in the management of these patients that need improvement.

While there are a plethora of guidelines (NICE, ACG, BCG, etc) on how to manage upper GI bleeding, treatment is often suboptimal, both in resuscitation and treatment of patients in the early stages, Dr Morris explained. He said inadequate risk assessment means particularly sick patients who need immediate endoscopy are not recognised, and there is also a deficit in the skills needed to deliver the therapy. This can be seen in the fact that UK mortality rates for acute upper GI bleeding remain at around 10 per cent, a figure that has only marginally improved in the last 20 years, he stated.

Dr Morris is now leading a UK-wide quality improvement and training programme in upper GI bleeding to improve outcomes with regards to mortality, risk of re-bleeding, length of hospital stay and quality-of-life. “For the first time, we are seeing real enthusiasm from colleagues to actually address what is a hidden epidemic in terms of patient management,” he said.

“We are now seeing an emerging quality improvement programme that will address this for the first time. It will focus on the initial management of these patients, so the first 24 hours for young doctors in emergency departments and acute medical units, and it will also focus on upskilling the existing workforce.”

Key to improving upper GI bleeding outcomes, he believes, is appropriate resuscitation, including more careful consideration of blood transfusion usage. “It is now very clear that over-transfusion can be counterproductive and affects re-bleeding and mortality. So by using a care bundle, we hope to standardise care across healthcare organisations.”

Dr Morris added the timing of endoscopy and the skill set of practitioners in improving GI bleeding outcomes is key, citing data showing that compared to early endoscopy out-of-hours, waiting until morning and concentrating on adequately resuscitating the patients leads to better outcomes.

“We are so fixated on 24/7 endoscopy care, but there is good evidence now that early endoscopy doesn’t make a difference to the outcome of these patients… But patients who are adequately resuscitated do far better.”

This is particularly important in smaller, regional units. Thus, placing services into hub-and-spoke networks with clear treatment protocols and pathways and where only hospitals with 24/7 on-site endoscopy admit these patients out-of-hours will help ensure a higher-quality approach, he said.

The main causes of major upper GI bleeds remain peptic ulcer disease and varices, and Dr Morris explained that most current guidelines recommend that all patients should be risk-assessed with a Glasgow Blatchford Score (GBS) calculated pre-endoscopy, followed by a full Rockall Score post-endoscopy, which is not always practical.

The Rockall Score was initially created to predict risk of re-bleeding and mortality and requires endoscopy for full calculation.

Dr Morris stated the GBS is straightforward and practical and has been shown to successfully predict the need for intervention (blood transfusion, endotherapy and surgery) and mortality risk. In the UK now, they are moving towards using the GBS as standard practice, and moving away from the confusion of having more than one score, according to Dr Morris.

He added that it is also useful for deciding when patients are safe to discharge from emergency departments without the need for admission.

However, choosing the right techniques and technologies for individual GI bleeding patients remains a challenge despite ongoing advancements, such as the increased usage of Hemospray to achieve endoscopic haemostasis, with debate on clipping.

“So in terms of training our endoscopists of the future, we need endoscopy non-technical skills, as it is not only about how you deliver the therapy, but selecting the appropriate therapy for the patient that you’ve seen,” he stated.

Dr Morris told the Medical Independent that while there have been significant improvements in other key medical emergencies, “this is the largest standout cause of mortality in patients admitted acutely to our hospitals”.

“So it is something that we as gastroenterologists, nurses and specialists should really focus on and I am optimistic that using a combination of evidence-based bundles and training courses, we can really make a difference for our patients.”

Dr Morris stated that he had received a lot of interest from Germany in the improvement programme: “This is by no means a UK and Ireland problem; it is a worldwide issue and if we can improve patient care, then I will be delighted.”

His presentation was well received by attendees, who noted that Ireland also needs to restructure services and create set pathways to ensure all upper GI bleeding patients receive the best care.

Despite hopes to have a long-mooted HSE clinical programme for gastroenterology in place at this stage, there was little progress in 2018 but it is hoped an appointment will be made in 2019, ISG President Prof Laurence Egan told MI. Organising the management of acute GI bleeding would be a key priority for the programme. “The way it is managed is very variable around the country, with a big difference between the larger and small hospitals in how it is managed, as well as availability of expertise. As Dr Morris pointed out, proper care pathways are equally as important in the management of upper GI bleeding as having 24/7 services, so that is something that could be implemented relatively easily across all the hospitals in the country,” Prof Egan commented.

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