Upper gastrointestinal bleeding (UGIB) is a common. Management of Nonvariceal Upper Gastrointestinal Bleeding UPPER GASTROINTESTINAL BLEEDING

Size: px
Start display at page:

Download "Upper gastrointestinal bleeding (UGIB) is a common. Management of Nonvariceal Upper Gastrointestinal Bleeding UPPER GASTROINTESTINAL BLEEDING"

Transcription

1 Management of Nonvariceal Upper Gastrointestinal Bleeding Case Study and Commentary, Sobia Asad Zuberi, MB, BCh, and Laura E. Targownik, MD, MSHS ABSTRACT Objective: To provide an overview of management of nonvariceal upper gastrointestinal bleeding (NVUGIB). Methods: Literature review in the context of a clinical case. Results: NVUGIB is a common condition, with approximately 30% to 50% of cases attributable to peptic ulcer disease. Endoscopy is the cornerstone of management. Comprehensive evidence-based guidelines exist to direct appropriate care for persons with NVUGIB. Adherence to these guidelines will promote the delivery of the most cost-effective care, allowing high-risk patients to receive appropriate management to reduce the risk of rebleeding and its complications and allow low-risk patients to be managed in the outpatient setting. Conclusion: Improvements in medical and endoscopic management have led to a decrease in the morbidity and mortality associated with gastrointestinal bleeding. It is hoped that further research will help better differentiate low-risk and high-risk patients and that further improvements in endoscopic techniques and post-endoscopic medical therapy may lead to a further reduction in rebleeding rates and mortality. Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency and a leading cause of mortality, with patients requiring admission to a hospital having a mortality rate of 4.5% to 8.2% [1]. It has an annual incidence of 48 to 100 cases per 100,000 adults [2 4] and poses a significant economic burden, costing the United States $2 million per year [5]. The latest research shows geographic variation in UGIB incidence and mortality [6]. UGIB is classically divided into variceal and nonvariceal bleeding (NVUGIB). A recent review article reports 80% to 90% of acute UGIB in Europe and North America as being nonvariceal in etiology [7]. Fortunately, advances in the management of NVUGIB have led to a decrease in mortality in recent years [3,4]. This review article aims to provide a brief overview of risk factors for NVUGIB, patient assessment, and pre- and post-endoscopic management. CASE STUDY Initial Presentation and History An 81-year-old man with a past medical history of type 2 diabetes mellitus, hypertension, ischemic heart disease (on aspirin), and gastroesophageal reflux disease presents to the emergency department with 2 episodes of melena. Physical Examination Blood pressure is 95/63 mm Hg and heart rate is 120 bpm. Hemoglobin has dropped from 79 g/l to 59 g/l, blood urea nitrogen is 20.1 mmol/l, and INR is 1.2. What clinical features are associated with UGIB? A retrospective analysis of risk predictors of UGIB reports the most common presenting symptom as hemetemesis (59%), followed by melena (29%) [8]. Hematochezia (passage of bright red blood per rectum) has been noted as a less common but more severe presentation of UGIB [9]. A recent review by Srygley et al [1] has shown that having a history of melena, epigastric pain, a positive nasogastric lavage, and melena on exam are strongly predictive of an UGI source, whereas finding clots in the stool is suggestive of the lower GI tract being the site of bleeding [1]. Elevation of the urea/creatinine ratio also is much more common in UGIB, with persons with a urea/creatinine ratio of 30 or greater having 7.5 times increased odds of having an upper GI bleed. Having a From the University of Manitoba, Winnipeg, Manitoba, Canada. 232 JCOM May 2013 Vol. 20, No. 5

2 CASE-BASED REVIEW normal hemoglobin also decreased the likelihood of an upper GI source by 75%. Table 1. Glasgow-Blatchford Score Admission risk marker Score What are risk factors for UGIB? Approximately 30% to 50% of NVUGIB cases can be attributed to peptic ulcer disease [7,10]. Peptic ulcer disease can have up to a 5% to 10% mortality rate, some of which may be credited to its prevalence in the geriatric population. Other causes of NVUGIB include (in order of decreasing incidence) erosive gastritis, esophagitis, Mallory- Weiss tear, malignancy, and miscellaneous (Dieulafoy s lesion, hemobilia, angiodysplasia, vasoenteric fistula, gastric antral vascular ectasia) [10]. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin (ASA) has been well documented to be a leading cause of NVUGIB [11,12]. Colonization of the gastrointestinal tract with Helicobacter pylori is another important risk factor that may eventually lead to peptic ulcer disease, which in turn may cause NVUGIB [13]. The use of anticoagulants has also shown to be a cause of NVUGIB [14]. The introduction of acid suppression therapy with proton pump inhibitors (PPIs) and proper eradication of H. pylori with triple therapy has proven to be beneficial in reducing the incidence of NVUGIB [15,16]. What are important components of preendoscopic management? Preendoscopic Treatment Pre-endoscopic treatment is an essential component of the management of NVUGIB. When patients present with signs and symptoms suggestive of any UGIB, they should be immediately resuscitated to maintain adequate blood pressure. If the patient s hemoglobin is less than or equal to 70 g/l, it is recommended that they be transfused with packed red blood cells, though transfusion at higher hemoglobin levels should probably be avoided [17]. It is often recommend to correct elevated INRs. If patients are on warfarin, their INR should be corrected with intravenous vitamin K (for those on warfarin) or replacement of fresh frozen plasma (for those with liver disease, or other coagulopathies). The use of concentrated clotting factors Blood urea nitrogen (mmol/l) Hemoglobin, male (g/l) > < Hemoglobin, female (g/l) < Systolic blood pressure (mm Hg) Others < 90 3 Pulse > Melena 1 Syncope 2 Hepatic disease 2 Cardiac disease 2 (eg, octoplex) can also be considered when coagulopathy is present and bleeding is ongoing and/or leading to hemodynamic instability [18]. However, a high INR does not warrant the need to delay endoscopic intervention if bleeding is severe [19,20]. There is also little evidence on how to best manage UGIB patients who are using the new oral factor Xa inhibiting anticoagulants, such as dagabatrin and/or rivaroxiban, as the effect of factor Xa inhibitors cannot be reversed with vitamin K or clotting factor replacement [21]. Although guidelines do not exist for patients who develop UGIB in this setting, one should proceed with urgent endoscopy if significant UGI bleeding has occurred. Risk Stratification Risk stratification is an essential component of the assessment of a patient with UGIB, both to determine which patients require a more urgent endoscopic assessment and also to better identify low-risk patients who may be able to be investigated electively. Several pre-endoscopic risk assessment tools have been created to help physicians decide whether Vol. 20, No. 5 May 2013 JCOM 233

