Stop the Bleeding Inside

Restrictive blood transfusions better helps patients with upper gastrointestinal bleeding

/ Author:  / Reviewed by: Robert Carlson, M.D

(RxWiki News) It's scary losing blood. And bleeding inside the body somewhere along the esophagus, stomach and the upper small intestine can be even scarier. But blood transfusions can help, especially with certain methods.

Using a restrictive strategy for blood transfusions can better help patients who bleed along the upper part of their gastrointestinal tract compared to other methods, a new study has found.

The restrictive technique lowered the risk of bleeding again and the number of complications involved with the procedure, researchers said.

"Talk to a doctor if you feel extremely tired."

In general, having acute upper gastrointestinal bleeding is linked with a higher risk of illness and death because of the loss of blood. These patients can receive donated blood during a blood transfusion to help replace what was lost.

The study, led by Càndid Villanueva, MD, from the Gastrointestinal Bleeding Unit in the Department of Gastroenterology at Hospital de Sant Pau, Autonomous University, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas in Barcelona, compared how well and how safe two different blood transfusions techniques work in helping patients with short-term bleeding in their intestines.

More than 900 adults who were admitted to the hospital between June 2003 and December 2009 for gastrointestinal bleeding were randomly assigned to the restrictive strategy or the liberal strategy.

In the restrictive strategy, the transfusion happens when the number of red blood cells in the body falls lower than 7 grams per deciliter of blood. The liberal strategy occurs when blood cells are below 9 grams per deciliter.

Patients were selected if they vomited blood, had the contents of their stomachs pumped out or had dark bloody stools.

About 31 percent of the patients had cirrhosis, or liver disease. Ulcers and enlarged veins inside the esophagus caused bleeding in 49 and 21 percent of patients, respectively.

Researchers excluded those who previously lost a lot of blood, had a blood transfusion within the three months leading up to the study, had previous surgeries or trauma or bled along the lower part of the gastrointestinal tract.

Each of the patients received one unit of red cells at the start of the transfusion. Their blood cell levels were measured and those who still had low levels were given a second unit of cells.

Within the first six hours of the transfusion, doctors examined their stomach and other parts of their upper digestive tract.

Researchers found that the restrictive strategy helped patients with their symptoms the most.

Ten percent of patients in the restrictive strategy group continued to bleed after the transfusion compared to 16 percent of patients from the liberal group.

Emergency surgery was needed among 2 percent of the restrictive strategy patients and 6 percent in the other group. Complications occurred in 40 percent of the restrictive group compared to 48 percent in the other.

Three patients (0.7 percent) in the restrictive group and 14 (3.1 percent) patients in the liberal group died because bleeding was not controlled successfully.

Treatment complications and associated diseases caused another 20 deaths among the restricted group and 27 in the liberal group.

"The most relevant finding was the improvement in survival rates observed with the restrictive transfusion strategy," researchers wrote in their report.

"This advantage was probably related to a better control of factors contributing to death, such as further bleeding, the need for rescue therapy, and serious adverse events."

The benefits of the transfusion strategy exceeded those observed in other populations, according to Maxwell Chait, MD, a gastroenterologist with ColumbiaDoctors Medical Group and dailyRx Contributing Expert.

"This study has provided evidence to guide practice and justify current recommendations for the management of upper gastrointestinal bleeding," Dr. Chait said.

"Previous results from studies in animals have shown that a restrictive transfusion strategy is beneficial in variceal bleeding to prevent rebound increases in portal pressure. However, the restrictive transfusion strategy's main benefit in the present study was observed among patients without portal hypertension."

The authors note that the results may not apply to everyone with gastrointestinal bleeding since patients with a low risk of bleeding or who lost a lot of blood were not included in the study.

In addition, researchers knew who was receiving which therapy strategy, which may cause the results to be biased.

The study, which was supported by Fundació Investigació Sant Pau, was published online January 3 in the New England Journal of Medicine. One of the authors received consulting fees from Sequana Medical, but no other conflicts of interest were reported.

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Review Date: 
January 1, 2013
Last Updated:
March 8, 2013