Management of acute upper gastrointestinal bleeding: summary of NICE guidance
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3412 (Published 13 June 2012) Cite this as: BMJ 2012;344:e3412
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In table 1 it should read 'melaena' not 'malaena'. The word comes from
the Greek melaina, meaning black - as, for example, in 'melanin' and 'melanoma'. [1]
It would be great if gastro-enterologists would lead the way (especially in important national guidance documents) in getting their specialty's most-often miss-spelt technical word correct!
I tried emailing the author directly but the given email address returned a delivery error message, hence this response.
Ref: Oxford English Dictionary (CD-ROM) 2nd Ed. 1989
Competing interests: An obsession with spelling correctly
In the NICE guidance, fresh frozen plasma has been suggested as treatment for patients with upper gastrointestinal bleeding whose clotting screen is prolonged more than 1.5 times normal, even in the absence of massive bleeding [1]. This is a recommendation which does not have an evidence basis. Coagulation screen was initially devised to diagnose individuals with single coagulation factor deficiencies like haemophilia and not to identify those patients who might be at risk of bleeding. In patients with and without liver disease, who have abnormal clotting tests, the risk of bleeding is NOT any higher than any other individual, something which has been conclusively shown in studies of patients to include cirrhosis [2,3]. In these patients, bleeding is often due to varices or ulcers which are akin to having an open surgical wound. As stated elsewhere in the guidance, endoscopic measures should be the definitive management. Abnormal coagulation tests should not distract the health care professionals from urgent endoscopy. The wait for plasma transfusion for correcting these abnormalities may prove deleterious in these settings. It is time that we do away with the dogma that an abnormal clotting screen means high risk of bleeding [4].
1. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K; on behalf of the Guideline Development Group. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012 Jun 13;344:e3412.
2. Tripodi A, Salerno F, Chantarangkul V, et al. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Hepatology 2005;41:553-558.
3. Lisman T, Bongers TN, Adelmeijer J, et al. Elevated levels of von Willebrand factor in cirrhosis support platelet adhesion despite reduced functional capacity. Hepatology 2006;44:53-61
4. Segal JB, Dzik WH. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive
Competing interests: No competing interests
Re: Management of acute upper gastrointestinal bleeding: summary of NICE guidance
Acute upper gastrointestinal bleed is a medical emergency. A large audit in theUK in 1995 showed a mortality of 11% in those who had bleeding as first diagnosis. Predicting bleeding and rebleeding from upper gastrointestinal bleed is an important outcome of any scoring system. Blatchford scoring system along with Rockall scoring system (more validated post–endoscopy) shows promising predictive value [1]. The Blatchford score appropriately identifies low risk patients [2]. The scoring comprises major risk markers like blood urea, haemoglobin, systolic blood pressure and minor markers like melena, syncope, hepatic disease and cardiac failure. Other markers are – peptic ulcer disease, gastro-duodenal erosion, oesophageal varices followed by Mallory Weiss tear. The tool can become a useful scoring system for establishing a risk analysis in front door emergency services [3]. This in turn leads to appropriate use of in-patient resources.
Reference:
1. Kim BJ,Park MK,Kim SJ,Kim ER,Min BH et al.Comparison of scoring system for the prediction of outcomes in patient with non-variceal upper gastrointestinal bleed : a prospective study. Dig Dis Sci. 2009 Nov, 54 (11):2523-9.
2. Srirajarkantham R,Conn R,Bulwer C,Irving P et al.The Glasgow Blatchford Scoring System enables accurate risk stratification of patients with upper GI haemorrhage .Int. J. Clin Prac 2010 June 6; 64(7):868-74.
3. Koksal O,Ozeren G,Oz Demir F et al. Prospective validation of the Glasgow Blatchford Scoring system in patients with upper GI bleeding in the emergency department .Turk J Gastroenterology . 2012 Oct ;23(5).Isayfa-Ssafya.
Competing interests: No competing interests