This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and ...presents new clinically relevant recommendations.
An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.
Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
Background Despite major advances in upper GI hemorrhage (UGIH) treatment, UGIH mortality has been reported as unchanged for the past 50 years. Objective To measure the UGIH in-hospital mortality ...rate and other important outcome trends from 1989 to 2009. Design A longitudinal study of UGIH hospitalizations by using the Nationwide Inpatient Sample. Setting Acute-care hospitals. Patients All patients admitted for UGIH. Patients who bled after admission were excluded. Main Outcome Measurements UGIH in-hospital mortality rate, incidence, in-hospital endoscopy and endoscopic therapy rates, length of hospital stay, and total in-hospital charges. Results The non-variceal UGIH mortality rate decreased from 4.5% in 1989 to 2.1% in 2009. The non-variceal UGIH incidence declined from 108 to 78 cases/100,000 persons in 1994 and 2009, respectively. In-hospital upper endoscopy and endoscopic therapy rates increased from 70% and 10% in 1989 to 85% and 27% in 2009, respectively. The early endoscopy rate increased from 36% in 1989 to 54% in 2009. The median length of hospital stay decreased from 4.5 days in 1989 to 2.8 days in 2009. Median total hospitalization charges increased from $9249 in 1989 to $20,370 in 2009. At the national level, the UGIH direct in-hospital economic burden increased from $3.3 billion in 1989 to $7.6 billion in 2009. Similar trends were found for variceal UGIH. Limitations Retrospective data, administrative database. Conclusion In-hospital mortality from UGIH has been decreasing over the past 2 decades, with a concomitant increase in rate of endoscopy and endoscopic therapy. However, despite decreasing length of stay, the total economic burden of UGIH is increasing.
We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal ...bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.
Background Although the early use of a risk stratification score in upper GI bleeding is recommended, existing risk scores are not widely used in clinical practice. Objective We sought to develop and ...validate an easily calculated bedside risk score, AIMS65, by using data routinely available at initial evaluation. Design Data from patients admitted from the emergency department with acute upper GI bleeding were extracted from a database containing information from 187 U.S. hospitals. Recursive partitioning was applied to derive a risk score for in-hospital mortality by using data from 2004 to 2005 in 29,222 patients. The score was validated by using data from 2006 to 2007 in 32,504 patients. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Main Outcome Measurements Mortality, length of stay (LOS), and cost of admission. Results The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years. For those with no risk factors, the mortality rate was 0.3% compared with 31.8% in patients with all 5 ( P < .001). The model had a high predictive accuracy (AUROC = 0.80; 95% CI, 0.78-0.81), which was confirmed in the validation cohort (AUROC = 0.77, 95% CI, 0.75-0.79). Longer LOS and increased costs were seen with higher scores ( P < .001). Limitations Database data used does not include outcomes such as rebleeding. Conclusions AIMS65 is a simple, accurate risk score that predicts in-hospital mortality, LOS, and cost in patients with acute upper GI bleeding.
The role of endoscopy in inflammatory bowel disease Shergill, Amandeep K., MD; Lightdale, Jenifer R., MD, MPH; Bruining, David H., MD ...
Gastrointestinal endoscopy,
05/2015, Letnik:
81, Številka:
5
Journal Article
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