Treatment of acute nonvariceal upper gastrointestinal hemorrhage

Abstract

Hospitalization for nonvariceal upper gastrointestinal hemorrhage (UGIH) is still common with an incidence of 100/100,000 adults/year. Mortality rates range between 8 and 14%. The most common etiologies of acute UGIH are gastric and duodenal ulcers which are associated with older age, Helicobacter pylori gastritis and nonsteroidal anti-inflammatory drugs. Approximately 70% of UGIH stop spontaneously, 10% bleed continuously and about 20% rebleed in the first 24-72 h. Mortality and the probability of rebleeding have been related to the ulcers' stigmata (Forrest) and to a variety of clinical findings (hematemesis, low initial hemoglobin, signs of shock, coagulopathy and liver disease). It is well established that only patients with continued bleeding or with a risk of rebleeding benefit from endoscopic or medical treatment. Endoscopic treatment (including heater probe, bipolar electrocoagulation, laser and injection therapy) control active bleeding in up to 90% and reduce significantly the rates of further bleeding, the need for blood transfusions, hospital costs and emergency surgery. Medical treatment is still controversial although positive results for somatostatin and octreotide have been found. A meta-analysis including 1,829 patients from 14 randomized trials showed the relative risk for continued bleeding or rebleeding of 0.53 (95% CI, 0.43-0.63) in favor of somatostatin and octreotide. Interventional endoscopy is the first line of treatment for UGIH. Somatostatin and its analogue octreotide may be a useful adjunct to endoscopic management or alternative when endoscopy is unsuccessful, contraindicated or unavailable.