Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGIB) is a frequently encountered medical emergency with an incidence of 84-160/100000 and associated with mortality of approximately 10%. Guidelines from the National Institute for Care and Care Excellence outline key features in the management of AUGIB. Patients require prompt resuscitation and risk assessment using validated tools. Upper gastrointestinal endoscopy provides accurate diagnosis, aids in estimating prognosis and allows therapeutic intervention. Endoscopy should be undertaken immediately after resuscitation in unstable patients and within 24 hours in all other patients. Interventional radiology may be required for bleeding unresponsive to endoscopic intervention. Drug therapy depends on the cause of bleeding. Intravenous proton pump inhibitors should be used in patients with high-risk ulcers. Terlipressin and broad-spectrum antibiotics should be used following variceal haemorrhage. Hospitals admitting patients with AUGIB need to provide well organised services and ensure access to relevant services for all patients, and particularly to out of hours endoscopy.

Role of Medical Therapy for Nonvariceal Upper Gastrointestinal Bleeding

Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Mortality from UGIB has remained 5-10% over the past decade. This article presents current evidence-based recommendations for the medical management of UGIB. Preendoscopic management includes initial resuscitation, risk stratification, appropriate use of blood products, and consideration of nasogastric tube insertion, erythromycin, and proton pump inhibitor therapy. The use of postendoscopic intravenous proton pump inhibitors is strongly recommended for certain patient populations. Postendoscopic management also includes the diagnosis and treatment of Helicobacter pylori, appropriate use of proton pump inhibitors and iron replacement therapy.

Management of Patients with Rebleeding

Peptic ulcer bleeding is a common emergency. Management of ulcer bleeding requires prompt risk stratification, initiation of pharmacotherapy, and timely evaluation for endoscopy. Although endoscopy can achieve primary hemostasis in more than 90% of peptic ulcer bleeding, rebleeding may occur in up to 15% of patients after therapeutic endoscopy and is associated with heightened mortality. Early identification of high-risk patients for rebleeding is important. Depending on bleeding severity and center availability, patients with rebleeding may be managed by second endoscopy, transarterial angiographic embolization, or surgery. This article reviews the current management of peptic ulcers with an emphasis on rebleeding.

Endoscopic management of tumor bleeding from inoperable gastric cancer

Tumor bleeding is not a rare complication in patients with inoperable gastric cancer. Endoscopy has important roles in the diagnosis and primary treatment of tumor bleeding, similar to its roles in other non-variceal upper gastrointestinal bleeding cases. Although limited studies have been performed, endoscopic therapy has been highly successful in achieving initial hemostasis. One or a combination of endoscopic therapy modalities, such as injection therapy, mechanical therapy, or ablative therapy, can be used for hemostasis in patients with endoscopic stigmata of recent hemorrhage. However, rebleeding after successful hemostasis with endoscopic therapy frequently occurs. Endoscopic therapy may be a treatment option for successfully controlling this rebleeding. Transarterial embolization or palliative surgery should be considered when endoscopic therapy fails. For primary and secondary prevention of tumor bleeding, proton pump inhibitors can be prescribed, although their effectiveness to prevent bleeding remains to be investigated.

Stress-related mucosal disease in the critically ill patient

Bleeding from stress-related mucosal disease in critically ill patients remains an important clinical management issue. Although only a small proportion (1-6%) of patients admitted to an intensive care unit (ICU) will bleed, a substantial proportion exhibit clinical risk factors (mechanical ventilation for >48 h and a coagulopathy) that predict an increased risk of bleeding. Furthermore, upper gastrointestinal mucosal lesions can be found in 75-100% of patients in ICUs. Although uncommon, stress-ulcer bleeding is a severe complication with an estimated mortality of 40-50%, mostly from decompensating an underlying condition or multiorgan failure. Although the vast majority of patients in ICUs receive stress-ulcer prophylaxis, largely with PPIs, some controversy surrounds their efficacy and safety. Indeed, no single trial has shown that stress-ulcer prophylaxis reduces mortality. Some reports suggest that the use of PPIs increases the risk of nosocomial infections. However, several meta-analyses and cost-effectiveness studies suggest PPIs to be more clinically effective and cost-effective than histamine-2 receptor antagonists, without considerable increases in nosocomial pneumonia. To help clinicians use the most appropriate strategy for treatment of patients in the ICU, this Review presents the latest information on all aspects of stress-related mucosal disease.

