Guidelines for Nonvariceal Upper GI Bleeding

Written by Clay Smith

Spoon Feed
These guidelines for nonvariceal upper GI bleeding are important for us to know from start to finish.

Why does the matter?
This is an update of similar guidelines from 2010. We need to know all aspects of management, including endoscopic management, to understand their individual risk when they bounce back to the ED after hospital discharge.

Turn off the hose
These guidelines were based on the best available evidence from extensive literature review and recommendation of a multidisciplinary panel.

Preendoscopic management

• Resuscitation should be initiated in patients with hemodynamic instability. Did they really need to say this?

• A Glasgow Blatchford score of ≤1 may allow for safe discharge home.

• They determined the transfusion trigger for patients without cardiovascular disease should be 8 g/dL; higher in patients with CV disease.

• Endoscopy should not be delayed for anticoagulated patients.

• Promotility agents should be used to improve endoscopic yield.

• If endoscopy finds low risk features, patients may be discharged home right away.

• PPIs may be used pre-endoscopy to “downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy.”

Endoscopic management

• Endoscopy should occur within 24 hours.

• It should be done with thermocoagulation, sclerosant, or clips. Clips are used only if high risk stimata, i.e. active bleeding or visible vessel in ulcer base.

• TC-325 can temporize when other endoscopic methods fail. It is also called Hemospray and is a mineral based compound that coheres and adheres when wet, which promotes clotting. It should not be used as the sole bleeding control method.

Post-endoscopy

• H2 blockers should not be used for active bleeding.

• Somatostatin/octreotide are not recommended for nonvariceal bleeds.

• For high risk stigmata on endoscopy, IV PPI loading and infusion are indicated.

• An ulcer requiring endoscopic therapy should get twice daily PPI oral treatment for 2 weeks, then daily.

Hospital management

• Patients may eat 24h after endoscopy.

• Most patients with high risk stigmata should stay in the hospital for 72 hours at least.

• Embolization or surgery are options after failed endoscopy.

Prevention

• Patients with prior bleeding ulcer who need an NSAID should get a COX-2 inhibitor + a PPI.

• Aspirin or anticoagulants for CV disease may be restarted as soon as benefit outweighs risk but should be given with a PPI.

Source
Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Ann Intern Med. 2019 Oct 22. doi: 10.7326/M19-1795. [Epub ahead of print]

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