3 Table 2. Rockall Risk Score Score Age (years)* < Shock* Systolic BP 100 Systolic BP 100 Systolic BP < 100 Heart rate < 100 Heart rate 100 Comorbidity* None Ischemic heart disease, cardiac failure, other major comorbidity Diagnosis Stigmata of hemorrhage Mallory-Weiss tear, no lesion, or no stigmata of hemorrhage None, or dark spot *These variables used to calculate pre-endoscopy risk score. All other diagnoses Malignancy of UGI tract Blood in UGI tract, adherent clot, visible or spurting vessel Renal failure, hepatic failure, disseminated malignancy or not the patient needs urgent intervention. The 2 most widely used and evaluated pre-endoscopic risk stratification scoring systems are the Glasgow-Blatchford bleeding score [22] (GBS) and the Rockall pre-endoscopic risk score [23]. Glasgow-Blatchford Score The GBS (Table 1) uses clinical and laboratory data to predict the need for blood transfusion, endoscopy, or surgery. The advantage of this scoring tool is in its simplicity, thus making it popular, even to medical students and junior residents. Using GBS, patients are classified as low risk and can be treated as outpatients if they meet the following criteria: blood urea nitrogen less than 6.5 mmol/l, hemoglobin more than 130 g/l (male) or 120 g/l (female), systolic blood pressure greater than or equal to 110 mm Hg, and pulse less than 100 beats per minute. A recent article validated the use of GBS in successfully identifying low-risk patients and therefore reducing the number of unnecessary admissions to hospital, demonstrating that a score of 0 or 1 on admission is associated with a 99% probability of not requiring an endoscopic intervention or transfusion [24]. Its main limitation is its poor specificity in identifying low risk patients, as the vast majority of persons with a GBS of 2 or greater will also not require an intervention Rockall Score Another risk stratification tool that is widely used in clinical practice is the pre-endoscopy Rockall score (Table 2). This is essentially a modified version of the Rockall scoring tool, which requires a diagnosis and endoscopy to predict the risk of rebleeding [25]. The pre-endoscopy Rockall score uses the patient s age, presence of shock and comorbidity to determine if a patient is low risk for rebleeding and death, and therefore eligible to be treated as an outpatient (similar to the GBS). However, more recent studies have reported this scoring tool as being less accurate than the GBS at predicting the need for intervention [26]. Pharmacologic Therapy Pharmacologic therapy is often used prior to performance of endoscopy in order to better prepare the upper GI tract for optimal visualization. During large UGIB episodes, parts of the stomach, especially the fundus, may be difficult to optimally evaluate due to the presence of retained blood clots. Therefore, agents that improve gastric emptying, specifically erythromycin and metoclopramide, have been evaluated in the pre-endoscopic setting in order to improve visualization of the upper GI tract. Erythromycin, given at a dose of 250 mg 20 minutes prior to endoscopy, has been shown to improve upper GI visualization compared to no therapy [27]. Metoclopramide has been less widely evaluated, but appears to also improve gastric visualization compared to placebo [28]. While pro-motility agents are not routinely recommended prior to endoscopy in UGIB, their use should be considered when large volume bleeding is suspected or when 234 JCOM May 2013 Vol. 20, No. 5

4 CASE-BASED REVIEW there are signs of ongoing bleeding and performance of endoscopy is imminent [7,29]. PPIs are also widely used prior to endoscopy. The evidence supporting the use of pre-endoscopic PPI emerged from a large trial where patients who presented with suspected UGIB were randomized to receive 80 mg IV pantoprazole, followed by an 8 mg per hour infusion or placebo [30]. It was determined that patients who received pre-endoscopic PPI therapy were less likely to require endoscopic hemostatic therapy (19.1% vs. 28.4% in the placebo group), more likely to have ulcers with clean bases (120 vs. 90 patients in the placebo group), and had shorter hospital stays. Pre-endoscopic PPI had no effects on rates of rebleeding or mortality. In spite of the lack of a demonstrable benefit on rebleeding rates, PPIs are still routinely recommended prior to endoscopy because of their relatively low cost, limited side-effect profile, and the potential to downgrade high-risk lesions may lead to cost-savings in prevented hospital admissions [31]. Case Continued The patient was resuscitated with intravenous fluids, transfused 3 units of packed red blood cells, was given 80 mg IV pantoprazole bolus, and then started on an 8 mg per hour infusion. His aspirin was held. The patient s Glasgow-Blatchford bleeding score was 10 and pre-endoscopy Rockall score was 6. What are guidelines for the use of endoscopy? Endoscopy is the cornerstone of management of patients with NVUGIB. The benefits of endoscopy are twofold. First, it allows direct visualization of the source of bleeding, providing a definitive diagnosis. Second, prognostic information of the likelihood of continued bleeding or recurrent bleeding is obtained, which may allow for more intensive therapy for persons at high risk of recurrent bleeding or UGIB-related complications as well as outpatient management of low-risk patients. Furthermore, endoscopy facilitates the delivery of direct therapeutic hemostasis, so that persons with ongoing bleeding or at high-risk of recurrent bleeding can undergo hemostatic treatment to prevent future bleeding episodes. The time frame during which to perform endoscopy is controversial. Most recent guidelines recommend that patients with NVUGIB have endoscopy within 24 hours of presentation [32,33]. A recent prospective national audit done in the UK showed a direct correlation between late endoscopy (greater than 24 hours) and increased length of hospital stay and a higher rebleeding rate [34]. Conversely, urgent endoscopy (less than 12 hours) was not associated with decrease in mortality but did show improved effectiveness of treatment, and decreased need for surgical intervention [35]. On the contrary, other retrospective analyses did not demonstrate that endoscopy within 6 hours of presentation was associated with decreased rates of mortality or the need for blood transfusions or surgery [36]. It is important to note that most patients undergoing urgent endoscopy are those with severe bleeding. Therefore, the lack of benefit seen with urgent endoscopy may be related to the patient population rather than the procedure itself. A few studies analyzed patients admitted on weekends with NVUGIB; they concluded that these patients are less like to get an endoscopy within 24 hours of presentation and are therefore associated with a higher in-hospital mortality [37,38]. In rare circumstances such as the patient having an acute coronary syndrome, it is recommended to delay endoscopy until the patient has been adequately stabilized [39]. Classification of Peptic Ulcers The main predictor of the risk of rebleeding is the appearance of the ulcer base at the time of initial endoscopy. The Forrest classification (Table 3) uses the characteristics of the lesion found on endoscopy to place patients into high-, intermediate-, or low-risk groups [40]. Forrest Ia lesions (active arterial spurting) are associated with an 85% to 100% risk of recurrent/ongoing bleeding in the absence of endoscopic hemostasis, whereas only one-quarter of Forrest 1b lesions (arterial oozing) will have recurrent bleeding. Forrest IIa (non-bleeding visible vessels) are associated with a 50% risk of recurrent bleeding if left untreated. All of these lesions should be considered for endoscopic hemostasis in order to decrease the risk of further hemorrhage. Conversely, Forrest IIc (hematin flat spot) and Forrest III (clean based) ulcers do not require application of hemostasis, as only 3% to 5% of these lesions will re-bleed [41]. Persons with Forrest IIb (adherent clots) are at intermediate risk of rebleeding, though it is recommended that clots should be removed after first injecting the surrounding tissue with 1:10000 epinephrine to determine if an underlying non-bleeding visible vessel is present [42]. Vol. 20, No. 5 May 2013 JCOM 235