Upper gastrointestinal bleeding: patient presentation, risk stratification, and early management

The established quality indicators for early management of upper gastrointestinal (GI) hemorrhage are based on rapid diagnosis, risk stratification, and early management. Effective preendoscopic treatment may improve survivability of critically ill patients and improve resource allocation for all patients. Accurate risk stratification helps determine the need for hospital admission, hemodynamic monitoring, blood transfusion, and endoscopic hemostasis before esophagogastroduodenoscopy (EGD) via indirect measures such as laboratory studies, physiologic data, and comorbidities. Early management before the definitive EGD is essential to improving outcomes for patients with upper GI bleeding.

Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance

BACKGROUND AND AIMS

To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group.

METHODS

The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade.

RESULTS

The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke.

CONCLUSIONS

The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.

Diagnosis, treatment, and outcome in patients with bleeding peptic ulcers and Helicobacter pylori infections

Upper gastrointestinal (UGI) bleeding is the most frequently encountered complication of peptic ulcer disease. Helicobacter pylori (Hp) infection and nonsteroidal anti-inflammatory drug (NSAID) administration are two independent risk factors for UGI bleeding. Therefore, testing for and diagnosing Hp infection are essential for every patient with UGI hemorrhage. The presence of the infection is usually underestimated in cases of bleeding peptic ulcers. A rapid urease test (RUT), with or without histology, is usually the first test performed during endoscopy. If the initial diagnostic test is negative, a delayed ¹³C-urea breath test (UBT) or serology should be performed. Once an infection is diagnosed, antibiotic treatment is advocated. Sufficient evidence supports the concept that Hp infection eradication can heal the ulcer and reduce the likelihood of rebleeding. With increased awareness of the effects of Hp infection, the etiologies of bleeding peptic ulcers have shifted to NSAID use, old age, and disease comorbidity.

Can the presence of endoscopic high-risk stigmata be predicted before endoscopy? A multivariable analysis using the RUGBE database

BACKGROUND

Many aspects in the management of acute upper gastrointestinal bleeding rely on pre-esophagogastroduodenoscopy (EGD) stratification of patients likely to exhibit high-risk stigmata (HRS); however, data predicting the presence of HRS are lacking.

OBJECTIVE

To determine clinical and laboratory predictors of HRS at the index EGD in patients presenting with acute upper gastrointestinal bleeding using retrospective data from a validated national database - the Canadian Registry in Upper Gastrointestinal Bleeding and Endoscopy registry. methods: Relevant clinical and laboratory parameters were evaluated. HRS was defined as spurting, oozing, nonbleeding visible vessel or adherent clot after vigorous irrigation. Multivariable modelling was used to identify predictors of HRS including age, sex, hematemesis, use of antiplatelet agents, American Society of Anesthesiologists (ASA) classification, nasogastric tube aspirate, hemoglobin level and elapsed time from the onset of bleeding to EGD.

RESULTS

Of the 1677 patients (mean [± SD] age 66.2 ± 16.8 years; 38.3% female), 28.7% had hematemesis, 57.8% had an ASA score of 3 to 5, and the mean hemoglobin level was 96.8 ± 27.3 g⁄L. The mean time from presentation to endoscopy was 22.2 ± 37.5 h. The best fitting multivariable model included the following significant predictors: ASA score 3 to 5 (OR 2.16 [95% CI 1.71 to 2.74]), a shorter time to endoscopy (OR 0.99 [95% CI 0.98 to 0.99]) and a lower initial hemoglobin level (OR 0.99 [95% CI 0.99 to 0.99]).

CONCLUSION

A higher ASA score, a shorter time to endoscopy and lower initial hemoglobin level all significantly predicted the presence of endoscopic HRS. These criteria could be used to improve the optimal selection of patients requiring more urgent endoscopy.

Is the AIMS65 score useful in predicting outcomes in peptic ulcer bleeding?

AIM: To evaluate the applicability of AIMS65 scores in predicting outcomes of peptic ulcer bleeding.

