Digestive Diseases and Sciences

, Volume 54, Issue 8, pp 1662–1666

Gastrointestinal Hemorrhage: Should We Transfuse Less?

Original Article


Although blood transfusion has an established place in the conventional management of acute upper gastrointestinal (GI) hemorrhage, there is growing evidence of adverse side effects of transfusion, both acute and later. An Ovid Medline literature search was performed to evaluate the significance and importance of these effects. Evidence of impaired hemostasis with repletion of blood volume in the acute phase was found in multiple studies and in uncontrolled studies in combat casualties. There are multiple large studies of a so-called immunosuppressive effect of transfused blood leading to increased infection rates and mortality dependent both on dose and on the age of the stored blood. In view of evidence of increased bleeding with early blood volume restoration and the growing evidence of so-called immunosuppressive effects of stored blood, there is a need to consider trials using a conservative utilization of blood in acute GI bleeding.


Blood transfusion Gastrointestinal hemorrhage Immunomodulation Bacteramia Nosocomial infection 


  1. 1.
    Blair SD, Janvrin SB, McCollum CM, Greenhalgh RM. Effect of early blood transfusion on gastrointestinal haemorrhage. Br J Surg. 1986;73:783–785. doi:10.1002/bjs.1800731007.PubMedCrossRefGoogle Scholar
  2. 2.
    Elta GA. Approach to patient with gross gastrointestinal bleeding. In: Yamada T, ed. Textbook of Gastroenterology. Vol. 1. 4th ed. Philadelphia: Lippincott, Williams and Wilkins; 2002:698–723.Google Scholar
  3. 3.
    Rockey DC. Gastrointestinal bleeding. In: Feldman M, Friedman LS, Sleisinger MH, eds. Sleisinger and Fordtran’s Gastrointestinal and Liver disease. Pathophysiology/Diagnosis/Management. Vol. 1. 8th ed. Philadelphia: WB Saunders; 2002:255–299.Google Scholar
  4. 4.
    Rockall TA, Northfield T. Gastrointestinal bleeding. In: Warrell DA, Cox TM, Firth JD, Benz EJ, eds. Oxford Textbook of Medicine. Vol. 2. 4th ed. Oxford: Oxford University Press; 2003:511–514.Google Scholar
  5. 5.
    Duggan JM. Crystalloid infusion in acute gastrointestinal haemorrhage. Is it beneficial? An historical perspective. Aliment Pharmacol Ther. 2006;24:493–496. doi:10.1111/j.1365-2036.2006.03011.x.PubMedCrossRefGoogle Scholar
  6. 6.
    Blumberg N. Deleterious clinical effects of transfusion immunomodulation: proven beyond a reasonable doubt. Transfusion. 2005;45:35s–40s. doi:10.1111/j.1537-2995.2005.00565.x.CrossRefGoogle Scholar
  7. 7.
    Vamvakas EC. Deleterous clinical effects of transfusion immunomodulation: proven beyond a reasonable doubt. Transfusion. 2006;46:492–493 (letter).PubMedCrossRefGoogle Scholar
  8. 8.
    Dossetor JS, Mackinnon KJ, Gault MM, Maclean LD. Cadaver kidney transplantation. Transplantation. 1967;5:844–853. doi:10.1097/00007890-196707001-00010.PubMedCrossRefGoogle Scholar
  9. 9.
    Garcia-Tsao G, Sangal AJ, Grace ND, Carey WD; Practice Guidelines Committee of the American Association of the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol. 2007;102:2086–2107. doi:10.1111/j.1572-0241.2007.01481.x.PubMedCrossRefGoogle Scholar
  10. 10.
    Vincent JL, Baron JF, Reinhart K, et al. Anaemia and blood transfusion in critically ill patients. JAMA. 2002;288:1499–1507. doi:10.1001/jama.288.12.1499.PubMedCrossRefGoogle Scholar
  11. 11.
    Corwin HL, Gettinger A, Pearl RG, et al. The CRIT study: anaemia and blood transfusion in the critically ill—current practice in the United States. Crit Care Med. 2004;32:39–52. doi:10.1097/01.CCM.0000104112.34142.79.PubMedCrossRefGoogle Scholar
  12. 12.
    Taylor RW, O’ Brien J, Trottier SJ, et al. Red blood cell transfusions and nosocomial infections in critically ill patients. Crit Care Med. 2006;34:2302–2308. doi:10.1097/01.CCM.0000234034.51040.7F.PubMedCrossRefGoogle Scholar
