An update on the management of non-variceal upper gastrointestinal bleeding

Abstract

Upper gastrointestinal bleeding (UGIB) continues to be a common gastrointestinal emergency that carries significant morbidity and mortality. The epidemiology of UGIB has been changing over the last few decades with an overall decrease in peptic ulcer disease and increase in the prevalence of other etiologies including vascular lesions and malignancy. Appropriate risk assessment and patient stratification are crucial to ensuring that optimal care is delivered to patients and some risk assessment tools have shown excellent ability to define a low-risk group who can be managed as outpatients safely. Regardless of the etiology of UGIB, resuscitative interventions by primary care providers remain the most important initial measures to improve the outcome for patients including hemodynamic stabilization, an appropriate blood transfusion strategy, with or without acid-lowering agents, while also providing subsequent urgent endoscopic assessment and intervention. In addition, with increasing use of antithrombotic agents in clinical practice and its associated risk of bleeding, the management of such agents in the acute setting has become a real challenge to all physicians. In this article, we provide an up-to-date, evidence-based, practical review of recent changes and advances in UGIB with a focus on non-variceal etiologies.

Keywords: UGIB; antithrombotic; endoscopic hemostasis; peptic ulcer; risk assessment.

Figure 1.

The Yano–Yamamoto classification of vascular lesions (modified from the study by Yano et al. [27])

Figure 2.

Actively bleeding Dieulafoy’s lesion in the small bowel

Figure 3.

Images of hemostasis with the use of through-the-scope clips (TTS). (A) Adherent clot on a duodenal ulcer; (B) the edge of the ulcer is injected with dilute epinephrine; (C) the clot is removed using a snare; (D) definite hemostasis is achieved using through-the-scope endoscopic clips.

Figure 4.

Image of hemostasis with the use of the over-the-scope clip (OTSC). Duodenal ulcer causing severe gastrointestinal bleeding that was refractory to endoscopic therapy with through-the-scope endoscopic clips and angiographic coiling (seen at the base of the ulcer); an OTSC was applied with successful hemostasis.

Figure 5.

The images of post-esophageal endoscopic mucosal resection bleeding managed by monopolar hemostatic forceps soft coagulation (MHFSC). (A) Active spurting bleeding noted after mucosal resection; (B) the MHFSC is used to grasp the bleeding vessel resulting in mechanical tamponade; (C) soft coagulation is then applied to the bleeding vessel; (D) successful hemostasis is achieved.

Figure 6.

The images of hemostasis with the use of topical hemostatic agent TC-325. (A) Actively oozing gastric adenocarcinoma; (B) hemostasis achieved following application of the topical hemostatic agent TC-325.

Figure 7.

Images of hemostasis with the use of topical hemostatic agent PuraStat. (A) Active bleeding during per-oral endoscopic myotomy; (B) bleeding managed by applying PuraStat gel to the bleeding site.

Figure 8.

Forrest plots of trials comparing topical hemostatic agents with conventional endoscopic modalities in malignant gastrointestinal bleeding [45]. (A) immediate hemostasis; (B) rebleeding.

Figure 9.

Management of patients on antithrombotics in the setting of acute gastrointestinal bleeding (modified from the study by Barkun et al. [150]). ^*Life-threatening hemorrhage is defined as major clinically overt or apparent bleeding resulting in hypovolemic shock or severe hypotension requiring pressors or surgery or associated with a decrease in hemoglobin of >5 g/dL, requiring transfusion of <5 units of packed red blood cells, or causing death; ^**defined as <100,000/μL; GI, gastrointestinal; VKA, vitamin K antagonist; PCC, prothrombin complex concentrate; FFP, fresh frozen plasma; DOAC, direct oral anticoagulants; ASA, aspirin.