METHODS: This was a retrospective study in a single center between January 2006 and December 2011. We enrolled 522 patients with upper gastrointestinal haemorrhage who visited the emergency room. High-risk patients were regarded as those who had re-bleeding within 30 d from the first endoscopy as well as those who died within 30 d of visiting the Emergency room. A total of 149 patients with peptic ulcer bleeding were analysed, and the AIMS65 score was used to retrospectively predict the high-risk patients.

RESULTS: A total of 149 patients with peptic ulcer bleeding were analysed. The poor outcome group comprised 28 patients [male: 23 (82.1%) vs female: 5 (10.7%)] while the good outcome group included 121 patients [male: 93 (76.9%) vs female: 28 (23.1%)]. The mean age in each group was not significantly different. The mean serum albumin levels in the poor outcome group were slightly lower than those in the good outcome group (P = 0.072). For the prediction of poor outcome, the AIMS65 score had a sensitivity of 35.5% (95%CI: 27.0-44.8) and a specificity of 82.1% (95%CI: 63.1-93.9) at a score of 0. The AIMS65 score was insufficient for predicting outcomes in peptic ulcer bleeding (area under curve = 0.571; 95%CI: 0.49-0.65).

CONCLUSION: The AIMS65 score may therefore not be suitable for predicting clinical outcomes in peptic ulcer bleeding. Low albumin levels may be a risk factor associated with high mortality in peptic ulcer bleeding.

Attitude and Knowledge of Indian Emergency Care Residents towards Use of Proton Pump Inhibitors

Objective. Several studies carried out in developed countries have reported disproportionately high usage of acid suppressive drugs, especially proton pump inhibitors (PPIs). However, systematic assessment of attitude and practices of health care providers towards the use of these drugs in developing countries is lacking. In this study, we assessed the knowledge, attitude, and preferences of resident doctors posted in the emergency department of a tertiary care hospital in North India, towards the use of PPIs. Methods. A questionnaire based survey was carried out. Results. Fifty resident doctors responded to the questionnaire. Thirty-six percent reported prescribing acid suppressive drugs for majority of their patients, while 12% prescribed them to almost all patients they attended. Acute gastritis was the most common indication for prescribing PPI/H₂ blockers (50%). The majority of respondents (92%) regarded PPIs as their first choice in acid suppressive agents and 58% administered it through intravenous route. Knowledge about PPI related adverse effects was low. Conclusions. Emergency care residents in India also tend to overuse PPIs in a manner similar to their counterparts in developed countries. Specific measures may be helpful in preventing such practices.

Acute upper gastrointestinal bleeding in the elderly: aetiology, diagnosis and treatment

Acute upper gastrointestinal bleeding (UGIB) is a common, potentially life threatening medical emergency. It is associated with higher rates of hospitalization, morbidity and mortality in the elderly when compared with younger patients, most likely due to higher prevalence of multiple comorbidities. Age is an independent risk factor for mortality in UGIB, with Helicobacter pylori infection and the use of non-steroidal anti-inflammatory agents and anticoagulants being the most prevalent causal risk factors. These patients require early risk assessment, resuscitation and an attempt to identify and treat the bleeding source. In the majority, this involves early endoscopy and endotherapy as required to achieve haemostasis, with radiological intervention or surgery needed in the minority with ongoing severe bleeding. In this article, we discuss UGIB in the elderly, focusing on aetiology, risk factors and management.

Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding

BACKGROUND

Treatment with proton pump inhibitors (PPIs) improves clinical outcomes in patients with peptic ulcer bleeding. However, the optimal dose and route of administration of PPIs remains controversial.

OBJECTIVES

To evaluate the efficacy of different regimens of PPIs in the management of acute peptic ulcer bleeding using evidence from direct comparison randomized controlled trials (RCTs).We specifically intended to assess the differential effect of the dose and route of administration of PPI on mortality, rebleeding, surgical intervention, further endoscopic haemostatic treatment (EHT), length of hospital stay, transfusion requirements and adverse events.

SEARCH METHODS

We searched CENTRAL (in The Cochrane Library 2010, Issue 3), MEDLINE and EMBASE (from inception to September 2010) and proceedings of major gastroenterology meetings (January 2000 to September 2010), without language restrictions. Original investigators were contacted to request missing data.

