Improving documented advice regarding anticoagulants and antiplatelets in acute upper gastrointestinal bleeds

Published Date: 01st October 2024

Publication Authors: Creed. E, Theis. V, Clark. K, Gurung. S, Motam. A, FarrellBinns. G

Conference Abstract

Introduction: Systemic anticoagulants are often prescribed to prevent and treat thromboembolism among other indications, yet presentations with Acute Upper Gastrointestinal Bleeds (AUGIB) in this cohort are common. Medical care bundles have been shown to improve both standards of care and patient outcomes. As a result, the British Society for Gastroenterology (BSG) created an AUGIB care bundle in 2019, and guidelines for endoscopy in patients on antiplatelets and anticoagulants in 2021. However, the former lacks definitive statements regarding resumption of antiplatelet/ anticoagulant therapy, while the latter is not routinely referred to by non-Gastrointestinal specialists. It is recognised however, that resumption of antiplatelets and anticoagulants is associated with improved survival and reduced incidence of thrombotic complications. Thus, all patients should have a clear plan.

Aims & Methods: Admissions with AUGIB proceeding to endoscopy over a 6 month period were analysed. Of the 319 patients, 72 (22.5%) were taking either an antiplatelet, warfarin or a Direct Oral Anticoagulant (DOAC). Medical records were reviewed in relation to pre-procedure management of these medications, advice from the endoscopist regarding resumption (or not) of antithrombotic therapy and whether these medicines were managed appropriately thereafter. Several interventions were then made; a change to the reporting software led to a prompt relating to antiplatelet/anticoagulant medications (though the template remains non-specific), an education campaign for post graduate doctors in training and medication guidance summaries visible in the endoscopy department. A second 6-month review was then undertaken to evaluate if there had been any improvement in outcomes. In this time frame, 283 patients underwent endoscopic evaluation for suspected AUGIB of whom 83 (29.3%) were taking antithrombotic therapy.
Result(s): Results can be found in Table 1: (Table present) A recurring theme was the discontinuation of aspirin in low-risk bleeds, and low quality medication advice given at the time of endoscopy with almost 4 in 10 reports simply stating 'continue medication'. Those without documentation resulted in further advice being sought (12.9% of cases) Further subanalysis of the data revealed that advice was almost always documented in those presenting with major upper gastrointestinal bleeds (defined as patients presenting with haemodynamic instability). In this cohort 87.5% of patients had clearly documented advice regarding their anticoagulation or antiplatelet medication.
Conclusion(s): Further education to junior staff around utility of the BSG AUGIB bundle, as well as the anticoagulation guidelines is needed to improve pre and post procedure care. Further upgrades to the templates on the reporting software will also serve as prompts to the endoscopist to provide more specific advice. Human factors also need to be considered; limited advice is likely related to the high endoscopy workload pressures. Sub-analysis of the data suggests that we are better at providing more specific advice in high-risk bleeds/where endotherapy is required, reflecting that antithrombotic therapy decisions are considered by the endoscopist. Improved documentation at procedure, should translate into improved post procedure management and reduce further demands on the service.

Creed, E.; Theis, V.; Clark, K.; Gurung, S.; Motam, A.; FarrellBinns, G. (2024). IMPROVING DOCUMENTED ADVICE REGARDING ANTICOAGULANTS and ANTIPLATELETS in ACUTE UPPER GASTROINTESTINAL BLEEDS. United European Gastroenterology Journal. 12(8), p.681. [Online]. Available at: https://dx.doi.org/10.1002/ueg2.12615 [Accessed 4 February 2026].