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Diagnosis and management of nonvariceal upper gastrointestinal bleeding
Marc Bardou1, Dalila Benhaberou-Brun, Isabelle Le Ray
1National Institute for Health and Medical Research (INSERM), CIC-P 803, Department of Gastroenterology, Centre Hospitalier Universitaire de Dijon, 14 rue Gaffarel, BP77908, 21079 Dijon, France. marc.bardou@ u-bourgogne.fr
Insights
This article outlines key recommendations for managing nonvariceal upper gastrointestinal bleeding (UGIB). Early endoscopic intervention and appropriate resuscitation are vital for improving patient outcomes in UGIB cases.
Area of Science:
- Gastroenterology
- Internal Medicine
- Emergency Medicine
Background:
- Nonvariceal upper gastrointestinal bleeding (UGIB) remains a significant cause of morbidity and mortality globally.
- Despite advances, mortality rates for UGIB persist at 5-10% over the last decade.
Purpose of the Study:
- To present essential recommendations for the effective management of nonvariceal upper gastrointestinal bleeding.
- To emphasize early intervention and multidisciplinary approaches for optimal patient resuscitation and treatment.
Main Methods:
- Review of current guidelines and evidence for UGIB management.
- Focus on pre-endoscopic assessment, resuscitation strategies, and timing of endoscopic intervention.
- Discussion of alternative treatments and post-endoscopic care, including medication management and H. pylori testing.
Main Results:
- Pre-endoscopic management, including scoring scales and stabilization, is critical for patient triage and resuscitation.
- Transfusion is recommended for hemoglobin levels ≤70 g/l unless comorbidities exist.
- Endoscopic therapy within 24 hours of admission is crucial for high-risk lesions; surgery or embolization are alternatives if endoscopy fails.
- Intravenous proton pump inhibitors (PPIs) post-endoscopy are recommended, while pre-endoscopic use is debated.
- Suspension and resumption of antiplatelet therapy (3-5 days) and H. pylori testing are advised.
Conclusions:
- A multidisciplinary, early approach to UGIB management, prioritizing timely endoscopic intervention, is essential.
- Optimized resuscitation, appropriate transfusion triggers, and recommended medication strategies improve outcomes.
- Adherence to these guidelines can help reduce the persistent mortality associated with nonvariceal upper gastrointestinal bleeding.
Abstract:
Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5-10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3-5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.
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