SELECTION CRITERIA

RCTs that compared at least two different regimens of the same or a different PPI in patients with acute peptic ulcer bleeding, diagnosed endoscopically.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies, extracted data and assessed risk of bias. We synthesized data using the Mantel-Haenszel random-effects method and performed multivariate meta-regression with random permutations based on Monte Carlo simulation. We measured heterogeneity with the I² statistic and Cochrane Q test and assessed publication bias with funnel plots and Egger's test. We graded the overall quality of evidence using the GRADE approach.

MAIN RESULTS

Twenty two RCTs were included; risk of bias was high in 17 and unclear in 5. The main analysis included 13 studies (1716 patients) comparing "high" dose regimens (72-hour cumulative dose > 600 mg of intravenous PPI) to other doses; there was no significant heterogeneity for any clinical outcome. We found low quality evidence that did not exclude a potential reduction or increase in mortality, rebleeding, surgical interventions or endoscopic haemostatic treatment (EHT) with "high" dose regimens. For mortality, pooled risk ratio (RR) was 0.85 (95% confidence interval (CI) 0.47 to 1.54); pooled risk difference (RD) was 0 more deaths per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more deaths per 100 treated). For rebleeding, pooled RR was 1.27 (95% CI 0.96 to 1.67); pooled RD was 2 more rebleeding events per 100 patients treated with "high" dose (95% CI from 0 fewer to 5 more rebleeding events per 100 treated). For surgical interventions, pooled RR was 1.33 (95% CI 0.63 to 2.77); pooled RD was 1 more surgical intervention per 100 patients treated with "high" dose (95% CI from 1 fewer to 2 more surgical interventions per 100 treated). For further EHT, pooled RR was 1.39 (95% CI 0.88 to 2.18), pooled RD was 2 more events per 100 patients treated with "high" dose PPI (95% CI from 1 fewer to 5 more events per 100 treated). We found moderate quality evidence suggesting no important difference between the two regimens with regards to length of hospital stay (mean difference (MD) 0.26 days; 95% CI -0.08 to 0.6 days) or blood transfusion requirements (MD 0.05 units; 95% CI -0.21 to 0.3 units). There was visual and statistical evidence of "inverse" publication bias for mortality (missing small studies with favourable outcomes for "high" dose), but not for any other outcome. The results were similar for all subgroup analyses (according to risk of bias, geographical location, route of administration for non-"high" dose regimens, continuous infusion vs. bolus administration for intravenous non-"high" regimens group), sensitivity analyses (restriction to patients who had EHT for high risk stigmata, use of different dose thresholds for comparative regimens) and post hoc analyses (inclusion of all studies (N = 22) that compared at least two PPI regimens with different cumulative 72 hour doses; restriction of the previous analysis to patients who had EHT for high risk stigmata). Meta-regression analysis did not show any statistically significant associations between treatment effect (for the outcomes of mortality, rebleeding and surgical intervention) and the three study-level factors that were assessed (geographical location (Asia versus not Asia), route of PPI administration (intravenous versus oral), within-study ratio among the 72-hour cumulative doses of the two PPI regimens).

AUTHORS' CONCLUSIONS

There is insufficient evidence for concluding superiority, inferiority or equivalence of high dose PPI treatment over lower doses in peptic ulcer bleeding.

Challenges in the management of acute peptic ulcer bleeding

Acute upper gastrointestinal bleeding is a common medical emergency worldwide, a major cause of which are bleeding peptic ulcers. Endoscopic treatment and acid suppression with proton-pump inhibitors are cornerstones in the management of the disease, and both treatments have been shown to reduce mortality. The role of emergency surgery continues to diminish. In specialised centres, radiological intervention is increasingly used in patients with severe and recurrent bleeding who do not respond to endoscopic treatment. Despite these advances, mortality from the disorder has remained at around 10%. The disease often occurs in elderly patients with frequent comorbidities who use antiplatelet agents, non-steroidal anti-inflammatory drugs, and anticoagulants. The management of such patients, especially those at high cardiothrombotic risk who are on anticoagulants, is a challenge for clinicians. We summarise the published scientific literature about the management of patients with bleeding peptic ulcers, identify directions for future clinical research, and suggest how mortality can be reduced.

