1. HEFT EMCAST UPPER GI BLEEDS; WHAT’S YOUR THRESHOLD?

2. GUIDELINES The British Society of Gastroenterology guidelines on Acute GI bleeding recommends the use of the Blatchford Score for Risk stratifying patients; Score of 0 equates to low risk Score of ≥1 equates to high risk

3. THE BLATCHFORD SCORE Systolic blood pressure Urea Comrobidities/other markers Haemoglobin

4. Risk markerAssociated score Systolic BP (mmHg) 100-1091 90-992 < 903 Urea ≥6.5 <8.02 ≥8.0 <10.03 ≥10.0 <25.04 ≥256 Comorbidities/other markers Pulse ≥ 100 bpm1 Presenting with malaena1 Presenting with syncope1 Hepatic disease2 Cardiac failure2 Haemoglobin (g/dl) men ≥12.0 <13.01 ≥10.0 <12.03 <10.06 Haemoglobin (g/dl) women ≥10.0 <12.01 <10.06

5. THE PAPER Transfusion strategies for acute upper gastrointestinal bleeding N Engl J Med. 2013

6. SCORE Blatchford score of 0 equates to low risk Approx 25% of ED patients are low risk British society for gastroenterology recommends; ‘for those with significant bleeding, early endoscopy plays a central role in management’ SIGN guideline UGIB - recommends endoscopy within 24 hours of presentation SIGN guideline UGIB

7. INCLUSION CRITERIA >18 years of age Experiencing either haematemesis (NG bloody aspirate), malaena or both as confirmed by hospital staff

8. EXCLUSION CRITERIA Patients declining to undergo transfusion Masive exsanguinating bleeding ACS Lower GI bleeding Rockall score of 0 with an HB of > 12 g/dl And others…….

9. INTERVENTION Restrictive strategy (RS) Threshold for transfusion was 7 g per dl Target of transfusion 7 – 9 g per dl Liberal-strategy (LS) Threshold for transfusion 9 g per dl Target range for transfusion of 9-11 g per dl

10. OUTCOMES Primary mortality within 45 days Secondary Further bleeding In hospital complications

11. RESULTS Primary outcome – mortality at 45 days RS 5% LS 9% p value 0.02

12. RESULTS Secondary outcomes Rate of further bleeding (after adjustment for baseline risk factors) lower in the RS Hazard ratio 0.68 95 % CI 0.47-0.98 Complication rate RS 40% LS 48%

13. REFERNECES British Society of Gastroenterology guidelines on Acute GI bleeding Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C. et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013; 368: 11–21