Outcomes for patients hospitalized with acute upper gastrointestinal bleeding (UGIB) in the UK have improved significantly over the past 15 years, although red blood cell transfusion practices remain inconsistent and sometimes inappropriate.

That’s according to a UK-wide reaudit conducted nearly two decades after the country’s first national review on acute UGIB care in 2007.

The 2022 updated audit shows that outcomes have improved, “thanks to better access to endoscopy and radiological services, but also highlights where we can do better,” first author Gaurav Nigam, MD, with the Translational Gastroenterology and Liver Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, England, said in a statement.

“Restrictive use of blood transfusions, early risk assessment, and investment in endoscopic training are key priorities to ensure every patient benefits from best practice care,” Nigam noted.

Acute UGIB remains a common medical emergency, causing around 60,000 hospital admissions annually in the UK and accounting for 1 in 10 hospital blood transfusions.

The original 2007 UK audit revealed wide variations in care, including overuse of liberal transfusion strategies and limited access to timely interventions. The results informed key national and international guidelines and helped shape clinical care protocols in acute UGIB management.

The 2022 reaudit was conducted to provide an updated overview of acute UGIB management in the UK. It was based on data from 5141 patients with acute UGIB (median age, 69 years; 59% male) across 147 UK hospitals. The results were published online in Gut.

Key Findings

The 2022 audit found lower in-hospital mortality rates (8.8% vs 10%), lower rates of rebleeding (9.7% vs 13.3%), and a shorter median hospital stay (5 vs 6 days) than the 2007 audit, despite an older and more medically complex patient population.

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 multivariate analysis, several factors significantly influenced the likelihood of death in patients presenting with acute UGIB.

Older age was a major predictor, with patients aged 80 years or older having more than double the odds of dying (adjusted odds ratio [aOR], 2.32). Shock at the presentation also strongly increased the risk (aOR, 2.22). Comorbidity further contributed to worse outcomes as did lower hemoglobin (≤ 70 g/L) at presentation (aOR, 1.56).

Anticoagulant use was associated with an increased risk of dying (aOR, 1.43), while the use of nonsteroidal anti-inflammatory agents and antiplatelet agents was associated with lower mortality (aOR, 0.49 and 0.68, respectively).

Trouble With Transfusion Practices?

Blood transfusion practices in 2022 remained inconsistent and, in some cases, inappropriate, the authors reported.

Of the 38% of patients who were given early transfusions (pre-endoscopy or within the first 24 hours), 43% were given at a hemoglobin > 70 g/L, with 24% classified as inappropriate due to hemodynamic stability.

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 (aOR, 1.60) — “a signal of harm,” the authors noted.

Encouragingly, more patients in 2022 than in 2007 received endoscopy and interventional radiology for bleeding control. Inpatient endoscopy rates rose from 74% to 83%, and the need for surgery fell from 1.9% to 0.7%, reflecting a shift toward less invasive management.

Only 58% of patients had a pre-endoscopy risk score recorded, highlighting the need for more consistent early risk assessment to guide care and resource use, the authors said.

The 2022 audit’s findings highlight “improvements in patient outcomes but raise concerns about the inappropriate use of red blood cell transfusions with the potential to increase the risk of rebleeding and mortality,” author Mike Murphy, MD, professor of transfusion medicine, University of Oxford, said in the press release.

This work was supported by funding from NHS Blood and Transplant and the British Society of Gastroenterology for the 2022 UK acute UGIB audit. The researchers declared having no conflicts of interest.