Non-variceal upper gastrointestinal bleeding: clinical, therapeutic and evolution aspects. Comparison between a tertiary medical center and a municipal hospital

Upper gastrointestinal bleeding (UGIB) is one of the most common emergencies in gastroenterology practice. In recent years, the introduction of urgent upper gastrointestinal endoscopy (UGIE) and of the treatment with proton pump inhibitors (PPIs) in high doses has resulted in an improvement of the treatment outcome in patients with UGIB, but without a significant improvement in mortality rates. In our study we compared the epidemiological, clinical, therapeutic, and prognostic aspects in patients with non-variceal UGIB admitted over a period of one year in a tertiary center where urgent UGIE is a routine procedure and in a municipal hospital where UGIE with endoscopic hemostasis is not available. Patients admitted to the tertiary medical center had more clinical and endoscopic severity factors compared to those from the municipal hospital: they were older, with more frequent intake of NSAIDs, several comorbidities, some of them severe, and more severe posthemorrhagic anemia. The endoscopic examination revealed that active bleeding and stigmata of recent hemorrhage were more frequent in these patients. Urgent UGIE and, where necessary because of lesions, endoscopic hemostasis were performed in most of these patients. Patients admitted to the municipal hospital were treated more frequently with high-dose intravenous PPIs. Patients undergoing urgent UGIE and endoscopic therapy had a shorter duration of hospitalization. However, there were no differences regarding the need for surgery or mortality rates. The results of our study are consistent with the literature.

Recent advances on the management of patients with non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding is a common emergency associated with significant morbidity and mortality. The mainstays of therapy include prompt resuscitation, early risk stratification, and appropriate access to endoscopy. Patients with high-risk endoscopic findings should receive endoscopic hemostasis with a modality of established efficacy. The pillar of post-endoscopic therapy is acid-suppression via proton pump inhibitors (PPI), although the optimal dose and route of administration are still unclear. Post-discharge management of patients with peptic ulcers includes standard oral PPI treatment and eradication of Helicobacter pylori infection. The risk of recurrent bleeding should be carefully considered and appropriate gastroprotection should be offered when non-steroid anti-inflammatory drugs, anti-platelet agents, and/or anticoagulation need to be used. This review seeks to survey new evidence in the management of non-variceal upper gastrointestinal bleeding that has emerged in the past 3 years and put it into context with recommendations from recent practice guidelines.

Management by the intensivist of gastrointestinal bleeding in adults and children

Intensivists are regularly confronted with the question of gastrointestinal bleeding. To date, the latest international recommendations regarding prevention and treatment for gastrointestinal bleeding lack a specific approach to the critically ill patients. We present recommendations for management by the intensivist of gastrointestinal bleeding in adults and children, developed with the GRADE system by an experts group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF), with the participation of the French Language Group of Paediatric Intensive Care and Emergencies (GFRUP), the French Society of Emergency Medicine (SFMU), the French Society of Gastroenterology (SNFGE), and the French Society of Digestive Endoscopy (SFED). The recommendations cover five fields of application: management of gastrointestinal bleeding before endoscopic diagnosis, treatment of upper gastrointestinal bleeding unrelated to portal hypertension, treatment of upper gastrointestinal bleeding related to portal hypertension, management of presumed lower gastrointestinal bleeding, and prevention of upper gastrointestinal bleeding in intensive care.

Pantoprazole before Endoscopy in Patients with Gastroduodenal Ulcer Bleeding: Does the duration of Infusion and Ulcer Location Influence the Effects?

