International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding
Alan N Barkun, Marc Bardou, Ernst J Kuipers, Joseph Sung, Richard H Hunt, Myriam Martel, Paul Sinclair, International Consensus Upper Gastrointestinal Bleeding Conference Group, Richard Hunt, Alan N Barkun, Marc Bardou, Ernst J Kuipers, Joseph Sung, Lars Agreus, David Armstrong, Xavier Calvet, Naoki Chiba, Livio Cipolletta, Henry Cohen, Robert Enns, Lars-Gunnar Ericsson, Ian Gralnek, Dennis Jensen, Michio Kaminishi, Fasiha Kanwal, Loren Laine, Angel Lanas, James Lau, Grigoris Leontiadis, Lars Lundell, Peter Malfertheiner, John Marshall, Janet Martin, David Metz, Paul Moayyedi, Jean-Pierre Quenot, Erik Rauws, Joseph Romagnuolo, Alaa Rostom, Brennan Spiegel, Frances Tse, Monique Van Leerdam, Christo Van Rensburg, Derek J Jones, Andres Gardeazabal, István Rácz, Pauline Lavigne, Paul Sinclair, Alan N Barkun, Marc Bardou, Ernst J Kuipers, Joseph Sung, Richard H Hunt, Myriam Martel, Paul Sinclair, International Consensus Upper Gastrointestinal Bleeding Conference Group, Richard Hunt, Alan N Barkun, Marc Bardou, Ernst J Kuipers, Joseph Sung, Lars Agreus, David Armstrong, Xavier Calvet, Naoki Chiba, Livio Cipolletta, Henry Cohen, Robert Enns, Lars-Gunnar Ericsson, Ian Gralnek, Dennis Jensen, Michio Kaminishi, Fasiha Kanwal, Loren Laine, Angel Lanas, James Lau, Grigoris Leontiadis, Lars Lundell, Peter Malfertheiner, John Marshall, Janet Martin, David Metz, Paul Moayyedi, Jean-Pierre Quenot, Erik Rauws, Joseph Romagnuolo, Alaa Rostom, Brennan Spiegel, Frances Tse, Monique Van Leerdam, Christo Van Rensburg, Derek J Jones, Andres Gardeazabal, István Rácz, Pauline Lavigne, Paul Sinclair
Abstract
Description: A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003.
Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.
Recommendations: Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.
Source: PubMed