5 Table 3. Forrest Classification of Peptic Ulcers Risk Grade Endoscopic Picture Rebleeding Risk High Ia Spurting hemorrhage % Intermediate Ib Oozing hemorrhage 10 27% IIa Visible vessel 50% IIb Adherent clot 30 35% Low IIc Hematin covered flat spot < 8% III No signs of hemorrhage < 3% What endoscopic treatment modalities are utilized? There are many different modalities of treatment using endoscopy. It is generally recommended that patients with Forrest Ia and IIa lesions be considered for endoscopic hemostasis [32]. Forrest IIb lesions may also require endoscopic hemostasis if a visible vessel is apparent following removal of the overlying clot. The common modes of endoscopic hemostasis include epinephrine injection, thermal coaptive coagulation, and application of mechanical clip devices [43]. Endoscopic therapy has been shown to decrease the risk of rebleeding and of mortality in patients with active arterial bleeding and those with non-bleeding visible vessels. The application of epinephrine in combination with either thermal therapy or mechanical therapy has been shown to be superior to epinephrine monotherapy [44,45]. The choice of endoscopic technique is generally left to the discretion of the endoscopist. In the event of recurrent bleeding following performance of endoscopic hemostasis, repeating endoscopy and reapplying hemostatic techniques has been shown to prevent surgery in approximately ¾ of cases [46]. Some studies have suggested that a routine second-look endoscopy may be useful even in the absence of signs of recurrent bleeding to identify occult ongoing bleeding and the continuing presence of high-risk lesions amenable to endoscopic therapy. While there is evidence that second-look endoscopy may decrease rebleeding rates, these studies come from an era where PPI therapy was not routinely used, so it is unclear whether these results are generalizable to patients in the current day [47]. Should initial hemostasis be unsuccessful or if rebleeding occurs after a second attempt at endoscopic hemostasis, the patient should receive urgent consultation with a surgeon for performance of surgical ligation of the bleeding vessel [48]. Alternatively, angiographic embolization has been shown to be effective in achieving hemostasis in patients with recurrent peptic ulcer bleeding, and can be considered if local expertise is available [49]. What is post-endoscopic management? The main goal of post-endoscopic management of NVUGIB is to determine which patients are at highest risk of rebleeding and continuing inpatient observation, preventing short-term rebleeding, and decreasing the risk of recurrent bleeding over the long term. It is now generally accepted that patients who are believed to be at low risk for recurrent bleeding should be discharged immediately following recovery from endoscopy [32]. There are several risk scores and treatment algorithms which have been used to better identify patients who are at low risk for recurrent hemorrhage [50 52]. In general, patients with lesions at low risk for rebleeding (esophagitis, Mallory-Weiss tears, and peptic ulcers without high-risk stigmata [Forrest IIc/III]) do not require admission to hospital. However, hospitalization should be considered for patients with severe concomitant comorbidities, those with poor social support, and persons who require reinitiation of anticoagulation, even if only low-risk findings are present on endoscopy Moreover, patients who are discharged may be adequately treated using oral PPIs [53]. Persons with higher-risk lesions, and thus at a higher risk of rebleeding in the short term, should be hospitalized, primarily for close observation and to allow the 236 JCOM May 2013 Vol. 20, No. 5

6 CASE-BASED REVIEW provision of IV PPI infusions. Continuous infusions of PPI are able to maintain an elevated intragastric ph, which promotes clot stability [54]. The initial evidence supporting the use of IV PPIs following endoscopy comes from the study by Lau et al [55], where persons with peptic ulcers with active bleeding or non-bleeding visible vessel were randomized to receive IV infusion of a placebo or omeprazole given as a 80-mg bolus and then 8 mg/hour infusion which was carried on for a total of 72 hours post endoscopy, followed by oral PPIs at 20 mg daily for the next 8 weeks. Subjects who received IV PPI therapy were significantly less likely to have rebleeding (7% vs. 23%) and also had shorter length of hospital stay following endoscopy. Similar findings have been reported in other studies of IV PPI for high-risk ulcers, including in North American and European populations. Because of the costs associated with IV PPI therapy, attempts have been made to look at the role of high-dose oral PPIs in reducing the risk of recurrent bleeding [56]. While there is some evidence that oral PPIs may be equally efficacious as IV PPIs [57,58], the evidence is not currently strong enough to recommend their routine use. IV H2-receptor antagonists (H2RAs) are likely ineffective for prevention of ulcer rebleeding; if IV PPIs are not available, it is preferable to substitute an oral PPI over administering an IV H2RA, as H2RAs have been proven to be ineffective in preventing recurrent bleeding. Lastly, IV PPIs are not sufficient on their own to prevent rebleeding, and are not a substitute for the performance of prompt endoscopy [59]. Following discharge, the goals of therapy are to eliminate or mediate the effects of the modifiable risk factors which are associated with the source of NVUGIB. This includes detection and treatment of H. pylori, discontinuation of ASA/NSAIDs/anticoagulants when possible, or decreasing the gastrointestinal toxicity of these agents when they cannot be discontinued. Testing for H. pylor is most commonly performed in the acute setting by obtaining gastric biopsies at the time of endoscopy, which can then be analyzed for H. pylori histologically or with rapid urease testing [32,60]. However, the false-negative rate for H. pylori has been reported to be high in the setting of an acute bleed, and repeat testing in the outpatient setting is recommended if H. pylori testing is negative, either with urea breath testing or serologic evaluation [61]. Serologic testing for H. pylori is very specific and is not affected by acute bleeding, though patients with prior H. pylori eradication may be falsely positive [62]. Eradication of H. pylori once detected is of paramount importance as those with proven H. pylori have shown up to a 20% rate of rebleeding, which drops to 2.7% if eradication is undertaken, and 1.1% if eradication is confirmed [63]. Following treatment, successful eradication should be confirmed either with urea breath testing, stool antigen testing, or via gastric biopsy. Chronic maintenance therapy with oral PPIs is not generally required following H. pylori eradication unless the patient is on chronic ASA, NSAIDs, or anticoagulation [15]. Patients using an NSAID when they developed a NVUGIB should ideally discontinue its use. However, if they need to continue for some reason, the use of COX-2 inhibitors in combination with an oral PPI has been shown to be superior to either a COX-2 inhibitor or PPI as monotherapy [64,65]. However, patients with known cardiovascular disease should not be given COX-2 inhibitors as they have been shown to increase the risk of MI [66]. In this case, continued use of an NSAID, preferably naproxen, with a PPI, is acceptable, though ideally the NSAID should be discontinued [67]. Patients who continue ASA following acute NVU- GIB have been shown to have a high rate of recurrent bleeding if there is no co-prescription of a PPI [68]. However, patients at high risk of cardiovascular disease may have an increased risk of coronary events if ASA is discontinued [69,70]. Persons with acute NVUGIB who had ASA discontinued have been shown to have a higher rate of cardiovascular-associated mortality at 8 weeks compared with those in whom ASA was continued, while recurrent gastrointestinal bleeding was nonsignificantly greater among those who continued ASA [71]. As the risk of bleeding was highest in the first few days, it seems reasonable to hold ASA for approximately 3 to 5 days following a bleeding event before restarting [72]. If the patient is on ASA for primary prevention, then it may be discontinued as evidence shows that the risk of recurrent gastrointestinal bleeding outweighs the cardiovascular benefits of continuing the medication. Clopidogrel, another antiplatelet agent used for cardioprophylaxis, has been reported to cause higher rebleeding rates than those on ASA combined with a PPI [73]. However, clopidogrel is often required for patients with recent coronary stenting and those at high risk of recurrent stroke. The bleeding risk associated with clopidogrel can be reduced through concomitant therapy with a PPI [74]. However, there is controversy as to whether PPIs may interfere with the antiplatelet effects of clopidogrel, increas- Vol. 20, No. 5 May 2013 JCOM 237