The aim of this study was to investigate the effect of preemptive pantoprazole infusion on early endoscopic findings in patients with acute ulcer bleeding. Records of 333 patients admitted with acute ulcer bleeding were analyzed. Ulcer bleeders were given either 80 mg bolus of pantoprazole followed by continuous infusion of 8 mg per hour or saline infusion until endoscopy. In 93 patients saline infusion whereas in 240 patients bolus plus infusion of pantoprazole was administrated with mean (±SD) durations of 5.45 ± 12.9 hours and 6.9 ± 13.2 hours, respectively (P = 0.29). Actively bleeding ulcers were detected in 46/240 (19.2%) of cases in the pantoprazole group as compared with 23/93 (24.7%) in the saline infusion group (P = 0.26). Different durations of pantoprazole infusion (0–4 hours, >4 hours, and >6 hours) had no significant effect on endoscopic and clinical outcome parameters in duodenal ulcer bleeders. Gastric ulcer bleeders on pantoprazole infusion longer than 4 and 6 hours before endoscopy had actively bleeding ulcers in 4.3% and 5% compared to the 19.5% active bleeding rate in the saline group (P = 0.02 and P = 0.04). Preemptive infusion of high-dose pantoprazole longer than 4 hours before endoscopy decreased the ratio of active bleeding only in gastric but not in duodenal ulcer patients.

Effect of intravenous proton pump inhibitor regimens and timing of endoscopy on clinical outcomes of peptic ulcer bleeding

BACKGROUND AND AIM

The most effective schedule of proton pump inhibitor (PPI) administration and the optimal timing of endoscopy in acute peptic ulcer bleeding remain uncertain. The aim of this study was to determine the most efficient PPI regimen and optimal timing of endoscopy.

METHODS

  Consecutive patients with suspected bleeding peptic ulcers were enrolled and randomized to receive either a standard regimen or a high-dose intensive intravenous regimen. Only patients with bleeding peptic ulcers diagnosed at initial endoscopy continued the study. High-risk patients received endoscopic hemostasis. The primary outcome measure of recurrent bleeding was compared between the two dosage regimens and between early and late endoscopy. Secondary outcome measures compared included need for endoscopic treatment, blood transfusion, hospital stay, surgery and mortality.

RESULTS

A total of 875 patients completed the study. Recurrent bleeding occurred in 11.0% in the standard regimen group, statistically higher than that in the intensive regimen group (6.4%, P=0.02). Mean units of blood transfused and duration of hospital stay were also higher in the standard regimen group (P<0.001 for each compared to intensive regimen group). However, no significant differences were noted between the two groups in the need for endoscopic hemostasis, need for surgery, and mortality. Recurrence of bleeding was similar between the early and late endoscopy groups. Units of blood transfused and length of hospital stay were both significantly reduced with early endoscopy.

CONCLUSION

High-dose PPI infusion is more efficacious in reducing rebleeding rate, blood transfusion requirements and hospital stay. Early endoscopy is safe and more effective than late endoscopy.

Management of non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a critical condition that demands a quick and effective medical management. Non-variceal UGIB, especially peptic ulcer bleeding is the most significant cause. Appropriate assessment and treatment have a major influence on the prognosis of patients with UGIB. Initial fluids resuscitation and/or transfusion of red blood cells are necessary in patients with clinical evidence of intravascular volume depletion. Endoscopy is essential for diagnosis and treatment of UGIB, and should be provided within 24 hours after presentation of UGIB. Pre-endoscopic use of intravenous proton pump inhibitor (PPI) can downstage endoscopic signs of hemorrhage. Post-endoscopic use of high-dose intravenous PPI can reduce the risk of rebleeding and further interventions such as repeated endoscopy and surgery. Eradication of Helicobacter pylori and withdrawal of non-steroidal anti-inflammatory drugs are recommended to prevent recurrent bleeding.

Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives

Acute upper gastrointestinal bleeding (UGIB) is a gastroenterological emergency with a mortality of 6%-13%. The vast majority of these bleeds are due to peptic ulcers. Nonsteroidal anti-inflammatory drugs and Helicobacter pylori are the main risk factors for peptic ulcer disease. Endoscopy has become the mainstay for diagnosis and treatment of acute UGIB, and is recommended within 24 h of presentation. Proton pump inhibitor (PPI) administration before endoscopy can downstage the bleeding lesion and reduce the need for endoscopic therapy, but has no effect on rebleeding, mortality and need for surgery. Endoscopic therapy should be undertaken for ulcers with high-risk stigmata, to reduce the risk of rebleeding. This can be done with a variety of modalities. High-dose PPI administration after endoscopy can prevent rebleeding and reduce the need for further intervention and mortality, particularly in patients with high-risk stigmata.

