A major UK-wide audit has shown significant improvements in outcomes for patients admitted to hospital with acute upper gastrointestinal bleeding – and highlighted clear areas for further progress.
This re-audit, which followed an earlier audit in 2007, was led from Oxford, conducted by experts across the country and supported by the British Society of Gastroenterology (BSG) and NHS Blood and Transplant (NHSBT). Its findings were published in the journal Gut.Acute upper gastrointestinal bleeding (AUGIB) is a common – and potentially life-threatening – medical emergency. It accounts for around 60,000 hospital admissions each year in the UK and is the cause of one in ten hospital blood transfusions.
The original 2007 UK audit – the first of its kind in the world – revealed wide variations in care, including overuse of liberal transfusion strategies and limited access to timely interventions. This landmark study informed key national recommendations, including NICE guidance and a 2015 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on gastrointestinal bleeding.
This re-audit – itself a world first and only the second such national audit – was conducted in 2022. It analysed data from more than 5,000 patients across 147 UK hospitals. Despite an older and more medically complex patient population, the study found lower mortality and rebleeding rates compared to 2007, reflecting advances in emergency endoscopy and interventional radiology services and less reliance on surgery.
However, the audit also identified key areas for improvement, including wider use of pre-endoscopy risk assessment and greater adherence to restrictive blood transfusion strategies.
Dr Gaurav Nigam, Clinical Lead for the 2022 UK AUGIB Audit and an NIHR Doctoral Research Fellow at the University of Oxford’s Nuffield Department of Medicine, said: “This audit provides the clearest national picture of gastrointestinal bleeding care in over 15 years. It shows that outcomes have improved, thanks to better access to endoscopy and radiological services, but also highlights where we can do better.
“Restrictive use of blood transfusions, early risk assessment, and investment in endoscopic training are key priorities to ensure every patient benefits from best-practice care.”
Dr Nigam added: “This project was only possible because of the commitment and collective effort of clinicians, nurses, and trainees across 147 hospitals. Their contribution has provided the evidence base to help shape the next phase of quality improvement in gastrointestinal bleeding care.”
Mike Murphy, Professor of Transfusion Medicine at the University of Oxford and Consultant Haematologist with NHS Blood & Transplant and Oxford University Hospitals NHS Foundation Trust, said: “The 2022 audit provides a comprehensive assessment of current practices, patient outcomes and resource availability of acute gastrointestinal bleeding management across NHS hospitals.
“Since the previous audit in 2007, there have been new practice guidelines, and improvements in endoscopy and other aspects of service delivery. The audit’s findings highlight improvements in patient outcomes but raise concerns about the inappropriate use of red blood cell transfusions with the potential to increase the risk of rebleeding and mortality.”
Among the key findings of the audit were:
- Overall in-hospital mortality fell from 10% to 8.8% between 2007 and 2022, and rebleeding rates from 13.3% to 9.7%.
- Patients are now more medically complex — two-thirds had comorbidities (up from 50% in 2007) and 15% had cirrhosis (up from 9% in 2007).
- More patients now receive endoscopy and interventional radiology for bleeding control, with inpatient endoscopy rates rising from 74% to 83% and the need for surgery falling from 1.9% to 0.7%, reflecting a shift towards less invasive management.
- Blood transfusion practices remain inconsistent: 50% of patients received red cell transfusions, 38% within 24 hours or pre-endoscopy, and one in four early transfusions were potentially inappropriate.
- In those patients with stable vital signs who were transfused above 80 g/L, mortality was higher, suggesting possible harm from liberal transfusion.
- Only 58% of patients had a pre-endoscopy risk score recorded, highlighting the need for more consistent early risk assessment to guide care and resource use.
Andy Douds, Chair of the AUGIB Steering Committee, Consultant Gastroenterologist at Norfolk and Norwich University NHS Trust and Honorary Associate Professor at University of East Anglia, added: “This seminal audit demonstrates a number of significant improvements in care but highlights areas where we can still improve.
“It was an enormous undertaking with many challenges post-COVID. I would like to express my sincere thanks to Dr Nigam, fellow members of the steering committee and all participating sites for their tireless commitment to this important audit. I must also thank the British Society of Gastroenterology for their resolute support.”
The 2022 AUGIB re-audit was coordinated by the National Comparative Audit of Blood Transfusion (NCA) at NHS Blood and Transplant, in collaboration with the British Society of Gastroenterology (BSG), the Royal College of Physicians (RCP) and specialist societies, including the British Association for the Study of the Liver (BASL), the Association of Upper Gastrointestinal Surgeons (AUGIS), and the British Society of Interventional Radiology (BSIR). The work was supported by the National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre.
A detailed national report, including local data for every participating hospital, has already been circulated to sites. Publication in Gut represents the next step in sharing the findings more widely, helping to identify real-world gaps in care and drive targeted quality-improvement initiatives across the NHS.