7 ing the risk of cardiovascular events [75]. The most recent data from well-designed observational trials suggests that although PPIs appear to inhibit clopidogrel action in vitro, the effect on cardiovascular outcomes is no different than those not given PPI [76,77]. Therefore, PPIs should still be used long term in persons who have a history of NVU- GIB who require chronic clopidogrel therapy. Case Continued The patient was taken for an endoscopy within 24 hours of presentation. Endoscopy revealed an ulcer in the duodenum and some old blood was seen in the stomach. The ulcer was classified as Forrest Class IIa (non-bleeding visible vessel) and endoscopic hemostasis was performed by injecting the area surrounding the ulcer with 10 cc of 1:10000 epinephrine and applying a hemostatic clip. A biopsy was taken from the antrum and body of the stomach and was sent for H. pylori testing (later came back as negative). The IV pantoprazole infusion was continued for a total of 48 hours after which the patient was started on an oral PPI. He was discharged home 2 days after endoscopy and instructed to continue taking the PPI. Aspirin was restarted a week after due to the patient s extensive cardiovascular disease. CONCLUSION NVUGIB is a common problem that health care professionals encounter every day. Comprehensive evidencebased guidelines exist to direct appropriate care for persons with NVUGIB, and it has been demonstrated that improvements in the medical and endoscopic management have led to a decrease in the morbidity and mortality associated with gastrointestinal bleeding. Adherence to these guidelines will promote the delivery of the most cost-effective care of these patients, allowing high-risk patients to receive appropriate management to reduce the risk of rebleeding and its complications, and allow low-risk patients to be managed in the outpatient setting, limiting the use of scarce healthcare resources. It is hoped that further research will help better differentiate low-risk and high-risk patients, and that further improvements in endoscopic techniques and post-endoscopic medical therapy may lead to a further reduction in rebleeding rates and mortality. Finally, greater efforts are required on the part of caregivers to better identify patients at risk of NVUGIB so that risk factors may be eliminated or their effects reduced through the preventative use of PPIs. Corresponding author: Laura E. Targownik, MD, MSHS, University of Manitoba, 805G-715 McDermot Ave., Winnipeg, MB Canada, laura.targownik@med.umanitoba.ca. Financial disclosures: Dr. Targownik has consulted for Pfizer Canada and Takeda Canada. REFERENCES 1. Srygley FD, Gerardo CJ, Tran T, et al. Does this patient have a severe upper gastrointestinal bleed? JAMA 2012;307: Lanas A, Garcia-Rodriguez LA, Polo-Tomas M, et al. Time trends and impact of upper and lower gastrointestinal bleeding and perforation in clinical practice. Am J Gastroenterol 2009;104: Laine L, Yang H, Chang SC, et al. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to Am J Gastroenterol 2012;107:1190-5; quiz Targownik LE, Nabalamba A. Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: Clin Gastroenterol Hepatol 2006;4: Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med 2008;359: Holster IL, Kuipers EJ. Management of acute nonvariceal upper gastrointestinal bleeding: current policies and future perspectives. World J Gastroenterol 2012;18: Bardou M, Benhaberou-Brun D, Le Ray I, et al. Diagnosis and management of nonvariceal upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 2012;9: Lahiff C, Shields W, Cretu I, et al. Upper gastrointestinal bleeding: predictors of risk in a mixed patient group including variceal and nonvariceal haemorrhage. Eur J Gastroenterol Hepatol 2012;24: Huang CS, Lichtenstein DR. Nonvariceal upper gastrointestinal bleeding. Gastroenterol Clin North Am 2003;32: Ferguson CB, Mitchell RM. Nonvariceal upper gastrointestinal bleeding: standard and new treatment. Gastroenterol Clin North Am 2005;34: Garcia Rodriguez LA, Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet 1994;343: Sorensen HT, Mellemkjaer L, Blot WJ, et al. Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin. Am J Gastroenterol 2000;95: DeCross AJ, Marshall BJ. The role of Helicobacter pylori in acid-peptic disease. Am J Med Sci 1993;306: Shorr RI, Ray WA, Daugherty JR, et al. Concurrent use of nonsteroidal anti-inflammatory drugs and oral anticoagulants places elderly persons at high risk for hemorrhagic peptic ulcer disease. Arch Intern Med 1993;153: Gisbert JP, Calvet X, Cosme A, et al. Long-term follow-up of 1,000 patients cured of Helicobacter pylori infection 238 JCOM May 2013 Vol. 20, No. 5

8 CASE-BASED REVIEW following an episode of peptic ulcer bleeding. Am J Gastroenterol 2012;107: Lanas A, Garcia-Rodriguez LA, Arroyo MT, et al. Effect of antisecretory drugs and nitrates on the risk of ulcer bleeding associated with nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. Am J Gastroenterol 2007;102: Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013;368: Lavenne-Pardonge E, Itegwa MA, Kalaai M, et al. Emergency reversal of oral anticoagulation through PPSB-SD: the fastest procedure in Belgium. Acta Anaesthesiol Belg 2006;57: Wolf AT, Wasan SK, Saltzman JR. Impact of anticoagulation on rebleeding following endoscopic therapy for nonvariceal upper gastrointestinal hemorrhage. Am J Gastroenterol 2007;102: Choudari CP, Rajgopal C, Palmer KR. Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment. Gut 1994;35: Harinstein LM, Morgan JW, Russo N. Treatment of Dabigatran-Associated Bleeding: Case Report and Review of the Literature. J Pharm Pract Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet 2000;356: Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;38: Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet 2009;373: Rockall TA, Logan RF, Devlin HB, et al. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ 1995;311: Stanley AJ, Dalton HR, Blatchford O, et al. Multicentre comparison of the Glasgow Blatchford and Rockall Scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage. Aliment Pharmacol Ther 2011;34: Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002;123: Barkun AN, Bardou M, Martel M, et al. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc 2010;72: Winstead NS, Wilcox CM. Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage: a cost-effectiveness analysis. Aliment Pharmacol Ther 2007;26: Lau JY, Leung WK, Wu JC, et al. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007;356: Tsoi KK, Lau JY, Sung JJ. Cost-effectiveness analysis of highdose omeprazole infusion before endoscopy for patients with upper-gi bleeding. Gastrointest Endosc 2008;67: Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152: Cooper GS, Kou TD, Wong RC. Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis. Gastrointest Endosc 2009;70: Hearnshaw SA, Logan RF, Lowe D, et al. Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit. Gut 2010;59: Lim LG, Ho KY, Chan YH, et al. Urgent endoscopy is associated with lower mortality in high-risk but not lowrisk nonvariceal upper gastrointestinal bleeding. Endoscopy 2011;43: Targownik LE, Murthy S, Keyvani L, et al. The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding. Can J Gastroenterol 2007;21: Haas JM, Gundrum JD, Rathgaber SW. Comparison of time to endoscopy and outcome between weekend/weekday hospital admissions in patients with upper GI hemorrhage. WMJ 2012;111: Ananthakrishnan AN, McGinley EL, Saeian K. Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis. Clin Gastroenterol Hepatol 2009;7: e Cappell MS, Iacovone FM, Jr. Safety and efficacy of esophagogastroduodenoscopy after myocardial infarction. Am J Med 1999;106: Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974;2: Katschinski B, Logan R, Davies J, et al. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci 1994;39: Kahi CJ, Jensen DM, Sung JJ, et al. Endoscopic therapy versus medical therapy for bleeding peptic ulcer with adherent clot: a meta-analysis. Gastroenterology 2005;129: Laine L, McQuaid KR. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol 2009;7: Marmo R, Rotondano G, Piscopo R, et al. Dual therapy versus monotherapy in the endoscopic treatment of highrisk bleeding ulcers: a meta-analysis of controlled trials. Am J Gastroenterol 2007;102: Sung JJ, Tsoi KK, Lai LH, et al. Endoscopic clipping versus injection and thermo-coagulation in the treatment of nonvariceal upper gastrointestinal bleeding: a meta-analysis. Gut 2007;56: Lau JY, Sung JJ, Lam YH, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Engl J Vol. 20, No. 5 May 2013 JCOM 239

