What is the role of transfusion in the initial assessment of upper gastrointestinal bleeding (UGIB)?

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

Based on the patient's initial hemoglobin level and clinical assessment of shock, a type and screen or type and crossmatch should be ordered in patients with suspected upper gastrointestinal (GI) bleeding (UGIB). The patient should be crossmatched for 2-6 units, based on the rate of active bleeding. The hemoglobin level should be monitored serially in order to follow the trend. An unstable hemoglobin level may signify ongoing hemorrhage requiring further intervention.

Patients generally require blood transfusions because of hypoperfusion and hypovolemia. Patients with significant comorbid conditions (eg, advanced cardiovascular disease) should receive blood transfusions to maintain myocardial oxygen delivery to avoid myocardial ischemia. [43, 44]

According to the 2008 Scottish Intercollegiate Guidelines Network (SIGN) guideline, patients in shock should receive prompt volume replacement. [45]

However, once the patient has been stabilized, controversy exists regarding strategies for transfusion of red blood cells in GI bleeding, with some studies suggesting improved outcomes with a more judicious use of blood transfusions. In a study that compared the efficacy and safety of a restricted transfusion strategy with those of a liberal transfusion strategy in 921 patients with severe acute UGIB, Villanueva et al concluded that a restrictive strategy (n = 461) significantly improved outcomes in patients with acute UGIB compared with that of a liberal transfusion strategy (n = 460). [43]  In the restrictive strategy, patients were transfused when their hemoglobin level fell below 7 g/dL; in the liberal strategy, patients were transfused when their hemoglobin level fell below 9 g/dL.

One of the criteria used to determine the need for surgical intervention is the number of units of transfused blood required to resuscitate the patient. The more units required, the higher the mortality. [25] Operative intervention may be indicated once the blood transfusion number reaches more than 5 units, as noted in the following table. [25]

Table 3. Effect of Number of Packed Erythrocyte Transfusions on Need for Surgery and Mortality from UGIB (Open Table in a new window)

Number of Units Transfused

Need for Surgery, %

Mortality, %

0

4

4

1-3

6

14

4-5

17

28

>5

57

43


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