Abstract
Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5–10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3–5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.
Key Points
-
Resuscitation should be initiated prior to any diagnostic procedure
-
Gastrointestinal endoscopy allows visualization of the stigmata, accurate assessment of the level of risk and treatment of the underlying lesion
-
Combination of endoscopic therapies improves control of the gastrointestinal hemorrhage
-
Intravenous PPI therapy after endoscopy is crucial to decrease the risk of cardiovascular complications and to prevent recurrence of bleeding
-
Helicobacter pylori testing should be performed in the acute setting
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Button, L. A. et al. Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study. Aliment. Pharmacol. Ther. 33, 64–76 (2011).
Barkun, A. N. et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann. Intern. Med. 152, 101–113 (2010).
Lau, J. Y. et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 84, 102–113 (2011).
Bardhan, K. D., Williamson, M., Royston, C. & Lyon, C. Admission rates for peptic ulcer in the Trent region, UK, 1972–2000: changing pattern, a changing disease? Dig. Liver Dis. 36, 577–588 (2004).
Soplepmann, J., Peetsalu, A., Peetsalu, M., Tein, A. & Juhola, M. Peptic ulcer haemorrhage in Tartu County, Estonia: epidemiology and mortality risk factors. Scand. J. Gastroenterol. 32, 1195–1200 (1997).
Barkun, A. et al. The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting. Am. J. Gastroenterol. 99, 1238–1246 (2004).
Hearnshaw, S. A. et al. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut 10, 1327–1335 (2011).
Liu, N. J. et al. Outcomes of bleeding peptic ulcers: a prospective study. J. Gastroenterol. Hepatol. 23, e340–e347 (2007).
Crooks, C., Card, T. & West, J. Reductions in 28-day mortality following hospital admission for upper gastrointestinal hemorrhage. Gastroenterology 141, 62–70 (2011).
Greenspoon, J. & Barkun, A. A summary of recent recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Pol. Arch. Med. Wewn. 120, 341–346 (2010).
Wee, E. Management of nonvariceal upper gastrointestinal bleeding. J. Postgrad. Med. 57, 161–167 (2011).
Bunn, F., Trivedi, D. & Ashraf, S. Colloid solutions for fluid resuscitation. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD001319. http://dx.doi.org/.10.1002/14651858.CD001319.pub3.
Jairath, V. et al. Red cell transfusion for the management of upper gastrointestinal haemorrhage. Cochrane Database of Systematic Reviews, Issue 9. CD006613. http://dx.doi.org/10.1002/14651858.CD006613.pub3.
Shalev, A. et al. Incidence, predictors and outcome of upper gastrointestinal bleeding in patients with acute coronary syndromes. Int. J. Cardiol. http://dx.doi.org/10.1016/j.ijcard.2010.12.081.
Jairath, V. et al. Red blood cell transfusion practice in patients presenting with acute upper gastrointestinal bleeding: a survey of 815 UK clinicians. Transfusion 51, 1940–1948 (2011).
Shingina, A. et al. Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding. Aliment. Pharmacol. Ther. 33, 1010–1018 (2011).
Guerrouij, M., Uppal, C. S., Alklabi, A. & Douketis, J. D. The clinical impact of bleeding during oral anticoagulant therapy: assessment of morbidity, mortality and post-bleed anticoagulant management. J. Thromb. Thrombolysis 31, 419–423 (2011).
Atkinson, R. J. & Hurlstone, D. P. Usefulness of prognostic indices in upper gastrointestinal bleeding. Best Pract. Res. Clin. Gastroenterol. 22, 233–242 (2008).
Blatchford, O., Murray, W. R. & Blatchford, M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 356, 1318–1321 (2000).
Stanley, A. J. et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 373, 42–47 (2009).
Chiu, P. W. & Sung, J. J. Acute nonvariceal upper gastrointestinal bleeding. Curr. Opin. Gastroenterol. 26, 425–428 (2010).
Srirajaskanthan, R., Conn, R., Bulwer, C. & Irving, P. The Glasgow Blatchford scoring system enables accurate risk stratification of patients with upper gastrointestinal haemorrhage. Int. J. Clin. Pract. 64, 868–874 (2010).
Cooper, G. S., Kou, T. D. & Wong, R. C. Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries. Gastroenterology 136, 108–114 (2009).