9 Med 1999;340: El Ouali S, Barkun AN, Wyse J, et al. Is routine secondlook endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis. Gastrointest Endosc 2012;76: Smith BR, Stabile BE. Emerging trends in peptic ulcer disease and damage control surgery in the H. pylori era. Am Surg 2005;71: Wong TC, Wong KT, Chiu PW, et al. A comparison of angiographic embolization with surgery after failed endoscopic hemostasis to bleeding peptic ulcers. Gastrointest Endosc 2011;73: Longstreth GF, Feitelberg SP. Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series. Gastrointest Endosc 1998;47: Lee JG, Turnipseed S, Romano PS, et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 1999;50: Cipolletta L, Bianco MA, Rotondano G, et al. Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial. Gastrointest Endosc 2002;55: Richardson P, Hawkey CJ, Stack WA. Proton pump inhibitors. Pharmacology and rationale for use in gastrointestinal disorders. Drugs 1998;56: Ghassemi KA, Kovacs TO, Jensen DM. Gastric acid inhibition in the treatment of peptic ulcer hemorrhage. Curr Gastroenterol Rep 2009;11: Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med 2000;343: Khuroo MS, Yattoo GN, Javid G, et al. A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med 1997;336: Bajaj JS, Dua KS, Hanson K, et al. Prospective, randomized trial comparing effect of oral versus intravenous pantoprazole on rebleeding after nonvariceal upper gastrointestinal bleeding: a pilot study. Dig Dis Sci 2007;52: Yen HH, Yang CW, Su WW, et al. Oral versus intravenous proton pump inhibitors in preventing rebleeding for patients with peptic ulcer bleeding after successful endoscopic therapy. BMC Gastroenterol 2012;12: Sung JJ, Chan FK, Lau JY, et al. The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: a randomized comparison. Ann Intern Med 2003;139: Laine L, Lewin D, Naritoku W, et al. Prospective comparison of commercially available rapid urease tests for the diagnosis of Helicobacter pylori. Gastrointest Endosc 1996;44: Gisbert JP, Abraira V. Accuracy of Helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis. Am J Gastroenterol 2006;101: Feldman M, Cryer B, Lee E, et al. Role of seroconversion in confirming cure of Helicobacter pylori infection. JAMA 1998;280: Gisbert JP, Khorrami S, Carballo F, et al. H. pylori eradication therapy vs. antisecretory non-eradication therapy (with or without long-term maintenance antisecretory therapy) for the prevention of recurrent bleeding from peptic ulcer. Cochrane Database Syst Rev 2004:CD Chan FK, Wong VW, Suen BY, et al. Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial. Lancet 2007;369: Targownik LE, Metge CJ, Leung S, et al. The relative efficacies of gastroprotective strategies in chronic users of nonsteroidal anti-inflammatory drugs. Gastroenterology 2008;134: Bhatt DL, Scheiman J, Abraham NS, et al. ACCF/ACG/ AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2008;52: Trelle S, Reichenbach S, Wandel S, et al. Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis. BMJ 2011;342:c Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from longterm low-dose aspirin use. N Engl J Med 2002;346: Collet JP, Montalescot G, Blanchet B, et al. Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 2004;110: Rodriguez LA, Cea-Soriano L, Martin-Merino E, et al. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. BMJ 2011;343:d Sung JJ, Lau JY, Ching JY, et al. Continuation of low-dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med 2010;152: Sung JJ, Chan FK, Chen M, et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut 2011;60: Chan FK, Ching JY, Hung LC, et al. Clopidogrel versus aspirin and esomeprazole to prevent recurrent ulcer bleeding. N Engl J Med 2005;352: Bhatt DL, Cryer BL, Contant CF, et al. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med 2010;363: Juurlink DN, Gomes T, Ko DT, et al. A population-based study of the drug interaction between proton pump inhibitors and clopidogrel. CMAJ 2009;180: O Donoghue ML, Braunwald E, Antman EM, et al. Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials. Lancet 2009;374: Douglas I, Evans S, Hingorani A, et al. Clopidogrel and the interaction with proton pump inhibitors: A comparison between cohort and within person study designs. BMJ 2012;345:e4388. Copyright 2013 by Turner White Communications Inc., Wayne, PA. All rights reserved. 240 JCOM May 2013 Vol. 20, No. 5

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk?

A bleeding ulcer: What can the GP do? Gastrointestinal bleeding is a relatively common. How is UGI bleeding manifested? Who is at risk? Focus on CME at the University of British Columbia A bleeding ulcer: What can the GP do? By Robert Enns, MD, FRCP Gastrointestinal bleeding is a relatively common disorder affecting thousands of Canadians

More information

Improved risk assessment in upper GI bleeding

Improved risk assessment in upper GI bleeding EDITORIAL Improved risk assessment in upper GI bleeding Acute upper GI bleeding is the most common GI emergency, with a reported incidence in various epidemiological studies ranging from 50 to over 100

More information

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding

On-Call Upper GI Bleeding. Upper Gastrointestinal Bleeding On-Call Upper GI Bleeding John R Saltzman MD, FACG Director of Endoscopy Brigham and Women s Hospital Associate Professor of Medicine Harvard Medical School Upper Gastrointestinal Bleeding 300,000000 hospitalizations/year

More information

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding

ACG Clinical Guideline: Management of Patients with Ulcer Bleeding ACG Clinical Guideline: Management of Patients with Ulcer Bleeding Loren Laine, MD 1,2 and Dennis M. Jensen, MD 3 5 1 Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut,

More information

Sangrado Gastrointestinal Alto Upper GI Bleeding

Sangrado Gastrointestinal Alto Upper GI Bleeding Sangrado Gastrointestinal Alto Upper GI Bleeding Curso Internacional Retos Clinicos en la Gastroenterologia de Urgencias Asociacion Colombiana de Gastroenterologia 31 de Agosto, 2012 Pereira, Risaralda

More information

Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication

Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication Aliment Pharmacol Ther 2004; 19 (Suppl. 1): 66 70. Review article: management of peptic ulcer bleeding the roles of proton pump inhibitors and Helicobacter pylori eradication G. HOLTMANN* & C. W. HOWDEN

More information

Simon Everett. Consultant Gastroenterologist, SJUH, Leeds. if this is what greets you in the morning, you probably need to go see a doctor

Simon Everett. Consultant Gastroenterologist, SJUH, Leeds. if this is what greets you in the morning, you probably need to go see a doctor Simon Everett Consultant Gastroenterologist, SJUH, Leeds if this is what greets you in the morning, you probably need to go see a doctor Presentation Audit data and mortality NICE guidance Risk assessment

More information

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula.

Anticoagulants are a contributing factor. Other causes are Mallory-Weiss tears, AV malformations, and malignancy and aorto-enteric fistula. Upper GI Bleeding EMU2018 Dr. Walter Himmel MD Incidence: In non-cirrhotics, the commonest causes are peptic ulcer disease (50%) followed by erosive gastritis. In cirrhotic patients, variceal bleeding

More information

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015

James Irwin Gastroenterology Department Palmerston North Hospital. Acute Medicine Meeting Hutt Hospital. June 21, 2015 The Management of Acute Upper Gastrointestinal Bleeding James Irwin Gastroenterology Department Palmerston North Hospital Acute Medicine Meeting Hutt Hospital June 21, 2015 Outline Common Definitions and

More information

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital

Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding for internists? Nonthalee Pausawasdi, M.D. Faculty of Medicine Siriraj Hospital Complicated issues in GI bleeding; Survey results from internists Optimal resuscitation

More information

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore

UGI BLEED. Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore UGI BLEED Dr. KPP Abhilash Associate Professor Department of Emergency Medicine Christian Medical College, Vellore Outline UGI bleed: etiology and presentation Management: Non variceal / variceal bleed

More information

ICU Volume 14 - Issue 2 - Summer Matrix

ICU Volume 14 - Issue 2 - Summer Matrix ICU Volume 14 - Issue 2 - Summer 2014 - Matrix Upper Gastrointestinal Bleeding Authors David Osman, MD Medical Intensive Care Unit Paris-South University Hospitals Assistance Publique-Hôpitaux de Paris