Management of non-variceal upper gastrointestinal tract hemorrhage: Controversies and areas of uncertainty

Upper gastrointestinal tract hemorrhage (UGIH) remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease (PUD) has revolutionized the treatment of UGIH. Despite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor (PPI) therapy has become standard empiric treatment for UGIH given that PUD is the leading cause of non-variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. However, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patients with evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today’s medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper endoscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low-risk lesions or admission for further monitoring and treatment in higher-risk lesions. Concomitant pharmacotherapy with non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severity, and potential treatment of UGIH. Long-term PPI use in patients taking chronic NSAIDs or clopidogrel is discussed thoroughly in this review.

Management of non-variceal upper gastrointestinal tract hemorrhage: controversies and areas of uncertainty

Upper gastrointestinal tract hemorrhage (UGIH) remains a common presentation requiring urgent evaluation and treatment. Accurate assessment, appropriate intervention and apt clinical skills are needed for proper management from time of presentation to discharge. The advent of pharmacologic acid suppression, endoscopic hemostatic techniques, and recognition of Helicobacter pylori as an etiologic agent in peptic ulcer disease (PUD) has revolutionized the treatment of UGIH. Despite this, acute UGIH still carries considerable rates of morbidity and mortality. This review aims to discuss current areas of uncertainty and controversy in the management of UGIH. Neoadjuvant proton pump inhibitor (PPI) therapy has become standard empiric treatment for UGIH given that PUD is the leading cause of non-variceal UGIH, and PPIs are extremely effective at promoting ulcer healing. However, neoadjuvant PPI administration has not been shown to affect hard clinical outcomes such as rebleeding or mortality. The optimal timing of upper endoscopy in UGIH is often debated. Upon completion of volume resuscitation and hemodynamic stabilization, upper endoscopy should be performed within 24 h in all patients with evidence of UGIH for both diagnostic and therapeutic purposes. With rising healthcare cost paramount in today's medical landscape, the ability to appropriately triage UGIH patients is of increasing value. Upper endoscopy in conjunction with the clinical scenario allows for accurate decision making concerning early discharge home in low-risk lesions or admission for further monitoring and treatment in higher-risk lesions. Concomitant pharmacotherapy with non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents, such as clopidogrel, has a major impact on the etiology, severity, and potential treatment of UGIH. Long-term PPI use in patients taking chronic NSAIDs or clopidogrel is discussed thoroughly in this review.

Diagnosis and management of nonvariceal upper gastrointestinal bleeding

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.

The overall approach to the management of upper gastrointestinal bleeding

This article presents a practical overview of the approach to managing a patient presenting with nonvariceal upper gastrointestinal bleeding (NVUGIB). The authors focus on initial resuscitation and risk stratification strategies that should be used in the Emergency Department, and put into context the subsequent optimal use of pharmacologic and endoscopic therapies and postendoscopic management. It is hoped that this framework will provide the reader with a practical and evidence-based approach to the management of NVUGIB from the patient's initial presentation through to hospital discharge.

What you need to know when you prescribe a proton pump inhibitor

Ever since they were launched, proton pump inhibitors (PPIs) have been regarded as profligate prescription interventions and have become a favourite target for pharmacy advisers. Now that they are cheap, with generic omeprazole 20 mg daily costing £1.88 per month (£24.51 per annum) in the UK, it is time to ask whether this status should be reviewed, whether there are areas where the message should be reversed and whether there are any circumstances in which the extra cost of branded PPIs or combined preparations is justified. Equally, with the recognition of an extended toxicity profile, is prescribing profligacy not an economic but a safety issue?

Pharmacologic therapy for nonvariceal upper gastrointestinal bleeding

There are many clinical outcome measures for evaluation of the effectiveness of a pharmacologic agent in the management of upper gastrointestinal bleeding (UGIB). As a preemptive treatment, it should reduce the need for emergency endoscopy and endoscopic intervention, facilitate the efficient identification of the bleeding source and, hence, shorten procedure time and reduce the risk of procedure-related complications. As an effective adjunctive therapy after endoscopic hemostasis, it should reduce the incidence of recurrent bleeding and the need to repeat endoscopic hemostasis. This article provides an overview of different pharmacologic agents that have been used in the management of UGIB.