Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol

Loftus, Tyler J.; Go, Kristina L.; Hughes, Steven J.; Croft, Chasen A.; Smith, R. Stephen; Efron, Philip A.; Moore, Frederick A.; Brakenridge, Scott C.; Mohr, Alicia M.; Jordan, Janeen R.

doi:10.1097/ta.0000000000001295

Cited by 13 publications

(9 citation statements)

References 28 publications

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“…Implementation of an institutional LGIB protocol prioritizing CTA for patients with active bleeding led to improvement in certain predefined process outcomes (increased use of the GI consultation service and increasing performance of CTA as opposed to tagged red blood cell scanning) and fewer transfusions (154). In another retrospective cohort analysis of patients with acute GIB, implementation of a multidisciplinary GIB protocol was able to successfully decrease PRBC transfusion, reduce hospital length of stay, and decrease hospital readmissions (155).…”

Section: Lgib Protocolsmentioning

confidence: 99%

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

et al. 2022

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Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospitalization in the United States and is associated with significant utilization of hospital resources, as well as considerable morbidity and mortality. These revised guidelines implement the Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the use of risk stratification tools, thresholds for red blood cell transfusion, reversal agents for patients on anticoagulants, diagnostic testing including colonoscopy and computed tomography angiography (CTA), endoscopic therapeutic options, and management of antithrombotic medications after hospital discharge. Important changes since the previous iteration of this guideline include recommendations for the use of risk stratification tools to identify patients with LGIB at low risk of a hospital-based intervention, the role for reversal agents in patients with life-threatening LGIB on vitamin K antagonists and direct oral anticoagulants, the increasing role for CTA in patients with severe LGIB, and the management of patients who have a positive CTA. We recommend that most patients requiring inpatient colonoscopy undergo a nonurgent colonoscopy because performing an urgent colonoscopy within 24 hours of presentation has not been shown to improve important clinical outcomes such as rebleeding. Finally, we provide updated recommendations regarding resumption of antiplatelet and anticoagulant medications after cessation of LGIB.

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Section: Lgib Protocolsmentioning

confidence: 99%

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

et al. 2022

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“…This is strong evidence for the implementation of these validated risk assessment scores for UGIB patients which provide information regarding the need for therapy, admission, rebleed risk, and mortality risk, while preventing unnecessary intervention and reducing the burden on an already strained health system 4 . Furthermore, research shows that clear evidence‐based multidisciplinary guidelines ameliorate the difficulties described and expedite the decision‐making process for junior and senior clinicians alike, thereby decreasing both the referral time and time to therapy 11 …”

Section: Discussionmentioning

confidence: 99%

Upper GI bleeding in rural Australia: general surgery still alive and well!

Sabat

McSweeney

Konno

et al. 2023

ANZ Journal of Surgery

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Background: The complex and critically unwell upper gastrointestinal bleeding (UGIB) patient is a common emergency presentation in Australia. Managed medically and endoscopically by rural general surgeons in rural and remote Australian hospitals which lack a gastroenterology service, this can be ameliorated by clear evidence-based guidelines. Methods: A single-centre retrospective review of adult patients who underwent emergency gastroscopy for UGIB at the Mackay Base Hospital, January 2019 to January 2022. Detailed patient data from the assessment, resuscitation, time to endoscopy, endoscopic intervention, and outcomes were compared against key international gastroenterology society safety and quality standards for UGIB. Results: Two hundred patients had a comprehensive initial assessment and resuscitation with PRBC (39%), anticoagulation reversal (18%), pantoprazole infusion (81%), tranexamic acid (10.50%) and octreotide (16.50%). Risk scores were calculated retrospectively as none were documented. Time-to-endoscopy targets were achieved in over 70% of variceal or non-variceal UGIB patients. Bleeding was found in 59.50% of patients but 63% of patients did not require a manoeuvre to stop the bleeding. Post-operative complications were scarce. Conclusion:This study reflects on the need for a local multidisciplinary protocol to help expedite the current high-quality healthcare delivered by rural general surgeons in managing patients with UGIB. Implementing risk assessment scores would shorten the time to endoscopy in the initial assessment Guidelines would optimize resuscitation ensuring appropriate replacement, medication administration, anticoagulation reversal, and preventing unnecessary therapy. Despite these nuisances, the time to endoscopy, endoscopic intervention, and patient outcomes were largely in line with international quality assurance and safety targets.

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“…Our results demonstrate several key points in the management of massive diverticular bleeding. Firstly, a multidisciplinary approach towards management of LGB including gastroenterology, colorectal surgery and interventional radiology can provide better outcomes for patients with LGIB 22,23 . This is especially so in multi‐modality treatments where each specialists' experience can be vital in making collaborative decisions individualized to every patient.…”

Section: Discussionmentioning

confidence: 99%

“…Firstly, a multidisciplinary approach towards management of LGB including gastroenterology, colorectal surgery and interventional radiology can provide better outcomes for patients with LGIB. 22,23 This is especially so in multi-modality treatments where each specialists' experience can be vital in making collaborative decisions individualized to every patient. A higher success in our series for non-operative therapy shows that a dedicated protocol, experienced endoscopy team and responsive radiological intervention can make a difference.…”

Section: Discussionmentioning

confidence: 99%

Adjunctive endoscopic clip marking enhances non‐operative management of massive lower gastrointestinal bleeding

Hui¹,

Lau³

et al. 2022

ANZ Journal of Surgery

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Backgrounds Massive lower gastrointestinal bleeding (LGB) is common especially in elderly patients. Controversy in the approach to management stems from location of bleeding and morbidity of surgery. Colonic diverticula disease (CD) is the leading cause of painless haematochezia and haemodynamic instability. Methods The use of a novel technique of endoscopic pre‐marking (EPM) with radiopaque metal clips to localize is described. EPM guided superselective active transarterial embolization (A‐TAE) when active vascular blush was seen. When no active contrast extravasation was seen, EPM also guided prophylactic superselective transarterial embolization (P‐TAE). Results From May 2004 to December 2021, there were 36 patients with massive LGB from diverticular disease encompassing 44 separate bleeding episodes. Spontaneous haemostasis was observed in 18.2% (8/44). The overall success rate in non‐operative management was 83.3% (30/36) patients. Three patients proceeded for emergency surgery. Of the 36 patients, six patients had documented EPM followed by TAE due to recurrent bleed in the same episode. A‐TAE was performed in two patients. P‐TAE was performed in the four patients without active contrast extravasation. Initial haemostasis was successful in five out of six patients. One patient failed embolization and proceeded to emergency surgery. Three months later, one patient encountered late rebleeding and was scheduled for elective colectomy. None of the six developed intestinal infarction from embolization. The 30‐day mortality was 0%. Conclusion A consistent approach to LGB and defined protocol of endoscopic haemostasis, with routine EPM and embolization, has the potential to mitigate the morbidity and mortality in this group of vulnerable patients.

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Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol

Cited by 13 publications

References 28 publications

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline

Upper GI bleeding in rural Australia: general surgery still alive and well!

Adjunctive endoscopic clip marking enhances non‐operative management of massive lower gastrointestinal bleeding

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