GuidelineThe role of endoscopy in the management of acute non-variceal upper GI bleeding
Introduction
Upper GI bleeding (UGIB) results in over 300,000 hospital admissions annually in the United States, with a mortality of 3.5% to 10%.2, 3 Appropriate management of patients with non-variceal UGIB has been demonstrated to improve patient outcomes.4 This updated ASGE guideline focuses on the role of GI endoscopy in patients with acute non-variceal UGIB. This guideline will not address obscure GI bleeding or the role of endoscopy in the management of variceal bleeding, both of which are addressed in existing ASGE practice guidelines.5, 6 UGIB refers to GI blood loss having an origin proximal to the ligament of Treitz. Acute UGIB can manifest as hematemesis, “coffee ground'' emesis, the return of red blood via a nasogastric tube, and/or melena with or without hemodynamic compromise. Hematochezia may occur in patients with extremely brisk UGIB.7, 8
Section snippets
Initial assessment
A primary goal of the initial assessment is to determine whether the patient requires urgent intervention (eg, endoscopic, surgical, transfusion) or can undergo delayed endoscopy or even be discharged to outpatient management. Although numerous factors from the patient history, physical examination, and initial tests have been examined for an association with a need for intervention, no single factor is sufficiently predictive of UGIB severity to be used for triage. The most predictive
Endoscopy in the management of UGIB
Endoscopy in patients with UGIB is effective in diagnosing and treating most causes of UGIB and is associated with a reduction in blood transfusion requirements and length of intensive care unit/total hospital stay.28 Early endoscopy (within 24 hours of hospital admission) has a greater impact than delayed endoscopy on length of hospital stay and requirements for blood transfusion.29 In appropriate settings, endoscopy can be used to assess the need for inpatient admission. Several studies have
Endoscopic treatment modalities for UGIB
There are a variety of endoscopic treatment modalities available for the management of UGIB, including injection methods, cautery, and mechanical therapy.34 These are reviewed briefly here. A full discussion of these techniques and their risks can be found in other ASGE documents.34, 35
Overview of endoscopic approaches to common causes of acute UGIB
In patients with UGIB, the most common etiologies are: PUD (20%-50%), gastroduodenal erosions (8%-15%), esophagitis (5%-15%), varices (5%-20%), Mallory-Weiss tears (8%-15%), and vascular malformations (about 5%), with other conditions (eg, malignancy) making up the remaining cases.41, 42
Recurrent bleeding after endoscopic therapy
Despite adequate initial endoscopic therapy, recurrent UGIB can occur in up to 24% of high-risk patients. The use of PPI therapy in addition to combination endoscopic therapy reduces the rate of recurrent bleeding to approximately 10%.54, 56 Patients with recurrent bleeding generally respond favorably to repeat endoscopic therapy.77, 78 Routine second-look endoscopy, defined as a planned endoscopy performed within 24 hours of the initial endoscopy, is not recommended.79 In cases where the
Recommendations
- •
We recommend that patients with UGIB be adequately resuscitated before endoscopy. ⊕○○○
- •
We recommend antisecretory therapy with PPIs for patients with bleeding caused by peptic ulcers or in those with suspected peptic ulcer bleeding awaiting endoscopy. ⊕⊕⊕⊕
- •
We suggest prokinetic agents in patients with a high probability of having fresh blood or a clot in the stomach when undergoing endoscopy. ⊕⊕○○
- •
We recommend endoscopy to diagnose the etiology of acute UGIB. ⊕⊕⊕○
The timing of endoscopy should
Disclosures
T. Ben-Menachem is a consultant for Boston Scientific. D. Fisher is a consultant for Epigenomics, Inc. K. Chathadi is a speaker for Boston Scientific. Rajeev Jain is a consultant for Boston Scientific and does research for Barxx. J. Saltzman is a consultant for Hemoclip Development and has a relationship with Cook Endoscopy. No other financial relationships relevant to this publication were disclosed.
References (79)
- et al.
The role of endoscopy in the management of obscure GI bleeding
Gastrointest Endosc
(2010) - et al.
ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005
Gastrointest Endosc
(2005) - et al.
Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding
Gastrointest Endosc
(2004) - et al.
Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding
Am J Emerg Med
(2007) - et al.
Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation
Lancet
(2009) - et al.
A risk score to predict need for treatment for upper-gastrointestinal haemorrhage
Lancet
(2000) - et al.
Variation in outcome after acute upper gastrointestinal haemorrhage
Lancet
(1995) - et al.
Management of antithrombotic agents for endoscopic procedures
Gastrointest Endosc
(2009) - et al.
Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures
Ann Emerg Med
(1999) - et al.
Prokinetics in acute upper GI bleeding: a meta-analysis
Gastrointest Endosc
(2010)
Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study
Gastrointest Endosc
Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial
Gastroenterology
Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage
Gastrointest Endosc
Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial
Gastrointest Endosc
Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial
Gastrointest Endosc
Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series
Gastrointest Endosc
Endoscopic hemostatic devices
Gastrointest Endosc
Complications of upper GI endoscopy
Gastrointest Endosc
A prospective, randomized trial of large-versus small-volume endoscopic injection of epinephrine for peptic ulcer bleeding
Gastrointest Endosc
A randomized trial comparing heater probe plus thrombin with heater probe plus placebo for bleeding peptic ulcer
Gastroenterology
The argon plasma coagulator: February 2002
Gastrointest Endosc
The frequency of peptic ulcer as a cause of upper-GI bleeding is exaggerated
Gastrointest Endosc
Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials
Clin Gastroenterol Hepatol
Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses
Gastrointest Endosc
Therapeutic endoscopy for nonvariceal gastrointestinal bleeding
Gastroenterol Clin N Am
The role of endoscopy in the management of patients with peptic ulcer disease
Gastrointest Endosc
Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials
Clin Gastroenterol Hepatol
Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding
Gastrointest Endosc
Severe Mallory-Weiss tear after endoscopy treated by endoscopic band ligation
Gastrointest Endosc
Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome
Gastrointest Endosc
Management and long-term prognosis of Dieulafoy lesion
Gastrointest Endosc
Primary aortoduodenal fistula: a case report and review of the literature
J Vasc Surg
Primary aortoenteric fistula: report of eight new cases and review of the literature
Ann Vasc Surg
Endoscopic treatment of major bleeding from advanced gastroduodenal malignant lesions
Mayo Clin Proc
GRADE: an emerging consensus on rating quality of evidence and strength of recommendations
BMJ
Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993-2003
Clin Gastroenterol Hepatol
Analysis of 3,294 cases of upper gastrointestinal bleeding in military medical facilities
Am J Gastroenterol
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
A prospective characterization of upper gastrointestinal hemorrhage presenting with hematochezia
Am J Gastroenterol
Cited by (240)
Diagnostic and treatment protocol for non-variceal upper gastrointestinal bleeding
2024, Medicine (Spain)Endoscopic Management of Tumor Bleeding: Techniques and Strategies
2024, Gastrointestinal Endoscopy Clinics of North AmericaLiver Severity Score-Based Modeling to Predict Six-Week Mortality Risk Among Hospitalized Cirrhosis Patients With Upper Gastrointestinal Bleeding
2024, Journal of Clinical and Experimental HepatologyUrgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding?
2023, Gastroenterologia y HepatologiaOvert Small Bowel Bleeding in the Older Adult
2023, Journal for Nurse Practitioners