More information

Acute Upper Gastro Intestinal (UGI) Bleeding

Acute Upper Gastro Intestinal (UGI) Bleeding T Acute Upper Gastro Intestinal (UGI) Bleeding University Hospitals of Leicester NHS Trust Guidelines for Management of Acute Medical Emergencies 1. Has there been a GI bleed? There are also UHL trust

More information

Scottish Medicines Consortium

Scottish Medicines Consortium Scottish Medicines Consortium esomeprazole, 40mg vial of powder for solution for intravenous injection or infusion (Nexium I.V. ) No. (578/09) AstraZeneca 09 October 2009 The Scottish Medicines Consortium

More information

Early Management of the Patient with Acute GI Bleeding

Early Management of the Patient with Acute GI Bleeding Early Management of the Patient with Acute GI Bleeding Dr Sarah Hearnshaw Consultant Gastroenterologist Newcastle upon Tyne NHS Trust Go through.. Stats Transfusion / resuscitation PPIs When to call us

More information

Antiplatelets in cardiac patients with suspected GI bleeding

Antiplatelets in cardiac patients with suspected GI bleeding Antiplatelets in cardiac patients with suspected GI bleeding Acute GI bleeding is a common major medical emergency. In the 2007 UK-wide audit, overall mortality of patients admitted with acute GI bleeding

More information

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT

UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital ABSTRACT Original Article Jewsuebpong T THAI J GASTROENTEROL 2008 Vol. 9 No. 2 May - Aug. 2008 67 UGI Bleeding: Impact and Outcome of Early Endoscopy at the Referral Community Hospital Jewsuebpong T ABSTRACT Background:

More information

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus

Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Emergency Surgery Board Department of General Surgery Rambam Health Care Campus Surgical Complications of Peptic Ulcer Disease Bleeding Case Presentation and Review of the Literature Case Presentation

More information

Clinical outcome of acute nonvariceal upper gastrointestinal bleeding after hours: the role of urgent endoscopy

Clinical outcome of acute nonvariceal upper gastrointestinal bleeding after hours: the role of urgent endoscopy ORIGINAL ARTICLE Korean J Intern Med 2016;31:470-478 Clinical outcome of acute nonvariceal upper gastrointestinal bleeding after hours: the role of urgent endoscopy Dong-Won Ahn 1,2,*, Young Soo Park 1,3,*,

More information

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist

Upper GI Bleeding. HH Tsai MD FRCP FECG Consultant Gastroenterologist Upper GI Bleeding HH Tsai MD FRCP FECG Consultant Gastroenterologist Financial Disclosures I have no financial relationship with any manufacturer or supplier of any product mentioned in this talk. GI Audits:

More information

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology

Upper gastrointestinal bleeding in children. Nguyễn Diệu Vinh, MD Department of Gastroenterology Upper gastrointestinal bleeding in children Nguyễn Diệu Vinh, MD Department of Gastroenterology INTRODUCTION Upper gastrointestinal (UGI) bleeding : arising proximal to the ligament of Treitz in the distal

More information

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient

Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient Turning off the tap: Endoscopy Blood & Guts: Transfusion and bleeding in the medical patient John Greenaway 1 Turning off the tap: Endoscopy Answer the questions Benefits and risks of endoscopy Urgency

More information

Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United States

Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United States Alimentary Pharmacology and Therapeutics Underutilization of gastroprotection for at-risk patients undergoing percutaneous coronary intervention: Spain compared with the United States R. Casado-Arroyo*,

More information

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA

When to Scope in Lower GI Bleeding: It Must Be Done Now. Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA When to Scope in Lower GI Bleeding: It Must Be Done Now Lisa L. Strate, MD, MPH Assistant Professor of Medicine University of Washington, Seattle, WA Outline Epidemiology Overview of available tests Urgent

More information

Eugenia Lauret, Jesús Herrero, Lorena Blanco, Olegario Castaño, Maria Rodriguez, Isabel Pérez, Verónica Alvarez, Adolfo Suárez, and Luis Rodrigo

Eugenia Lauret, Jesús Herrero, Lorena Blanco, Olegario Castaño, Maria Rodriguez, Isabel Pérez, Verónica Alvarez, Adolfo Suárez, and Luis Rodrigo Gastroenterology Research and ractice Volume 2013, Article ID 584540, 5 pages http://dx.doi.org/10.1155/2013/584540 Clinical Study Epidemiological Clinical Features and Evolution of Gastroduodenal Ulcer

More information

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy Gut and Liver, Vol. 3, No. 4, December 2009, pp. 266-270 original article Comparison of the Effectiveness of Interventional Endoscopy in Bleeding Peptic Ulcer Disease according to the Timing of Endoscopy

More information

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital

Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital Original Article on Endoscopic Therapy Page 1 of 7 Management for non-variceal upper gastrointestinal bleeding in elderly patients: the experience of a tertiary university hospital Koichiro Kawaguchi,

More information

Bleeds in Cardiovascular Disease

Bleeds in Cardiovascular Disease Preventing Gastrointestinal Bleeds in Cardiovascular Disease Patients t on Aspirin i Joel C. Marrs, Pharm.D., BCPS Clinical Assistant Professor OSU/OHSU College of Pharmacy Pharmacy Practice IX (PHAR 766)

More information

Peptic ulcer bleeding remains the most common cause of hospitalization

Peptic ulcer bleeding remains the most common cause of hospitalization CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:311 316 Predicting Mortality in Patients With Bleeding Peptic Ulcers After Therapeutic Endoscopy PHILIP W. Y. CHIU,* ENDERS K. W. NG,* FRANCES K. Y. CHEUNG,*

More information

Gastrointestinal bleeding, the most common cause of hospitalization

Gastrointestinal bleeding, the most common cause of hospitalization The new england journal of medicine Clinical Practice Caren G. Solomon, M.D., M.P.H., Editor Upper Gastrointestinal Bleeding Due to a Peptic Ulcer Loren Laine, M.D. This Journal feature begins with a case

More information

Gastrointestinal Hemorrhage

Gastrointestinal Hemorrhage Gastrointestinal Hemorrhage Quality Measures Length of Stay RCC Costs per Case Mortality Rate Eligible Readmission Within 30 Days. Critical Event(s) Evaluation Phase/Acute Phase Baseline pain assessment

More information

New Techniques. Incidence of Peptic Ulcer. Changing. Contents - with an emphasis on peptic ulcer bleeding. Cause of death in peptic ulcer bleeding

New Techniques. Incidence of Peptic Ulcer. Changing. Contents - with an emphasis on peptic ulcer bleeding. Cause of death in peptic ulcer bleeding Contents - with an emphasis on peptic ulcer bleeding New Techniques in Treating GI Bleeding Incidence and cause of death Acid suppression Endoscopic hemostasis Prediction of rebleeding and death Second

More information

Management of acute upper gastrointestinal bleeding

Management of acute upper gastrointestinal bleeding 1 Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow G4 OSF, UK 2 Section of Digestive Diseases, Yale School of Medicine, New Haven, and VA Connecticut Healthcare System, West Haven, Connecticut,

More information

Digestive and Liver Disease

Digestive and Liver Disease Digestive and Liver Disease 46 (2014) 313 317 Contents lists available at ScienceDirect Digestive and Liver Disease jou rnal h om epage: www.elsevier.com/locate/dld Alimentary Tract Time trends and outcome

More information

Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY

Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY Lower GI bleeding Management DR EHSANI PROFESSOR IN GASTROENTEROLOGY AND HEPATOLOGY 15 FEB 2018 Sources Sources Sources Initial evaluation History Physical examination Laboratory evaluation Obtained at

