Guideline
The role of endoscopy in the management of acute non-variceal upper GI bleeding

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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.

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