Treatment of nonvariceal upper gastrointestinal bleeding

The etiology, pathophysiology, prognostic factors, pharmacologic treatment, and pharmacoeconomic considerations of nonvariceal upper-gastrointestinal-tract bleeding (UGB) are reviewed.

UGB is associated with substantial morbidity and mortality. While UGB can be caused by a wide variety of medical conditions, 50% of UGB cases are caused by peptic ulcers. Approximately 80% of all UGB episodes stop bleeding spontaneously. Recurrence of gastrointestinal hemorrhage is associated with an increased mortality rate, a greater need for surgery, blood transfusions, a prolonged length of hospital stay, and increased overall health care costs. All patients with UGB should be evaluated for signs and symptoms of hemodynamic instability and active hemorrhage. Endoscopy within the first 24 hours of a UGB episode is considered the standard of therapy for the management of the initial hemorrhage. However, approximately 20% of patients will experience a rebleeding episode. Acid-suppressive therapy with proton-pump inhibitors (PPIs) in addition to endoscopic hemostasis is effective in reducing the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay, but not mortality rates. There are multiple dosing options for administration of PPIs in this setting. More studies are necessary to elucidate the best therapeutic approach to manage UGB.

Acid-suppressive therapy is beneficial in the management of UGB. It reduces the frequency of rebleeding, the need for surgery, transfusion requirements, and the length of hospital stay. To date, no pharmacologic intervention has demonstrated a reduction in the mortality rates of patients with UGB. An optimal acid-suppressive regimen has not yet been clearly established.