Lower gastrointestinal bleeding 2015

National Comparative Audit of lower gastrointestinal bleeding and the use of blood (2015)

Key Aim

To characterise the clinical characteristics, management strategies and outcomes of patients with acute lower gastrointestinal bleeding (LGIB) presenting to UK hospitals.

Specific Objectives

Describe the use of inpatient investigations, treatments including emergency surgery and quantify the volume of blood product transfusion in comparison to established national guidelines and protocols.

Who took part?

We audited 2528 patients from 143 acute hospitals across the United Kingdom over 2 months in 2015.

What did we find?

Full report (PDF)

Lower gastrointestinal bleeding (LGIB) patients

Most LGIB patients were elderly, with other medical problems and often they were taking antiplatelet or anticoagulant medications. Anaemia and shock were very uncommon, but this over 25% patients received a red cell transfusion. Single unit transfusions were used in only 20% cases. Many patients did not have the source of bleeding investigated during their admission, even those with severe bleeding. Patients that were investigated often waited more than 24 hours for crucial tests.

Lower gastrointestinal bleeding services

Treatment of LGIB can be delivered endoscopically, via interventional radiology procedures such as mesenteric embolisation, or surgically. All hospitals provided 24/7 on-site access to surgery, 73% provided 24/7 access to endoscopy and 55% provided 24/7 access to interventional radiology. Most patients with LGIB are admitted under surgical teams, but even though most patients were elderly, only 20% hospitals reported providing surgical patients routine access to specialist elderly care doctors.

Key Recommendations

The full list of recommendations is included in the audit report (PDF)

Key recommendations are as follows:

Hospitals have a duty of care to provide acute haemorrhage control. Those that do not provide on-site interventional radiology should liaise with their regional centre to establish an agreed formalised network
Hospitals should examine their transfusion practice to ensure appropriate transfusion thresholds are being utilised.
Hospitals should develop comprehensive local guidelines that cover both upper and lower gastrointestinal bleeding, and should include the management of anticoagulants and antiplatelets.

Resources available to help improve practice

Guidance on the safe provision of interventional radiology services has been provided by the Royal College of Radiologists and the British Society of Interventional Radiologists

NICE guidance on blood transfusion; NG24, November 2015

Audit report

Full report (PDF)

Audit tool

The methodology, audit tool and auditable standards can be found in the published protocol for the audit

Endorsements

This findings and recommendations from this audit are endorsed by the British Society of Gastroenterology, the British Society of Interventional Radiology, NHS Blood and Transplant and the Association of Coloproctology of Great Britain and Ireland.

Project Group

This project was jointly funded by NHS Blood and Transplant and the Bowel Disease Research Foundation

Associated Publications

Journal articles

Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. The Lancet Gastroenterology & Hepatology 2(9) · June 2017 DOI: 10.1016/S2468-1253(17)30150-4

Acute lower GI bleeding in the UK: Patient characteristics, interventions and outcomes in the first nationwide audit. Gut Published Online First: 01 February 2017. doi: 10.1136/gutjnl-2016-313428

Study protocol: First nationwide comparative audit of acute lower gastrointestinal bleeding in the UK. BMJ Open 6(8):e011752 · August 2016 DOI: 10.1136/bmjopen-2016-011752

Abstracts

Blood Transfusion in Lower Gastrointestinal Bleeding: Results From a National Study in the United Kingdom. Transfusion 2016 Vol. 56 Supplement S4 P171A Abstract SP366

Outcomes of acute lower gastrointestinal bleeding: data from a large nationwide audit. Accepted for poster presentation, United European Gastroenterology Journal; 2016: 2 (Supplement 1) A274 P0337

The use of surgery in the management of acute lower gastrointestinal bleeding: results from a large national audit. Colorectal Disease 2016; 18(Suppl 1) LTP54

Provision of interventional radiology, endoscopy and surgery for acute lower gastrointestinal bleeding in the United Kingdom: preliminary results of a national comparative audit. Cardiovasc Intervent Radiol (2016) 39(Suppl 3): 35. https://doi.org/10.1007/s00270-016-1405-3