A Focus On: Blood Transfusion in Gastrointestinal Bleeding

A Focus On: Blood Transfusion in Gastrointestinal Bleeding

Fig. 1. Upper GI endoscopy showing longitudinal mucosal breaks in severe oesophagitis. Courtesy of Dr. A. Mee. Taken from Chapter 6: Gastroenterology, in Oxford Handbook of Clinical Medicine (8 ed.). Murray Longmore, Ian Wilkinson, Edward Davidson, Alexander Foulkes, and Ahmad Mafi. ©  OUP 2010. DOI 10.1093/med/9780199232178.001.0001

 

Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency accounting for 70,000 hospitalisations annually in the UK. It can present with life-threatening haemorrhage, making it the single leading indication for transfusion of red blood cells (RBCs) in England. Excluding patients with severe haemorrhage where the benefit of transfusion is self-evident, there is surprisingly limited evidence available on which types of patients benefit from RBCs after AUGIB, at what threshold they should receive them, and how much they should receive. There is considerable practice variation and the perception of the appropriate threshold for transfusion is subjective, but both are likely to be influenced by patient, clinician, and healthcare system-related factors. In other critically ill cohorts, a more liberal approach to transfusion has been associated with an adverse clinical outcome, including death, even after adjustment for confounders. Potential sources of harm from RBCs are poorly understood, but include adverse effects resulting from changes to RBCs that occur during blood storage and immune modulating effects of transfusion.

 

It seems paradoxical that more liberal transfusion following AUGIB might actually be harmful. However, two large observational studies from the UK and Canada found a strikingly similar association between transfusion in patients with a haemoglobin >8 g/dL, and an increased risk of further bleeding. Furthermore, a large randomised trial from Spain has now confirmed a causal relationship between more liberal RBC transfusion (transfusion target 9-11 g/dL) after AUGIB and further bleeding and mortality. The mechanisms underlying this are unclear, although in patients with cirrhosis and portal hypertension, this is likely due to elevated portal pressures through more liberal transfusion. The observed increased mortality is most likely mediated through further bleeding, since this event is strong and independent predictor of death.  These results now need to be reproduced in a more pragmatic multi-centre setting, currently being conducted in the UK.

 

Universal access to safe blood remains an important goal for global healthcare agencies. However, individual clinicians have a responsibility to ensure appropriate prescription of RBCs. The emerging evidence for the management of AUGIB suggests that a restrictive approach may be the safest approach, something unthinkable a decade ago. Regardless, caution must be exercised in patients with ischaemic heart disease and certainly those with exsanguinating bleeding.

 

Further reading

Hearnshaw, S. A., Logan, R. F., Palmer, K. R., Card, T. R., Travis, S. P., & Murphy, M. F. (2010). Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding. Aliment Pharmacol Ther, 32(2), 215-224.

Restellini, S., Kherad, O., Jairath, V., Martel, M., & Barkun, A. N. (2012). Red blood cell transfusion is associated with increased rebleeding in patients with nonvariceal upper gastrointestinal bleeding. Aliment Pharmacol Ther.

Villanueva, C., Colomo, A., Bosch, A., Concepcion, M., Hernandez-Gea, V., Aracil, C., et al. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med, 368(1), 11-21.

 

Dr Vipul Jairath, NIHR Clinical Lecturer, Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK.


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