![]() ![]() Management of Patients with Ulcer Bleeding. Abstract. Loren Laine, MD1,2 and Dennis M. Jensen, MD3–5. 1Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA; 2. VA Connecticut Healthcare System, New Haven, Connecticut, USA; 3. David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA; 4. CURE Digestive Diseases Research Center, Los Angeles, California, USA; 5.
VA Greater Los Angeles Healthcare System, Los Angeles, California, USA. This guideline presents recommendations for the step- wise management of patients with overt upper gastrointestinal bleeding. Hemodynamic status is first assessed, and resuscitation initiated as needed. Patients are risk- stratified based on features such as hemodynamic status, comorbidities, age, and laboratory tests. Pre- endoscopic erythromycin is considered to increase diagnostic yield at first endoscopy. Pre- endoscopic proton pump inhibitor (PPI) may be considered to decrease the need for endoscopic therapy but does not improve clinical outcomes. Upper endoscopy is generally performed within 2. The endoscopic features of ulcers direct further management. ![]() Patients with active bleeding or non- bleeding visible vessels receive endoscopic therapy (e. PPI with a bolus followed by continuous infusion. Patients with flat spots or clean- based ulcers do not require endoscopic therapy or intensive PPI therapy. Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment; if bleeding persists or recurs, treatment with surgery or interventional radiology is undertaken. Alternative medicine or fringe medicine are practices claimed to have the healing effects of medicine but which are disproven, unproven, impossible to prove, or are. Prevention of recurrent bleeding is based on the etiology of the bleeding ulcer. Nonsteroidal anti- inflammatory drugs (NSAIDs) are stopped; if they must be resumed low- dose COX- 2- selective NSAID plus PPI is used. Patients with established cardiovascular disease who require aspirin should start PPI and generally re- institute aspirin soon after bleeding ceases (within 7 days and ideally 1–3 days). Patients with idiopathic ulcers receive long- term anti- ulcer therapy. Am J Gastroenterol 2. February 2. 01. 2Received 3. July 2. 01. 1; accepted 2. December 2. 01. 1. Correspondence: Loren Laine, MD, Section of Digestive Diseases, Yale University School of Medicine, 3. Cedar Street/1. 08. LMP, New Haven, Connecticut 0. USA. E- mail: loren. Introduction. Ulcers are the most common cause of hospitalization for upper gastrointestinal bleeding (UGIB), and the vast majority of clinical trials of therapy for nonvariceal UGIB focus on ulcer disease. This guideline provides recommendations for the management of patients with overt UGIB due to gastric or duodenal ulcers. Here are some fun things involving the English language. To the best of my knowledge, none of this is copyrighted, unless annotated so.![]() We first discuss the initial management of UGIB in patients without known portal hypertension, including initial assessment and risk stratification, pre- endoscopic use of medications and gastric lavage, and timing of endoscopy. We then focus on the endoscopic and medical management of ulcer disease, including endoscopic findings and their prognostic implications, endoscopic hemostatic therapy, post- endoscopic medical therapy and disposition, and prevention of recurrent ulcer bleeding. Each section of the document presents the key recommendations related to the section topic, followed by a summary of the supporting evidence. A summary of recommendations is provided in Table 1. A search of MEDLINE via the OVID interface using the Me. SH term . The GRADE system was used to grade the strength of recommendations and the quality of evidence (1). The quality of evidence, which influences the strength of recommendation, ranges from . The strength of a recommendation is graded as strong when the desirable effects of an intervention clearly outweigh the undesirable effects and is graded as conditional when uncertainty exists about the trade- offs (1). In addition to quality of evidence and balance between desirable and undesirable effects, other factors affecting the strength of recommendation include variability in values and preferences of patients, and whether an intervention represents a wise use of resources (1). Table 1. Summary and strength of recommendations. Initial assessment and risk stratification. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed (Strong recommendation). Blood transfusions should target hemoglobin > = 7 g/dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease (Conditional recommendation). Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as timing of endoscopy, time of discharge, and level of care (Conditional recommendation). Discharge from the emergency department without inpatient endoscopy may be considered in patients with urea nitrogen < 1. Hg; pulse < 1. Conditional recommendation). Pre- endoscopic medical therapy. Intravenous infusion of erythromycin (2. However, erythromycin has not consistently been shown to improve clinical outcomes (Conditional recommendation). Pre- endoscopic intravenous PPI (e. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death (Conditional recommendation). If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding (Conditional recommendation). Gastric lavage. 8. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect (Conditional recommendation). Timing of endoscopy. Patients with UGIB should generally undergo endoscopy within 2. Conditional recommendation). In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non- emergent setting to identify the substantial proportion of patients with low- risk endoscopic findings who can be safely discharged (Conditional recommendation). ![]() In patients with higher risk clinical features (e. Conditional recommendation). Endoscopic diagnosis. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending risk of further bleeding, are active spurting, non- bleeding visible vessel, active oozing, adherent clot, flat pigmented spot, and clean base (Strong recommendation). Endoscopic therapy. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non- bleeding visible vessel (Strong recommendation). Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefit may be greater in patients with clinical features potentially associated with a higher risk of rebleeding (e. Conditional recommendation). Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a flat pigmented spot (Strong recommendation). Epinephrine therapy should not be used alone. If used, it should be combined with a second modality (Strong recommendation). Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e. Strong recommendation). Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant alone to achieve initial hemostasis (Conditional recommendation). Medical therapy after endoscopy. After successful endoscopic hemostasis, intravenous PPI therapy with 8. Strong recommendation). Patients with ulcers that have flat pigmented spots or clean bases can receive standard PPI therapy (e. PPI once daily) (Strong recommendation). Repeat endoscopy. Routine second- look endoscopy, in which repeat endoscopy is performed 2. Conditional recommendation). Repeat endoscopy should be performed in patients with clinical evidence of recurrent bleeding and hemostatic therapy should be applied in those with higher risk stigmata of hemorrhage (Strong recommendation). If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is generally employed (Conditional recommendation). Hospitalization. 25. Patients with high- risk stigmata (active bleeding, visible vessels, clots) should generally be hospitalized for 3 days assuming no rebleeding and no other reason for hospitalization. They may be fed clear liquids soon after endoscopy (Conditional recommendation). Patients with clean- based ulcers may receive a regular diet and be discharged after endoscopy assuming they are hemodynamically stable, their hemoglobin is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult (Strong recommendation). Long- term prevention of recurrent bleeding ulcers. After documentation of eradication, maintenance antisecretory therapy is not needed unless the patient also requires NSAIDs or antithrombotics (Strong recommendation). In patients with NSAID- associated bleeding ulcers, the need for NSAIDs should be carefully assessed and NSAIDs should not be resumed if possible. In patients who must resume NSAIDs, a COX- 2 selective NSAID at the lowest effective dose plus daily PPI is recommended (Strong recommendation). In patients with low- dose aspirin- associated bleeding ulcers, the need for aspirin should be assessed. If given for secondary prevention (i. Long- term daily PPI therapy should also be provided. If given for primary prevention (i. Conditional recommendation). In patients with idiopathic (non- H. Based on other models of hemorrhage (2), the first step in management of patients presenting with overt upper gastrointestinal bleeding (UGIB) is assessment of hemodynamic status and initiation of resuscitative measures as needed.
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