October 23, 2019
The International Consensus Group has released an updated practice guideline on the management of nonvariceal upper gastrointestinal bleeding (UGIB). The guideline highlights resuscitation and risk assessment; pre-endoscopic, endoscopic, and pharmacologic management; and secondary prophylaxis for recurrent UGIB.
“The management of UGIB has advanced with new endoscopic techniques, and the pharmacologic landscape has changed. Anticoagulant or antiplatelet therapy, including combination therapy, is becoming more common, substantially increasing the risk for UGIB,” the guideline authors wrote.
To update the guideline, the international multidisciplinary group of experts reviewed evidence cited in previous guidelines and literature that they identified by searching the MEDLINE, Embase, and Cochrane databases from inception to April 2018, with supplemental searches to mid-May 2018.
The guideline developed by the group includes the following recommendations based on strong evidence:
- It is recommended that patients with acutely bleeding ulcers with high-risk stigmata receive endoscopic therapy with thermocoagulation or sclerosant injection.
- For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, it is recommended that proton-pump inhibitor (PPI) therapy via intravenous (IV) loading dose followed by continuous IV infusion be administered (as opposed to no treatment or H2-receptor antagonists).
The guideline also includes the following recommendations based on conditional or low evidence, for patients with acute UGIB:
- The authors suggest the use of the Glasgow-Blatchford bleeding score (a score of 1 or less) to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy.
- The authors suggest against the use of the AIMS65 Score for Upper GI Bleeding Mortality to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy.
- The authors suggest blood transfusions for patients without underlying cardiovascular disease and who have a hemoglobin level less than 80 g/L.
- The authors suggest that patients who are admitted undergo endoscopy within 24 hours of presentation.
- The authors suggest not to delay endoscopy among patients who are receiving anticoagulants.
- The authors suggest the use of twice-daily oral PPIs through 14 days, followed by once daily among patients who present with ulcer bleeding at high risk for rebleeding.
- The authors suggest the use of PPI therapy over no PPI therapy for patients with previous ulcer bleeding receiving cardiovascular prophylaxis with single- or dual-antiplatelet therapy.
Barkun AN, Almadi M, Kuipers EJ, et al; International Consensus Group. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group [published online October 22, 2019]. Ann Intern Med. doi:10.7326/M19-1795.