Gastrointestinal (GI) bleeding is the most common GI diagnosis necessitating. Upper GI bleeding (UGIB) refers to bleeding originating from sites in the esophagus, stomach, or duodenum.

Abstract

The American Journal of Gastroenterology society performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding.

Risk stratification:

Guidelines suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up.

Red blood cell transfusion:

For patients hospitalized with upper gastrointestinal bleeding, guidelines suggest red blood cell transfusion at a threshold of 7 g/dL.

Pre-endoscopic medical therapy

Prokinetic therapy with erythromycin:

Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation.

PPI therapy

Guidelines could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.

In the absence of evidence for clinical benefit, the panel could not make a recommendation for pre-endoscopic PPI therapy. Nevertheless, the panel did not recommend against pre-endoscopic PPI therapy, given the imprecision of the evidence and other very indirect evidence.

Pre-endoscopic PPI therapy might provide some benefit in a minority of patients with UGIB. Furthermore, in patients who will not undergo endoscopy and endoscopic hemostatic therapy or in whom it will be delayed, the panel felt pre-endoscopic PPI therapy might be given based on very indirect evidence from a meta-analysis.

Endoscopic hemostatic therapy for ulcers with active bleeding or nonbleeding visible vessels:

Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels.

Choice of endoscopic hemostatic therapy for bleeding ulcers:

Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis.

Antisecretory therapy after endoscopic hemostatic therapy for bleeding ulcers:

After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy.

Recurrent ulcer bleeding after successful endoscopic hemostatic therapy

We suggest that patients with recurrent bleeding after endoscopic therapy for a bleeding ulcer undergo repeat endoscopy and endoscopic therapy rather than undergo surgery or transcatheter arterial embolization.

If endoscopic therapy fails, transcatheter embolization is suggested.

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