Chen, I. C., Hung., M. S., Chiu, T. F., Chen, J. C. & Hsiao, C. T. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding. Am. J. Emerg. Med. 25, 774–779 (2007).
Lim, L. G. et al. Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Endoscopy 43, 300–306 (2011).
Rockall, T. A., Logan, R. F., Devlin, H. B. & Northfield, T. C. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38, 316–321 (1996).
Enns, R. A. et al. Validation of the Rockall scoring system for outcomes from non-variceal upper gastrointestinal bleeding in a Canadian setting. World J. Gastroenterol. 12, 7779–7785 (2006).
Kim, B. J. et al. Comparison of scoring systems for the prediction of outcomes in patients with nonvariceal upper gastrointestinal bleeding: a prospective study. Dig. Dis. Sci. 54, 2523–2529 (2009).
Sarwar, S. et al. Predictive value of Rockall score for rebleeding and mortality in patients with variceal bleeding. J. Coll. Physicians Surg. Pak. 17, 253–256 (2007).
British Society of Gastroenterology. Scope for improvement: a toolkit for a safer upper gastrointestinal bleeding (UGIB) service [online], (2011).
Abe, Y. et al. Education and imaging. Gastrointestinal: aneurysmal artery in a gastric ulcer after endoscopic hemostasis. J. Gastroenterol. Hepatol. 24, 323 (2009).
Chandra, S. et al. External validation of the Glasgow–Blatchford Bleeding Score and the Rockall Score in the US setting. Am. J. Emerg. Med. http://dx.doi.org/10.1016/j.ajem.2011.03.010.
Farooq, F. T., Lee, M. H., Das, A., Dixit, R. & Wong, R. C. Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding. Am. J. Emerg. Med. 30, 129–134 (2010).
Gralnek, I. M., Barkun, A. N. & Bardou, M. Management of acute bleeding from a peptic ulcer. N. Engl. J. Med. 359, 928–937 (2008).
Forrest, J. A., Finlayson, N. D. & Shearman, D. J. Endoscopy in gastrointestinal bleeding. Lancet 2, 394–397 (1974).
Marmo, R. et al. Predicting mortality in non-variceal upper gastrointestinal bleeders: validation of the Italian PNED score and prospective comparison with the Rockall Score. Am. J. Gastroenterol. 105, 1284–1291 (2010).
Rotondano, G. et al. Artificial neural networks accurately predict mortality in patients with nonvariceal upper GI bleeding. Gastrointest. Endosc. 73, 218–226 (2011).
Witting, M. D. “You wanna do what?!” Modern indications for nasogastric intubation. J. Emerg. Med. 33, 61–64 (2007).
Palamidessi, N., Sinert, R., Falzon, L. & Zehtabchi, S. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad. Emerg. Med. 17, 126–132 (2010).
Pateron, D. et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann. Emerg. Med. 57, 582–589 (2011).
Barkun, A., Bardou, M. & Marshall, J. K. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann. Intern. Med. 139, 843–857 (2003).
Aljebreen, A. M., Fallone, C. A. & Barkun, A. N. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest. Endosc. 59, 172–178 (2004).
Pitera, A. & Sarko, J. Just say no: gastric aspiration and lavage rarely provide benefit. Ann. Emerg. Med. 55, 365–366 (2010).
Anderson, R. S. & Witting, M. D. Nasogastric aspiration: a useful tool in some patients with gastrointestinal bleeding. Ann. Emerg. Med. 55, 364–365 (2010).
Frossard, J. L. et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 123, 17–23 (2002).
Barkun, A. N., Bardou, M., Martel, M., Gralnek, I. M. & Sung, J. J. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest. Endosc. 72, 1138–1145 (2010).
Bai, Y., Guo, J. F. & Li, Z. S. Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding. Aliment. Pharmacol. Ther. 34, 166–171 (2011).
Szary, N. M. et al. Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis. Scand. J. Gastroenterol. 46, 920–924 (2011).
Altraif, I. et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest. Endosc. 73, 245–250 (2011).
Coffin, B. et al. Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Gastrointest. Endosc. 56, 174–179 (2002).
Lau, J. Y. et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N. Engl. J. Med. 356, 1631–1640 (2007).
Sreedharan, A. et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD005415. http://dx.doi.org/10.1002/14651858.CD005415.pub3.
Sung, J. J. et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann. Intern. Med. 150, 455–464 (2009).
