Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding

Abstract

Background: The management of patients with acute nonvariceal upper gastrointestinal bleeding has evolved substantially over the past 10 years amid a paucity of published consensus guidelines.

Purpose: To provide evidence-based management recommendations that address clinically relevant issues. REVIEW AND CONSENSUS PROCESSES: A multidisciplinary consensus group of 25 voting participants representing 11 national societies used a 7-step approach to develop recommendation statements according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. The quality of the evidence, the strength of the recommendation, and the level of consensus were graded according to recognized classifications.

Main findings: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. The placement of endoscopic clips for endoscopic hemostasis appears promising. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding should be tested for Helicobacter pylori infection and receive eradication therapy if infection is present.

Future directions: The efficacy of newer endoscopic therapeutic technologies, the optimal regimen of proton-pump inhibition, and the roles of other pharmacologic agents require further research.