Quality standard
Quality statement 5: Treatment of non-variceal bleeding after first or failed endoscopic treatment
Quality statement 5: Treatment of non-variceal bleeding after first or failed endoscopic treatment
Quality statement
People with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment.
Rationale
Sometimes endoscopic therapy is technically difficult and the endoscopist cannot achieve or secure haemostasis, or bleeding recurs despite full or maximal endoscopic treatment. One additional therapeutic option is interventional radiology (embolisation), which can identify and treat the bleeding point. This can be preferable to surgery, because postoperative mortality is high for this group of patients, most of whom are extremely ill at the time of surgery.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable are given interventional radiology treatment (embolisation).
Data source: Local data collection.
Process
Proportion of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable who receive interventional radiology treatment (embolisation).
Numerator – the number of people in the denominator who receive interventional radiology treatment (embolisation).
Denominator – the number of people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.
Data source: Local data collection. The British Society of Gastroenterology's UK comparative audit of upper gastrointestinal bleeding and the use of blood (2007) shows the proportion of people having either surgery or radiological intervention.
What the quality statement means for different audiences
Service providers ensure that systems are in place for people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable to be given interventional radiology treatment.
Healthcare practitioners give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.
Commissioners ensure that they commission services that give interventional radiology treatment to people with non-variceal acute upper gastrointestinal bleeding who continue to bleed or re-bleed after endoscopic treatment and who are haemodynamically unstable.
People with acute upper gastrointestinal bleeding from the stomach or duodenum who continue to bleed or re-bleed after endoscopic treatment and whose blood pressure or pulse is unstable are given interventional radiology treatment. A long narrow plastic tube called a catheter is inserted into an artery in the groin and, under X-ray guidance, is then steered to the site of bleeding. After a small injection of X-ray dye to confirm that the tube is in the right place, the bleeding artery is blocked off to stop the bleeding. A CT scan may be needed beforehand to guide treatment if endoscopy has not identified the site of bleeding.
Source guidance
Acute upper gastrointestinal bleeding in over 16s: management. NICE guideline CG141 (2012, updated 2016), recommendation 1.4.7 (key priority for implementation)
Definitions of terms used in this quality statement
NICE's guideline on acute upper gastrointestinal bleeding, recommendation 1.4.7, states that if interventional radiology is not promptly available people should be referred urgently for surgery.