Nur Fitriyani Afiqah Binti Abu Bakar

Newcastle University Medicine Malaysia

SSC 1

Adherence to 2012 NICE guideline: An audit of endoscopy therapy and

PPI treatment in acute non variceal upper gastrointestinal bleeding in
Hospital Sultan Ismail
Introduction
Acute upper gastrointestinal bleeding (UGIB) is defined by haemorrhage arise
from upper gastrointestinal tract ; oesophagus, stomach and duodenum. UGIB is
the common major emergency managed by gastroenterologist in UK with overall
incidence ranges from 50 150 per 100, 000 of population. It is an important
causes of hospital admission and have high mortality per year. Upper GI bleeding
accounts for 70% of all gastrointestinal bleeding with peptic ulcer is the most
frequent causes of upper GI bleed with, occurring in 30-50 % of cases. Variceal
bleeding accounting 5-10% of the cases.
Over the decades, there are significant improvement of diagnosis and treatment
of upper GI bleeding . However, the mortality rate is still higher despite of the
improvement. Non variceal bleeding account for major cases of upper GI
bleeding. Non varicella can be caused by peptic ulcer, oesphagitis, Mallory-Wiess
tear and Dieulafoy lesion.
Management
Endoscopy is the primary diagnostic investigation in upper gastrointestinal
bleeding which should be performed within 24 hours of admission. Endoscopy
also predict the risk outcomes of the bleeding and most importantly as
therapeutic management to stop the bleeding.
In non variceal bleeding, endoscopy treatment can involve adrenaline injection,
mechanical intervention or thermal therapy. Evidence shows that combination of
injection therapy with other treatment are more effective than adrenaline
monotherapy alone.
Objective
Primary Objective: To assess the adherence of endoscopy therapy and PPI
treatment in acute non variceal upper gastrointestinal bleeding in Hospital Sultan
Ismail to NICE 2012 guideline.
-

Assess whether adrenaline injection is given alone or combination with

another in endoscopy therapy
To determine whether PPI was given after endoscopy therapy

Secondary objective: To study the relationship between adherence of the

management to the guideline and the incidence of re-bleeding
Methods
A retrospective study was conducted involving patients in Hospital Sultan Ismail
from January 2014 to February 2014
All patients presented to the emergency department due to acute non variceal
upper GI bleeding initially evaluated for hemodynamic stability. Patient can be
referred from other hospital or general practice.

Nur Fitriyani Afiqah Binti Abu Bakar

Newcastle University Medicine Malaysia

SSC 1

Data collected from .. with the permission of Results were

tabulated using statistic calculation
Inclusion criteria:
Patients who are >18 years old with suspected non variceal upper GI bleeding
presented with either hematemesis ( fresh red blood or coffee ground vomiting
or malena, black tarry stools )
Exclusion criteria :
Patient with suspected variceal bleeding with or without portal hypertension due
to chronic liver disease.
Patients were follow up for 4 weeks for risk of re-bleeding
Results
Discussion
Conclusion
Recommendation

Nur Fitriyani Afiqah Binti Abu Bakar

Newcastle University Medicine Malaysia

SSC 1

Standards for acute upper GI bleeding clinical audit

Managing nonvariceal bleeding
Standards

Guidanc
e
referenc
e

Endoscopy treatment
Do not use adrenaline as
monotherapy for the endoscopic
treatment of nonvariceal upper
gastrointestinal bleeding.

1.4.1

1.4.2

For the endoscopic treatment of nonvariceal upper gastrointestinal

bleeding, use one of the following:
-

a mechanical method (for

example, clips) with or
without adrenaline
thermal coagulation with
adrenaline
fibrin or thrombin with
adrenaline.

Proton pump inhibitor

Do not offer acid-suppression
drugs (proton pump inhibitors
or H2-receptor antagonists)
before endoscopy to patients
with suspected non-variceal
upper gastrointestinal
bleeding.
Offer proton pump inhibitors
to patients with non-variceal
upper gastrointestinal
bleeding and stigmata of
recent haemorrhage shown at
endoscopy.

1.4.3

1.4.4

Definitions

Nur Fitriyani Afiqah Binti Abu Bakar

Newcastle University Medicine Malaysia

SSC 1

Data collection form for Acute upper gastrointestinal

bleeding
clinical audit
Audit ID:

Sex:

Age:

The audit ID should be an anonymous code. Patient identifiable information should never be recorded.
Presenting Complains
Malaysian

Malay

Chinese

Indian

Non Malaysian

White

Black

Others

No.

Question

MANAGING NON-VARICEAL BLEEDING

Endoscopic treatments
1

For endoscopic treatment, were the following used?

adrenaline monotherapy
a mechanical method with adrenaline
a mechanical method without adrenaline
thermal coagulation with adrenaline
fibrin with adrenaline
thrombin with adrenaline

Proton pump inhibitors

2

Was the patient offered acid suppression drugs

before endoscopy when non-variceal upper
gastrointestinal bleeding was suspected?

If the patient with non-variceal upper gastrointestinal

bleeding had stigmata of recent haemorrhage
shown at endoscopy, were they offered a proton

Others

Yes

No

Exception*/
NA/Notes

Nur Fitriyani Afiqah Binti Abu Bakar

Newcastle University Medicine Malaysia
No.

Question
pump inhibitor?

SSC 1

Yes

No

Exception*/
NA/Notes