Update on the management of upper gastrointestinal bleeding

Abstract

Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.

Keywords: Gastroenterology; Gastrointestinal diseases.

Figure 1

Comparisons of prediction scores related to the need for any intervention (transfusion, endoscopic treatment, interventional radiology, or surgery) or 30 day mortality (n=1704). All figures compared patients with complete data for all compared scores. AUROC=area under the receiver operating characteristic curve; PNED=Progretto Nazionale Emorragia Digestiva

Figure 2

Comparison of mortality and further bleeding between urgent (<6 h) versus early (6-24 h) endoscopy in patients with high risk gastrointestinal bleeding (Glasgow Blatchford Score ≥12)

Figure 3

Effect of tranexamic acid versus placebo on death due to bleeding within 5 days of an upper gastrointestinal bleed

Figure 4

Peptic ulcer with persistent oozing of blood (left image), treated endoscopically with epinephrine injection and clips, and then haemostatic powder (right image)