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Acute upper gastrointestinal bleeding is the commonest emergency managed by gastroenterologists. It has an incidence ranging from approximately 50 to 150 per 100 000 of the population each year, the incidence being highest in areas of the lowest socioeconomic status. An audit of patients admitted to hospital in the UK published in 1995 reported 11% mortality in patients admitted to hospital because of bleeding and 33% mortality in those who developed gastrointestinal bleeding while hospitalised for other reasons.1 Most deaths occur in elderly patients who have significant comorbidity and the majority are inevitable, despite improvements in medical and surgical expertise. Mortality is reported to be lower in specialist units2,3 and this is probably not related to technical developments but because of adherence to protocols and guidelines. Thus guidelines do have the potential to improve prognosis and in addition may be of value in making the best use of resources by fast tracking low risk patients, thereby optimising duration of hospital stay.
“Medline” and “EMBASE” were searched to identify the evidence used in formulating these guidelines. The term “gastrointestinal hemorrhage” was used to identify general reviews, leading articles, meta-analyses, and randomised clinical trials. Not all of the recommendations have been subjected to clinical trial but represent what, in the view of the British Society of Gastroenterology (BSG) endoscopy committee, defines best clinical practice. Guidelines cannot replace clinical judgment in the management of any specific patient. Best management depends on close cooperation between medical and surgical gastroenterologists and “combined care” is essential in managing the critically ill bleeding patient.
The specific management of acute variceal haemorrhage is a special subject and is not considered in detail.
1.1 Grading of recommendations
Evidence from large randomised clinical trials
High quality study of non-randomised cohorts who did not receive therapy
High quality case series