Al-Sabah, S. et al. Cost-effectiveness of proton pump inhibitors before endoscopy in upper gastrointestinal bleeding. Clin. Gastroenterol. Hepatol. 6, 418–425 (2008).
Sung, J. J. et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 60, 1170–1177 (2011).
Hearnshaw, S. A. et al. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut 59, 1022–1029 (2010).
González-González, J. A. et al. Predictors of in-hospital mortality in patients with non-variceal upper gastrointestinal bleeding. Rev. Esp. Enferm. Dig. 103, 196–203 (2011).
Halland, M. et al. Bleeding peptic ulcer: characteristics and outcomes in Newcastle, NSW. Intern. Med. J. 41, 605–609 (2011).
Targownik, L. E., Murthy, S., Keyvani, L. & Leeson, S. The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding. Can. J. Gastroenterol. 21, 425–429 (2007).
Cipolletta, L., Bianco, M. A., Rotondano, G., Marmo, R. & Piscopo, R. Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial. Gastrointest. Endosc. 55, 1–5 (2002).
Sung, J. J., Tsoi, K. K., Lai, L. H., Wu, J. C. & Lau, J. Y. Endoscopic clipping versus injection and thermo-coagulation in the treatment of bleeding non-variceal upper gastrointestinal bleeding: a meta-analysis. Gut 56, 1364–1373 (2007).
Barkun, A. N., Martel, M., Toubouti, Y., Rahme, E. & Bardou, M. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest. Endosc. 69, 786–799 (2009).
Laine, L. Systematic review of endoscopic therapy for ulcers with clots: can a meta-analysis be misleading? Gastroenterology 129, 2127–2128 (2005).
Marmo, R. et al. Outcome of endoscopic treatment for peptic ulcer bleeding: is a second look necessary? A meta-analysis. Gastrointest. Endosc. 57, 62–67 (2003).
Tsoi, K. K. et al. Second-look endoscopy with thermal coagulation or injections for peptic ulcer bleeding: a meta-analysis. J. Gastroenterol. Hepatol. 25, 8–13 (2010).
Giday, S. A. et al. Long-term randomized controlled trial of a novel nanopowder hemostatic agent (TC-325) for control of severe arterial upper gastrointestinal bleeding in a porcine model. Endoscopy 43, 296–299 (2011).
Sung, J. J. et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy 43, 291–295 (2011).
Racz, I., Karasz, T. & Saleh, H. Endoscopic hemostasis of bleeding gastric ulcer with a combination of multiple hemoclips and endoloops. Gastrointest. Endosc. 69, 580–583 (2009).
Kim, D. H. et al. Endoscopic hemostasis with multiple hemoclips and an endoloop for uncontrolled peptic ulcer bleeding. Endoscopy 43 (Suppl. 2), E3–E4 (2011).
Lau, J. Y. et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N. Engl. J. Med. 340, 751–756 (1999).
Choy, T. Y. et al. Results of surgical treatment of uncontrollable upper gastrointestinal hemorrhage using endoscopy. Hepatogastroenterology 58, 89–95 (2011).
Loffroy, R. et al. Short- and long-term results of transcatheter embolization for massive arterial hemorrhage from gastroduodenal ulcers not controlled by endoscopic hemostasis. Can. J. Gastroenterol. 23, 115–120 (2009).
Loffroy, R. et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin. Gastroenterol. Hepatol. 7, 515–523 (2009).
Mirsadraee, S., Tirukonda, P., Nicholson, A., Everett, S. M. & McPherson, S. J. Embolization for non-variceal upper gastrointestinal tract haemorrhage: a systematic review. Clin. Radiol. 66, 500–509 (2011).
Bardou, M., Martin, J. & Barkun, A. Intravenous proton pump inhibitors: an evidence-based review of their use in gastrointestinal disorders. Drugs 69, 435–448 (2009).
Ghassemi, K. A., Kovacs, T. O. & Jensen, D. M. Gastric acid inhibition in the treatment of peptic ulcer hemorrhage. Curr. Gastroenterol. Rep. 11 462–469 (2009).
Laine, L. & McQuaid, K. R. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin. Gastroenterol. Hepatol. 7, 33–47 (2009).
Leontiadis, G. I., Sharma, V. K. & Howden, C. W. Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta-analysis of randomized controlled trials. Mayo Clin. Proc. 82, 286–296 (2007).
Khuroo, M. S. et al. A comparison of omeprazole and placebo for bleeding peptic ulcer. N. Engl. J. Med. 336, 1054–1058 (1997).
