The Editors in chief of GUT, Professors Matias A. Avila, William Grady and Thomas Rösch, have selected Dr Gaurav Nigam (and the wider acute upper gastrointestinal bleeding audit team) from the Translational Gastroenterology and Liver Unit, Oxford University Hospitals NHS Trust, Oxford, UK, to do the next #GUTBlog. Dr Gaurav Nigam is the first author on this paper.

The #GUTBlog focusses on the paper entitled “Acute upper gastrointestinal bleeding in the UK: 2022 audit update” which was published in paper copy in GUT in April 2026.

 

Dr Gaurav Nigam writes:

“Two decades of national audits: what the 2022 UK AUGIB audit tells us about gastrointestinal bleeding care”

Acute upper gastrointestinal bleeding (AUGIB) remains one of the most common and challenging medical emergencies encountered by gastroenterologists. Every day across the UK, patients present to emergency departments with haematemesis and/or melaena, triggering a cascade of investigations, transfusion decisions and urgent endoscopy. Despite advances in endoscopic therapy, pharmacological treatments and multidisciplinary care, AUGIB continues to carry significant morbidity and mortality. Understanding how these patients are managed in real-world clinical settings is therefore essential if we are to improve outcomes.

The recently published 2022 UK Audit of AUGIB in Gut provides the most comprehensive contemporary assessment of AUGIB care across the UK National Health Services (NHS). Conducted across 147 hospitals and including over 5,000 patients, the audit offers a rare opportunity to examine how an entire national healthcare system manages gastrointestinal bleeding. For those of us involved in the project, however, the dataset represents far more than numbers on a spreadsheet. It reflects a national collaborative effort and builds on nearly two decades of work aimed at understanding and improving the care of patients with gastrointestinal bleeding.

The origins of this programme lie in the national audit infrastructure developed through NHS Blood and Transplant (NHSBT) and the National Comparative Audit programme. A key milestone was the landmark 2007 UK audit of AUGIB led by Dr Sarah Hearnshaw. That study provided the first comprehensive national picture of how patients with AUGIB were managed across the UK and played an important role in shaping national guidelines and clinical practice.

The work that followed illustrates how national audit data can generate research questions that ultimately lead to major clinical trials. Professor Vipul Jairath subsequently built on this foundation through a series of influential studies addressing key management questions in gastrointestinal bleeding. These include landmark trials such as the TRIGGER trial investigating transfusion strategies and the international HALT-IT trial evaluating tranexamic acid. Together, these studies demonstrate how carefully collected national data can drive hypothesis generation and ultimately inform international research efforts.

The national audit programme was later expanded with the 2015 UK Lower Gastrointestinal Bleeding (LGIB) Audit led by Dr Kathryn Oakland, which generated similarly important insights into the management of LGIB across the UK healthcare system.

The 2022 audit therefore represents the next chapter in this evolving story of gastrointestinal bleeding research in the UK. It also highlights the importance of mentorship and continuity within academic medicine (Figure 1), where successive trainees and researchers have contributed to advancing knowledge in this field.

 

Although described as an audit, the 2022 project effectively functioned as a large prospective multicentre observational study, with hospitals across the UK prospectively collecting detailed data on patients with AUGIB over a two-month period. The resulting dataset is remarkable in its scale and depth. Few countries have the infrastructure to capture such detailed clinical information across an entire healthcare system, making this one of the largest contemporary cohorts describing AUGIB management anywhere in the world.

Importantly, the manuscript recently published in Gut represents only the first in a series of analyses from this dataset. While the current paper focuses on patient characteristics, diagnoses and outcomes, the audit captured extensive information on multiple aspects of care including transfusion practices, endoscopic management, pre- and post-endoscopy care, and the management of both variceal and non-variceal bleeding. The dataset also includes information on access to rescue therapies such as interventional radiology and surgery. Together, these data offer a valuable opportunity to explore how different elements of care influence outcomes in routine clinical practice.

One of the most striking findings from the study is how the population presenting with AUGIB has changed over time. Compared with the 2007 audit, patients presenting with bleeding today are older and have substantially greater comorbidity. The prevalence of cirrhosis has increased, and a much larger proportion of patients are now taking anticoagulant medications. These changes reflect broader shifts in healthcare, where ageing populations and increasingly complex medical conditions influence the types of patients presenting to acute services.

Despite this higher-risk population, outcomes appear to have improved. The audit found lower rates of rebleeding and a modest reduction in mortality compared with the earlier national audit, likely reflecting advances in endoscopic therapy, multidisciplinary care and wider availability of specialist services. Access to inpatient endoscopy has improved, and the management of refractory bleeding has evolved with greater use of interventional radiology and less reliance on surgery.

At the same time, the findings highlight areas where clinical practice may not fully align with evidence-based recommendations. One example relates to transfusion practice. Almost half of patients in the audit received red blood cell transfusions, and a substantial proportion received them early during their admission. However, a notable proportion of early transfusions occurred at haemoglobin levels above recommended thresholds or in haemodynamically stable patients. Exploratory analyses suggested that liberal transfusion strategies in stable patients may be associated with worse outcomes, reinforcing concerns raised by previous trials about overly liberal transfusion practices in gastrointestinal bleeding.

Behind the scenes, assembling this dataset required an enormous collective effort. Hundreds of clinicians, trainees, nurses and audit teams across the UK contributed to data collection alongside busy clinical schedules. The project also relied heavily on the expertise and support of the National Comparative Audit team at NHSBT. Importantly, much of this work took place as healthcare services were still recovering from the disruption caused by the COVID-19 pandemic, making the level of national engagement and collaboration particularly remarkable.

The entire audit steering committee, chaired by Dr Andrew Douds, worked tirelessly to deliver the project, supported by the British Society of Gastroenterology and other specialist societies involved in gastrointestinal bleeding care across the UK. Projects of this scale depend on the goodwill and dedication of many individuals who contribute alongside their routine clinical work, and the success of the audit reflects that collaborative effort.

Looking ahead, the 2022 UK AUGIB audit provides a rich dataset that will continue to generate insights into the management of gastrointestinal bleeding. Future analyses will explore specific aspects of care including transfusion strategies, endoscopic management and access to rescue therapies. The scale and richness of the dataset also create opportunities to develop and validate risk prediction tools using modern data-driven approaches, including machine learning, to support clinical decision-making in acute gastrointestinal bleeding. More broadly, national datasets such as this allow healthcare systems to benchmark care, identify variation in clinical practice and learn from one another. The findings also emphasise the importance of ensuring that endoscopists managing acute bleeding are appropriately trained in haemostatic techniques, particularly as patients presenting with bleeding become older and more medically complex.

Ultimately, the aim of such work is simple: to ensure that patients presenting with gastrointestinal bleeding receive timely, effective and evidence-based care wherever they are treated. If the 2007 audit provided the first national mirror for AUGIB care in the UK, the 2022 audit reminds us that sustained collaborative work of clinicians, researchers and institutions remains essential to continue improving outcomes for patients with this common and potentially life-threatening condition.”

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Dr Gaurav Nigam @drgauravbnigam