A summary of recent recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding

Abstract

Recommendations in managing patients with nonvariceal upper gastrointestinal bleeding were recently updated, addressing resuscitation, risk assessment and pre-endoscopic care, endoscopy, pharmacotherapy, and secondary prophylaxis. Initial adequate resuscitation and risk stratification using validated scales remain critical. Intravenous erythromycin improves visualization when likely to find blood in the stomach. Pre-endoscopic proton pump inhibition (PPI) does not improve outcomes, but downstages high-risk endoscopic lesions and may be considered. In patients on anticoagulants, correction of a coagulopathy is recommended, but should not delay early endoscopy (within 24 h), as it improves clinical outcomes. In patients with high-risk endoscopic stigmata, although better than doing nothing, epinephrine injection alone provides suboptimal efficacy and should be combined with another modality such as clips, thermal or sclerosant injection, which are also efficacious alone. Following an attempt at dislodgment, adherent clots can be treated with high-dose intravenous PPI infusion alone (80 mg bolus and 8 mg/h for 3 days) or following endoscopic hemostasis. The combination is indicated for all other patients with high-risk stigmata as there is currently a lack of high-quality generalizable data supporting other intravenous or oral PPI regimens. A second-look endoscopy is recommended only selectively after endoscopic hemostasis. A negative Helicobacter pylori test requires confirmation in the acute setting. Following appropriate discussions, acetylsalicylic acid (ASA) can soon be restarted acutely after bleeding; long-term PPI co-therapy is imperative in patients having bled on nonsteroidal anti-inflammatory drugs if still needed (preferably with a cyclooxygenase-2, if appropriate) or ASA (not clopidogrel alone). Further work is needed to implement and disseminate these recommendations.