Kaviani, M. J. et al. Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized clinical trial. Aliment. Pharmacol. Ther. 17, 211–216 (2003).
Leontiadis, G. I., Sharma, V. K. & Howden, C. W. Systematic review and meta-analysis: enhanced efficacy of proton-pump inhibitor therapy for peptic ulcer bleeding in Asia—a post hoc analysis from the Cochrane Collaboration. Aliment. Pharmacol. Ther. 21, 1055–1061 (2005).
Høie, O., Stallemo, A., Matre, J. & Stokkeland, M. Effect of oral lansoprazole on intragastric pH after endoscopic treatment for bleeding peptic ulcer. Scand. J. Gastroenterol. 44, 284–288 (2009).
Sung, J. J. et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann. Intern. Med. 152, 1–9 (2010).
Jin, B. et al. Cytochrome P450 2C19 polymorphism is associated with poor clinical outcomes in coronary artery disease patients treated with clopidogrel. Mol. Biol. Rep. 38, 1697–1702 (2011).
O'Donoghue, M. L. et al. Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials. Lancet 374, 989–997 (2009).
Ho, P. M. et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA 301, 937–944 (2009).
Bhatt, D. L. et al. Clopidogrel with or without omeprazole in coronary artery disease. N. Engl. J. Med. 363, 1909–1917 (2010).
Storey, R. F. Pharmacology and clinical trials of reversibly-binding P2Y12 inhibitors. Thromb. Haemost. 105 (Suppl. 1), S75–S81 (2011).
Achar, S. Pharmacokinetics, drug metabolism, and safety of prasugrel and clopidogrel. Postgrad. Med. 123, 73–79 (2011).
Talley, N. J. & Li, Z. Helicobacter pylori: testing and treatment. Expert Rev. Gastroenterol. Hepatol. 1, 71–79 (2007).
Sfarti, C., Stanciu, C., Cojocariu, C. & Trifan, A. 13C-urea breath test for the diagnosis of Helicobacter pylori infection in bleeding duodenal ulcer. Rev. Med. Chir. Soc. Med. Nat. Iasi. 113, 704–709 (2009).
Gisbert, J. P. & Abraira, V. Accuracy of Helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis. Am. J. Gastroenterol. 101, 848–863 (2006).
Stenstrom, B., Mendis, A. & Marshall, B. Helicobacter pylori—the latest in diagnosis and treatment. Aust. Fam. Physician 37, 608–612 (2008).
Ramirez-Lazaro, M. J. et al. Real-time PCR improves Helicobacter pylori detection in patients with peptic ulcer bleeding. PLoS ONE 6, e20009 (2011).
Sanchez-Delgado, J. et al. Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression. Am. J. Gastroenterol. 106, 398–405 (2011).
Greenspoon, J. et al. Management of patients with nonvariceal upper gastrointestinal bleeding. Clin. Gastroenterol. Hepatol. http://dx.doi.org/10.1016/j.cgh.2011.07.025.
Author information
Authors and Affiliations
Contributions
All authors contributed substantially to researching data for the article, discussion of the content, writing the manuscript and editing the text.
Corresponding author
Ethics declarations
Competing interests
A. N. Barkun has acted as a consultant for AstraZeneca and Takeda Canada. The other authors declare no competing interests.
Rights and permissions
About this article
Cite this article
Bardou, M., Benhaberou-Brun, D., Le Ray, I. et al. Diagnosis and management of nonvariceal upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 9, 97–104 (2012). https://doi.org/10.1038/nrgastro.2011.260
Published:
Issue Date:
DOI: https://doi.org/10.1038/nrgastro.2011.260
This article is cited by
-
Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis
BMC Gastroenterology (2019)
-
What Is the Best Endoscopic Strategy in Acute Non-variceal Gastrointestinal Bleeding?
Current Treatment Options in Gastroenterology (2018)
-
Relevance of surgery in patients with non-variceal upper gastrointestinal bleeding
Langenbeck's Archives of Surgery (2017)
-
Gastrointestinale Blutung nach Anlage einer biliodigestiven Anastomose
Der Gastroenterologe (2015)
-
Predictive Factors for Endoscopic Visibility and Strategies for Pre-endoscopic Prokinetics Use in Patients with Upper Gastrointestinal Bleeding
Digestive Diseases and Sciences (2015)