  13. 13.
    Hébert PC, Wells G, Blajchman MA. A multicentre, randomized controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409–417. doi:10.1056/NEJM199902113400601.PubMedCrossRefGoogle Scholar
  14. 14.
    Koch CG, Liang L, Sessler DI, et al. Duration of red cell storage and complications of cardiac surgery. N Engl J Med. 2008;358:1229–1239. doi:10.1056/NEJMoa070403.PubMedCrossRefGoogle Scholar
  15. 15.
    van de Watering L, Lorinser J, Versteegh M, et al. Effects of storage time of red blood cell transfusions on the prognosis of coronary artery bypass graft patients. Transfusion. 2006;46:1712–1718.PubMedCrossRefGoogle Scholar
  16. 16.
    Bennett-Guerrero E, Veldman TH, Doctor A, et al. Evaluation of adverse changes in stored RBC’s. Proc Natl Acad Sci USA. 2007;104:1706.CrossRefGoogle Scholar
  17. 17.
    Winslow RM, Intaglietta M. Red cell age and loss of function: advance or SNO-job? Transfusion. 2008;48:411–414. doi:10.1111/j.1537-2995.2008.01657.x.PubMedCrossRefGoogle Scholar
  18. 18.
    Tinmouth A, Ferguson D, Tee IC, et al. Clinical consequences of red cell storage in the critically ill. Transfusion. 2006;46:2014–2027. doi:10.1111/j.1537-2995.2006.01026.x.PubMedCrossRefGoogle Scholar
  19. 19.
    Tarrter PL, Quintero S, Barron DM. Peri operative blood transfusion associated with infectious complications after colorectal cancer operations. Am J Surg. 1986;152:479–482. doi:10.1016/0002-9610(86)90207-2.CrossRefGoogle Scholar
  20. 20.
    Tarrter PL. Blood transfusion and post operative infections. Transfusion. 1989;29:456–459. doi:10.1046/j.1537-2995.1989.29589284149.x.CrossRefGoogle Scholar
  21. 21.
    Carson JL, Altman DC, Duff A, et al. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion. 1999;39:694–700. doi:10.1046/j.1537-2995.1999.39070694.x.PubMedCrossRefGoogle Scholar
  22. 22.
    Chang H, Hall GA, Geerts WH, Greenwood C, McLeod RS, Sher GD. Allogeneic red cell transfusion is an independent risk factor for the development of post operative bacterial infection. Vox Sang. 2000;78:13–18. doi:10.1159/000031143.PubMedCrossRefGoogle Scholar
  23. 23.
    Offner PJ, Moore EE, Biffl WL, Johnson JL, Stillman CC. Increased rate of infection associated with transfusion of old blood after severe injury. Arch Surg. 2002;137:711–716. doi:10.1001/archsurg.137.6.711.PubMedCrossRefGoogle Scholar
  24. 24.
    Nichols RL, Smith JW, Klein DB, et al. Risk of infection after penetrating abdominal trauma. N Engl J Med. 1984;311:1065–1070.PubMedCrossRefGoogle Scholar
  25. 25.
    Shorr AF, Jackson WL. Transfusion practice and nosocomial infection: assessing the evidence. Curr Opin Crit Care. 2005;11:468–472. doi:10.1097/01.ccx.0000176689.18433.f4.PubMedCrossRefGoogle Scholar
  26. 26.
    Rockall T, Logan RFA, Devlin HB, Northfield TC; Steering Committee of the National Audit of Acute Gastrointestinal Haemorrhage. Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Gut. 1997;41:606–611.PubMedGoogle Scholar
  27. 27.
    St. Elsewhere's Hospital. National comparative audit of blood transfusion. http://hospital.blood.co.uk/library/pdf/UGI_Bleed_%20Audit_St%. Accessed September 7, 2008.
  28. 28.
    Duggan JM, O’Connor D, Heller R, Ghosh H. Causes of hospital-acquired septicaemia—a case control study. QJM. 1993;86:479–483. doi:10.1093/qjmed/86.8.479.PubMedCrossRefGoogle Scholar
  29. 29.
    Murphy GJ, Reeves VC, Rogers CA, et al. Increased mortality, post-operative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation. 2007;116:2544–2552. doi:10.1161/CIRCULATIONAHA.107.698977.PubMedCrossRefGoogle Scholar
  30. 30.
    El-Mastri MH, Hammad TA, McLeskey SW, et al. Predictors of nosocomial blood stream infections among critically ill adult trauma patients. Infect Control Hosp Epidemiol. 2004;25:656–663. doi:10.1086/502457.CrossRefGoogle Scholar