More information

Acute Upper Gastrointestinal Hemorrhage Surgical Perspective. Dr.J.H.Barnard Dept. of Surgery PAH

Acute Upper Gastrointestinal Hemorrhage Surgical Perspective. Dr.J.H.Barnard Dept. of Surgery PAH Acute Upper Gastrointestinal Hemorrhage Surgical Perspective Dr.J.H.Barnard Dept. of Surgery PAH Introduction: AGH is a leading cause of admissions into ICU. Overall mortality 5-12%, but increases to 40%

More information

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease

Helicobacter pylori. Objectives. Upper Gastrointestinal Bleeding Peptic Ulcer Disease Upper Gastrointestinal Bleeding Peptic Ulcer Disease Pharmacotherapy Issues in Acute Management and Secondary Prevention Peter J. Zed, B.Sc., B.Sc.(Pharm), Pharm.D. Pharmacotherapeutic Specialist - Emergency

More information

Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding

Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding Gastrointestinal Tract Risk factors of the rebleeding according to the patterns of nonvariceal upper gastrointestinal bleeding Ji Hyung Nam 1, Tae Joo Jeon 2, Jae Hee Cho 3, Jae Hak Kim 1 1 Department

More information

Supplementary appendix

Supplementary appendix Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Oakland K, Jairath V, Uberoi R, et al. Derivation

More information

Original Article INTRODUCTION

Original Article INTRODUCTION Original Article Endoscopic treatment for high risk bleeding peptic ulcers: A randomized, controlled trial of epinephrine alone with epinephrine plus fresh Mahsa Khodadoostan, Mohammad Karami Horestani,

More information

Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding

Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding Joseph J Y Sung, 1 Francis K L Chan, 2 Minhu Chen, 3 Jessica Y L Ching, 3 K Y Ho, 4 Udom Kachintorn, 3 Nayoung Kim,

More information

Upper Gastrointestinal Bleeding Score for Differentiating Variceal and Nonvariceal Upper Gastrointestinal Bleeding ABSTRACT

Upper Gastrointestinal Bleeding Score for Differentiating Variceal and Nonvariceal Upper Gastrointestinal Bleeding ABSTRACT 44 Original Article Upper Gastrointestinal Bleeding Score for Differentiating Variceal and Jaroon Chasawat Varayu Prachayakul Supot Pongprasobchai ABSTRACT Background: Upper gastrointestinal bleeding (UGIB)

More information

Upper Gastrointestinal Bleeding and the Importance of an Early Endoscopic Study for Diagnosis: A Retrospective Study

Upper Gastrointestinal Bleeding and the Importance of an Early Endoscopic Study for Diagnosis: A Retrospective Study Case Report imedpub Journals http://www.imedpub.com/ Medical Case Reports DOI: 10.21767/2471-8041.100062 Upper Gastrointestinal Bleeding and the Importance of an Early Endoscopic Study for Diagnosis: A

More information

Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results of a Nationwide Inquiry in Hungary

Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results of a Nationwide Inquiry in Hungary Gastroenterology Research and Practice Volume 2012, Article ID 956434, 6 pages doi:10.1155/2012/956434 Research Article Management of Peptic Ulcer Bleeding in Different Case Volume Workplaces: Results

More information

Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal

Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal ORIGINAL ARTICLE Korean J Intern Med 2019;34:288-295 Predictors for the need for endoscopic therapy in patients with presumed acute upper gastrointestinal bleeding Su Sun Kim, Kyung Up Kim, Sung Jun Kim,

More information

MANAGEMENT OF NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING: A REVIEW

MANAGEMENT OF NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING: A REVIEW MANAGEMENT OF NON-VARICEAL UPPER GASTROINTESTINAL BLEEDING: A REVIEW Dr. Laxmi Narayan Goit 1 * and Prof. Dr. Yang Shaning 2 1Department of Cardiology, the first affiliated Hospital of Yangtze University,

More information

ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding

ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding ACG Clinical Guideline: Management of Patients with Acute Lower Gastrointestinal Bleeding Lisa L. Strate, MD, MPH, FACG 1 and Ian M. Gralnek, MD, MSHS 2 1 Division of Gastroenterology, University of Washington

More information

Peptic ulcers remain the most common cause of upper

Peptic ulcers remain the most common cause of upper CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:33 47 STATE OF THE ART Endoscopic Therapy for Bleeding Ulcers: An Evidence-Based Approach Based on Meta-Analyses of Randomized Controlled Trials LOREN LAINE*

More information

Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding

Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding ORIGINAL ARTICLE Korean J Intern Med 2016;31:54-64 Predictive factors of mortality within 30 days in patients with nonvariceal upper gastrointestinal bleeding Yoo Jin Lee 1,*, Bo Ram Min 1,*, Eun Soo Kim

More information

Acute Gastrointestinal Haemorrhage. Dr Reena Sidhu Consultant Gastroenterologist Hon Sen Lecturer University of Sheffield

Acute Gastrointestinal Haemorrhage. Dr Reena Sidhu Consultant Gastroenterologist Hon Sen Lecturer University of Sheffield Acute Gastrointestinal Haemorrhage Dr Reena Sidhu Consultant Gastroenterologist Hon Sen Lecturer University of Sheffield Scope of Talk Introduction Upper GI haemorrhage-non variceal - Pathology/ risk stratification/management

More information

Risk assessment in UGIB: recent PCI & ACS. Dr Martin James PhD FRCP October 20 th 2016 Nottingham Endoscopy Masterclass

Risk assessment in UGIB: recent PCI & ACS. Dr Martin James PhD FRCP October 20 th 2016 Nottingham Endoscopy Masterclass Risk assessment in UGIB: recent PCI & ACS Dr Martin James PhD FRCP October 20 th 2016 Nottingham Endoscopy Masterclass Clinical scenario 65 yr male Previous smoker, hyperlipidaemia, DM PCI < 48 hours Dual

More information

Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial

Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical trial Aliment Pharmacol Ther 2003; 17: 211 216. doi: 10.1046/j.0269-2813.2003.01416.x Effect of oral omeprazole in reducing re-bleeding in bleeding peptic ulcers: a prospective, double-blind, randomized, clinical

More information

Guidelines for the Management of Upper gastrointestinal bleeding

Guidelines for the Management of Upper gastrointestinal bleeding Guidelines for the Management of Upper gastrointestinal bleeding By Dr. Sinan Butrus F.I.C.M.S Clinical Standards & Guidelines Kurdistan Board For Medical Specialties Upper gastrointestinal bleeding is

More information

Risk of GI Bleeding and Use of PPIs

Risk of GI Bleeding and Use of PPIs Risk of GI Bleeding and Use of PPIs ESC 211 August 28, 211 Marc S. Sabatine, MD, MPH Chairman, TIMI Study Group Associate Physician, Cardiovascular Division, BWH Associate Professor of Medicine, Harvard

More information

Outcome of Upper Gastrointestinal Hemorrhage According to the BLEED Risk Classification: a Two-year Prospective Survey

Outcome of Upper Gastrointestinal Hemorrhage According to the BLEED Risk Classification: a Two-year Prospective Survey Bahrain Medical Bulletin, Vol. 29, No. 1, March 2007 Outcome of Upper Gastrointestinal Hemorrhage According to the BLEED Risk Classification: a Two-year Prospective Survey Javad Salimi, MD* Ahmad Salimzadeh,

More information

British Society of Gastroenterology. St. Elsewhere's Hospital. National Comparative Audit of Blood Transfusion

British Society of Gastroenterology. St. Elsewhere's Hospital. National Comparative Audit of Blood Transfusion British Society of Gastroenterology UK Com parat ive Audit of Upper Gast roint est inal Bleeding and t he Use of Blood Transfusion Extract December 2007 St. Elsewhere's Hospital National Comparative Audit

