Acute upper gastrointestinal bleeding in the UK: 2022 audit update

Background

Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency with evolving demographics and management strategies, particularly in medical/endoscopic therapy and transfusion strategies.

Objective

To provide key data of the most recent 2022 UK audit and compare it with the preceding audit in 2007.

Design

Prospective multicentre audit conducted from 3 May to 2 July 2022, including adults (≥16 years) with AUGIB across 147 UK hospitals (response rate 86% vs 84% in 2007). AUGIB was defined by clinical symptoms (haematemesis, haematochezia, coffee ground vomiting or melaena confirmed by medical personnel). Patients were followed until discharge, death or 28 days, with re-admissions during the study period counted as new episodes.

Results

Among 5141 patients (59% male; median age 69), 15% had cirrhosis, 19% reported excess alcohol use, 7% used non-steroidal anti-inflammatory drugs (NSAIDs) and 46% were on antithrombotics. Most (77%) were new admissions, who were younger with fewer comorbidities, while the remainder bled during hospitalisation. Peptic ulcer disease accounted for 32% of cases, varices for 10% and no abnormality was found in 33%. Pre-endoscopic risk stratification was not performed in 42%.

Compared with 2007, patients in 2022 had higher comorbidity (67% vs 50%), more cirrhosis (15% vs 9%), greater anticoagulant use (31% vs 13%) and higher transfusion rates (50% vs 43%). In 2022, among early transfusions (pre-endoscopy or within first 24 hrs; 38%), 43% were given at haemoglobin (Hb)>70 g/L, with 24% classified as inappropriate due to haemodynamic stability. A signal of harm was observed: while inappropriate transfusion was not associated with rebleeding at either 70 or 80 g/L, at 80 g/L it was linked to higher adjusted mortality (adjusted OR (aOR) 1.60, 95% CI 1.00 to 2.56).

Inpatient endoscopy was more common (83% vs 74%), though endotherapy use remained modest (27% vs 23%). Salvage therapy rates were unchanged (3.3% vs 3.1%) but shifted from surgery to interventional radiology. Outcomes improved, with lower rebleeding (9.7% vs 13.3%), reduced in-hospital mortality (8.8% vs 10.0%) and shorter median stay (5 vs 6 days). In multivariate analysis, mortality was independently predicted by older age (≥80 years: aOR 2.32, 95% CI 1.64 to 3.30), shock (aOR 2.22, 95% CI 1.53 to 3.17) and comorbidity, while lower Hb at presentation increased risk (≤70 g/L: aOR 1.56, 95% CI 1.15 to 2.11). Anticoagulant use was associated with increased mortality (aOR 1.43, 95% CI 1.11 to 1.85), whereas NSAID use (aOR 0.49, 95% CI 0.25 to 0.96) and antiplatelet use (aOR 0.68, 95% CI 0.54 to 0.87) were associated with lower mortality.

Conclusions

Despite a higher-risk case mix and incomplete adherence to guidelines (notably in transfusion thresholds and risk stratification), outcomes in AUGIB have improved. The observation of increased mortality with liberal transfusion above 80 g/L in stable patients reinforces the importance of restrictive transfusion practice. Quality improvement initiatives focused on risk stratification, endoscopic training and multidisciplinary care could further enhance outcomes in the UK and internationally.