REVIEW URRENT C OPINION

Nonvariceal upper gastrointestinal bleeding Tina Park and Wahid Wassef

Purpose of review Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastrointestinal bleeding and understand therapeutic modalities available in achieving hemostasis. This article summarizes guidelines in management of acute nonvariceal upper gastrointestinal bleeding and reviews recent advances in the field. Recent findings Recent study showed that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days. Endoscopic therapy should be performed on actively bleeding ulcers and ulcers with visible vessel or adherent clot. An over-the-scope clip is a novel device that can be used to achieve hemostasis. It may be a useful tool for achieving hemostasis for patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy. Doppler ultrasound probe can evaluate arterial flow to the ulcer and identify ulcers that are at high risk of rebleeding. Summary Upper gastrointestinal bleeding from peptic ulcer disease is not a new clinical problem. Yet, the approach to management continues to evolve with the accumulation of data and well designed studies on the subject. Keywords over-the-scope clip, peptic ulcer disease, transfusion goals, upper gastrointestinal bleeding

INTRODUCTION Acute upper gastrointestinal bleeding (UGIB) is one of the most common medical emergencies with an annual incidence of approximately 100 per 100 000 adults and approximately 400 000 annual hospitalizations in the United States [1]. Patients hospitalized with a UGIB have a mortality rate of 4.5–8.2% [2]. The most common etiology of acute nonvariceal UGIB is peptic ulcer disease, accounting for approximately 60% of etiologies (Fig. 1) [1]. This review will focus on guidelines for the recent trends in the management of patients with UGIB from peptic ulcer disease.

higher than 12 000/ml have increased likelihood of severe UGIB [2]. Upon presentation, patients suspected of UGIB should be resuscitated with intravenous fluids, pressors, and blood products as needed. The threshold for transfusion of packed red blood cells is hemoglobin lower than 7 g/dl. In a recent randomized controlled trial, patients in the restrictive-resuscitation strategy group with threshold of transfusion lower than 7 g/dl (posttransfusion hemoglobin level 7–9 g/dl) had significantly lower mortality at 45 days than those in the liberal-resuscitation strategy group with threshold of transfusion lower than 9 g/dl (posttransfusion hemoglobin level 9–11 g/dl) (5 vs. 9%, P ¼ 0.02) [3 ]. The risk of rebleeding and adverse events, such as transfusion reactions and pulmonary edema, was lower in the &&

RESUSCITATION AND RISK ASSESSMENT Factors predictive of a bleed from the upper gastrointestinal tract include history of melena (likelihood ratio 5.1–5.9), ratio of blood urea nitrogen to serum creatinine greater than 30 (likelihood ratio 7.5), blood or coffee grounds in nasogastric lavage (likelihood ratio 9.6), and melena on examination (likelihood ratio of 25) [2]. Patients with hemoglobin level lower than 8 g/dl, serum urea nitrogen level higher than 90 mg/dl, or a white blood cell count of

University of Massachusetts, Worcester, Massachusetts, USA Correspondence to Wahid Wassef, MD, University of Massachusetts, 55 Lake Avenue North, Worcester, MA 01655, USA. Tel: +1 508 856 3068; fax: +1 508 856 3981; e-mail: [email protected] Curr Opin Gastroenterol 2014, 30:603–608 DOI:10.1097/MOG.0000000000000123

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Stomach and duodenum

KEY POINTS  A recent study demonstrated that patients who received blood transfusion with threshold hemoglobin below 7 g/dl rather than below 9 g/dl had significantly lower mortality at 45 days.  Patients who failed endoscopic therapy with epinephrine injection, clip, or thermal therapy may be candidates for a novel device: the OTSC.  Doppler ultrasound probe may improve hemostasis by identifying arterial flow and feeding vessels in treated ulcers both of which may benefit from additional therapy.

restrictive-strategy group than in the liberal-strategy group [3 ]. Once stable, patients should be evaluated for coagulopathies and platelet abnormalities. Correcting international normalized ratio to lower than 1.8 was associated with lower mortality and fewer myocardial infarctions in one study [4]. Other studies have shown no difference in mortality, rebleeding, and complication rates between patients whose international normalized ratio was corrected to 1.5–2.5 by using fresh frozen plasma and a control group who did not receive anticoagulants. Therefore, correction of coagulopathy is recommended but should not delay endoscopy. The need for endoscopic intervention can be evaluated with the Blatchford score. Blatchford score

utilizes clinical and laboratory data (systolic blood pressure, pulse, melena, syncope, hepatic disease, heart failure, hemoglobin, blood urea nitrogen) to provide a score between 0 and 23 that helps predict patients in need of intervention (Table 1). In a study of 1748 patients, 50% of patients who had Blatchford score 6 required endoscopic intervention, and 100% of patients with Blatchford score at least 14 required endoscopic intervention [5]. Although Blatchford score does not reliably identify all patients who will require endoscopic intervention, patients with Blatchford score of 0 have less than 1% chance of requiring endoscopic intervention and could be considered for outpatient evaluation according to the authors of the study. However, this assertion would need to be evaluated in a prospective fashion before it can be utilized in clinical practice.

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PRE-ENDOSCOPY PHARMACOLOGIC THERAPY Prokinetic agents, such as erythromycin 250 mg intravenously, should be considered 30 min prior to endoscopy to improve visibility. A meta-analysis of three trials demonstrated that the use of erythromycin prior to endoscopy reduced the need for repeat endoscopy in patients suspected of having blood in their stomach as compared with placebo or no treatment [4]. However, this use did not demonstrate any benefit in other clinical parameters such as transfusion requirement, length of hospital stay, or need for surgery.

Etiologies of Nonvariceal Upper GI Bleeding

Tumor Angioectasia

Other‡

Mallory-Weiss Tear

Source not identified by endoscopy

Peptic ulcer disease Erosive disease

FIGURE 1. Etiologies of nonvariceal upper gastrointestinal bleeding. zRare etiologies of upper gastrointestinal bleeding include aortoenteric fistulas, Dieulafoy’s lesion, hemobilia, and hemosuccus pancreaticus. 604

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Nonvariceal upper gastrointestinal bleeding Park and Wassef Table 1. Blatchford score Laboratory data and risks

Score

Blo od urea nitrogen (mmol/l) 6.5–7.9

2

8.0–9.9

3

10.0–24.9

4

25

6

Hemoglobin (g/dl) for men 12–12.9

1

10–11.9

3

Nonvariceal upper gastrointestinal bleeding.

Acute upper gastrointestinal bleeding is one of the most common medical emergencies. It is important to recognize potential etiologies of upper gastro...
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