  31. 31.
    Shorr AF, Duh MS, Kelly KM, et al. Red blood cell transfusion and ventilation associated pneumonia: a potential link. Crit Care Med. 2004;32:666–674. doi:10.1097/01.CCM.0000114810.30477.C3.PubMedCrossRefGoogle Scholar
  32. 32.
    Purdy FR, Tweeddale MG, Merrick PM. Association of mortality with age of blood transfused in septic ICU patients. Can J Anaesth. 1997;42:1256–1261.CrossRefGoogle Scholar
  33. 33.
    Vamvakas EC, Carven JH. Transfusion and post operative pneumonia in CABG patients. Effect of the length of storage of transfusion cells. Transfusion. 1999;39:701–710. doi:10.1046/j.1537-2995.1999.39070701.x.PubMedCrossRefGoogle Scholar
  34. 34.
    Lapierre V, Auperin A, Tiberghien P. Transfusion-related immunomodulation following cancer surgery: fact or fiction? J Natl Cancer Inst. 1998;90:573–580. doi:10.1093/jnci/90.8.573.PubMedCrossRefGoogle Scholar
  35. 35.
    Busch ORC, Hop WCJ, van Papendrect MAWD, Marquet RL, Jeekel J. Blood transfusions and prognosis in colorectal cancer. N Engl J Med. 1993;328:1372–1376. doi:10.1056/NEJM199305133281902.PubMedCrossRefGoogle Scholar
  36. 36.
    Houbiers JG, Brand A, van der Watering IM, et al. Randomized controlled trial comparing transfusion of leucocyte-depleted or buffy-coat-depleted blood in surgery for colorectal cancer. Lancet. 1994;344:573–578. doi:10.1016/S0140-6736(94)91965-8.PubMedCrossRefGoogle Scholar
  37. 37.
    Hyllner M. Prestorage leucocyte filtration of blood: effects on cytokine generation and complement activation. Curr Anaesth Crit Care. 2004;15:95–100. doi:10.1016/j.cacc.2004.01.002.CrossRefGoogle Scholar
  38. 38.
    Vamvakas EC. White-blood-cell-containing allogeneic blood transfusion, post operative infection or mortality: an updated meta-analysis. Vox Sang. 2007;92:224–232. doi:10.1111/j.1423-0410.2006.00889.x.PubMedCrossRefGoogle Scholar
  39. 39.
    van Hilten JA, van de Watering LM, van Bockl JH, et al. Effects of transfusion with red cells filtered to remove leukocytes: randomized control trial in patients undergoing major surgery. BMJ. 2004;328:1281. doi:10.1136/bmj.38103.735266.55.PubMedCrossRefGoogle Scholar
  40. 40.
    Beecher HK. Resuscitation of men severely wounded in battle. In: De Bakey ME, ed. Surgery in WWII in Vol 11 General Surgery. Washington: Office of the Surgeon General, Dept. of the Army; 1955:3–39.Google Scholar
  41. 41.
    Bickell WH, Ward MJ, Pepe PE, et al. Immediate versus delayed resuscitation in hypotensive patients with penetrating injuries. N Engl J Med. 1994;331:1105–1109. doi:10.1056/NEJM199410273311701.PubMedCrossRefGoogle Scholar
  42. 42.
    Shaftan GW, Chiu CJ, Dennis C, Harris R. Fundamentals of physiological control of arterial hemorrhage. Surgery. 1965;58:85–86.Google Scholar
  43. 43.
    Bickell WH, Bruttig SP, Millnamow GA, O’Benar J, Wade CE. The detrimental effects of intravenous crystalloid after aortotomy in swine. Surgery. 1991;180:529–536.Google Scholar
  44. 44.
    Duggan JM. Review article: transfusion in gastrointestinal haemorrhage—if, when and how much? Aliment Pharmacol Ther. 2001;15:1109–1113. doi:10.1046/j.1365-2036.2001.01013.x.PubMedCrossRefGoogle Scholar
  45. 45.
    Ivy AC, Grossman MI, Bachrach WH. Peptic Ulcer. Philadelphia: The Blakiston Company; 1950:937.Google Scholar
  46. 46.
    Hill SR, Carless PA, Henry DA, et al. Transfusion thresholds and other strategies for guiding allogenic red blood cell transfusion. Cochrane Database Syst Rev. Issue 1. Art. No. CD 002042. doi:10.1002/4651858.CD 002042.2000.

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.Division of Clinical Practice and Population Health, Faculty of Health SciencesNewcastle UniversityNewcastleAustralia
  2. 2.HamiltonAustralia

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