Advances in transfusion medicine: gastrointestinal bleeding

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Gastrointestinal bleeding is a common reason for emergency presentation to hospital. In the UK, upper gastrointestinal bleeding (UGIB) has a hospitalised incidence of 134/100000(Button et al.,2011), and there are an estimated 21 120 admissions to hospital each year with acute lower gastrointestinal bleeding (LGIB) (Oakland et al.,2017).
Traditionally, UGIB and LGIB have been distinguished by the origin of bleeding in relation to the ligament of Treitz. UGIB corresponds to bleeding in the oesophagus, stomach and duodenum, whereas LGIB encompasses bleeding in the small bowel, colon and anorectum. Developments in options for investigating bleeding in the small bowel have led to the emergence of the term ‘mid‐GI’ bleeding (Raju et al.,2007), corresponding to bleeding originating in the jejunum and ileum. At presentation, UGIB can present with fresh blood haematemesis, coffee ground vomitus or melaena. LGIB can cause bright rectal bleeding, clots, blood mixed in with stool or melaena. Melaena may therefore indicate an upper‐, mid‐ or lower GI source.
In the UK, the most common causes of UGIB are bleeding peptic ulcers and oesophagitis (Hearnshaw et al.,2011). Variceal bleeding accounts for only 11% of cases (Hearnshaw et al.,2011). Interventions include oesophagogastroduodenoscopy (OGD); interventional radiology, including transjugular intrahepatic portosystemic shunt (TIPS); and, rarely, surgery. In‐hospital mortality is 7% (Hearnshaw et al.,2011) and is higher in patients who bleed as an established inpatient and those with chronic comorbidity (Rockall et al.,1996).
In LGIB, the most frequent causes are diverticular disease, colitis and benign anorectal conditions (Oakland et al.,2017). Interventions also include OGD, colonoscopy, flexible sigmoidoscopy, interventional radiology and surgery, but these are less frequently used in comparison to UGIB (Oakland et al.,2017). In‐hospital mortality is also less common, occurring in 3.4% of cases, and is also higher in established inpatients (Oakland et al.,2017).
In the UK, GIB is the second most common indication for red blood cell (RBC) transfusion after haematological malignancy (Tinegate et al.,2016). This review summarises the evidence supporting this use of RBC transfusion, including transfusion triggers and targets in the context of the recent focus on patient blood management, and investigates whether restrictive transfusion is appropriate in all clinical subtypes of GIB, e.g. bleeding associated with cirrhosis. Indications for the transfusion of platelets or fresh frozen plasma (FFP) are also explored, including their use in patients who develop GIB whilst receiving anticoagulant or antiplatelet drugs. The value of alternatives to transfusion, such as tranexamic acid, is described with the overall aim of summarising the available evidence for the transfusion of stable patients with acute GIB.
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