More information

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami

COPYRIGHTED MATERIAL. 1 Approach to the patient with gross gastrointestinal bleeding. Grace H. Elta, Mimi Takami 1 Approach to the patient with gross gastrointestinal bleeding Grace H. Elta, Mimi Takami Gastrointestinal (GI) bleeding is a common clinical problem that requires more than 300 000 hospitalizations annually

More information

Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy

Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful endoscopic therapy Yen et al. BMC Gastroenterology 2012, 12:66 RESEARCH ARTICLE Open Access Oral versus intravenous proton pump inhibitors in preventing re-bleeding for patients with peptic ulcer bleeding after successful

More information

Assessment of short term prognosis in patients with upper gastrointestinal bleeding

Assessment of short term prognosis in patients with upper gastrointestinal bleeding Medical Communication Biosci. Biotech. Res. Comm. 10(3): 341-345 (2017) Assessment of short term prognosis in patients with upper gastrointestinal bleeding Saeid Hashemieh (MD) 1, Ramtin Moradi (MD) 2,

More information

Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers

Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers Intragastric ph With Oral vs Intravenous Bolus Plus Infusion Proton- Pump Inhibitor Therapy in Patients With Bleeding Ulcers LOREN LAINE, ABBID SHAH, and SHAHROOZ BEMANIAN Division of Gastrointestinal

More information

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT

ACUTE UPPER GASTROINTESTINAL HEMORRHAGE: PHARMACOLOGIC MANAGEMENT DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care

More information

Endoscopic Management of Tumor Bleeding from Inoperable Gastric Cancer

Endoscopic Management of Tumor Bleeding from Inoperable Gastric Cancer FOCUSED REVIEW SERIES: Endoscopic Management of Upper Gastrointestinal Bleeding Clin Endosc 2015;48:121-127 Print ISSN 2234-2400 / On-line ISSN 2234-2443 http://dx.doi.org/10.5946/ce.2015.48.2.121 Open

More information

SELECTED ABSTRACTS. Figure. Risk Stratification Matrix A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY

SELECTED ABSTRACTS. Figure. Risk Stratification Matrix A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY SELECTED ABSTRACTS A CLINICIAN S GUIDE TO THE SELECTION OF NSAID THERAPY The authors of this article present a 4-quadrant matrix based on 2 key clinical parameters: risk for adverse gastrointestinal (GI)

More information

Application of Forrest Classifiction in the Risk Assessment and Prediction of Rebleeding in Patients with Bleeding Peptic Ulcer in Ado-Ekiti, Nigeria

Application of Forrest Classifiction in the Risk Assessment and Prediction of Rebleeding in Patients with Bleeding Peptic Ulcer in Ado-Ekiti, Nigeria American Journal of Medicine and Medical Sciences 214, 4(4): 18-113 DOI: 1.5923/j.ajmms.21444.2 Application of Forrest Classifiction in the Risk Assessment and Prediction of Rebleeding in Patients with

More information

Juan G Martínez-Cara, Rita Jiménez-Rosales, Margarita Úbeda-Muñoz, Mercedes López de Hierro, Javier de Teresa and Eduardo Redondo-Cerezo.

Juan G Martínez-Cara, Rita Jiménez-Rosales, Margarita Úbeda-Muñoz, Mercedes López de Hierro, Javier de Teresa and Eduardo Redondo-Cerezo. Original Article Comparison of AIMS65, Glasgow Blatchford score, and Rockall score in a European series of patients with upper gastrointestinal bleeding: performance when predicting in-hospital and delayed

More information

Systematic Review of the Predictors of Recurrent Hemorrhage After Endoscopic Hemostatic Therapy for Bleeding Peptic Ulcers

Systematic Review of the Predictors of Recurrent Hemorrhage After Endoscopic Hemostatic Therapy for Bleeding Peptic Ulcers American Journal of Gastroenterology ISSN 0002-9270 C 2008 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2008.02070.x Published by Blackwell Publishing CLINICAL REVIEWS Systematic Review of

More information

Review Article The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding

Review Article The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding Ulcers Volume 2012, Article ID 361425, 8 pages doi:10.1155/2012/361425 Review Article The Acute Management of Nonvariceal Upper Gastrointestinal Bleeding Hisham AL Dhahab and Alan Barkun Department of

More information

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE

NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE SCOPE NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE 1 Guideline title SCOPE Gastrointestinal bleeding: the management of acute upper gastrointestinal bleeding 1.1 Short title Acute upper GI bleeding

More information

Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding

Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding ISSN: 2347-3215 Volume 2 Number 7 (July-2014) pp. 203-208 www.ijcrar.com Efficacy of dual therapy (APC & Adrenaline) in high risk peptic ulcer bleeding Saleh Azad Bakht*, Manouchehr Khoshbaten, Kamal Bostani,

More information

Early Management of the Patient with Acute GI Bleeding

Early Management of the Patient with Acute GI Bleeding Early Management of the Patient with Acute GI Bleeding Dr Sarah Hearnshaw Consultant Gastroenterologist Newcastle upon Tyne NHS Trust Go through.. Transfusion / resuscitation Anticoagulants new and old..

More information

NON-VARICEAL UGIB. Clinical Practice from Bench to Bedside Is there a great divide?? MARCELIANO T. AQUINO JR. MD FPCP, FPSG, FPSDE

NON-VARICEAL UGIB. Clinical Practice from Bench to Bedside Is there a great divide?? MARCELIANO T. AQUINO JR. MD FPCP, FPSG, FPSDE NON-VARICEAL UGIB Clinical Practice from Bench to Bedside Is there a great divide?? MARCELIANO T. AQUINO JR. MD FPCP, FPSG, FPSDE OBJECTIVE To compare and correlate the bedside clinical practice of Filipino

More information

Clinical guideline Published: 13 June 2012 nice.org.uk/guidance/cg141

Clinical guideline Published: 13 June 2012 nice.org.uk/guidance/cg141 Acute upper gastrointestinal bleeding in over 16s: management Clinical guideline Published: June 2012 nice.org.uk/guidance/cg141 NICE 2018. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).

More information

PEPTIC ULCER DISEASE JOHN R SALTZMAN, MD. Director of Endoscopy Brigham and Women s Hospital Professor of Medicine Harvard Medical School

PEPTIC ULCER DISEASE JOHN R SALTZMAN, MD. Director of Endoscopy Brigham and Women s Hospital Professor of Medicine Harvard Medical School PEPTIC ULCER DISEASE JOHN R SALTZMAN, MD Director of Endoscopy Brigham and Women s Hospital Professor of Medicine Harvard Medical School No disclosures Disclosures Overview Causes of peptic ulcer disease

More information

Mitigating GI Risks Associated with the Use of NSAIDs

Mitigating GI Risks Associated with the Use of NSAIDs bs_bs_banner Pain Medicine 2013; 14: S18 S22 Wiley Periodicals, Inc. Mitigating GI Risks Associated with the Use of NSAIDs Mahnaz Momeni, MD,* and James D. Katz, MD Departments of *Rheumatology, Medicine,

More information

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage

Clinical Application of AIMS65 Scores to Predict Outcomes in Patients with Upper Gastrointestinal Hemorrhage ORIGINAL ARTICLE Clin Endosc 2015;48:380-384 http://dx.doi.org/10.5946/ce.2015.48.5.380 Print ISSN 2234-2400 On-line ISSN 2234-2443 Open Access Clinical Application of AIMS65 Scores to Predict Outcomes

More information

Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage

Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage Alimentary Pharmacology and Therapeutics Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage A. J. Stanley*,

More information

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy

Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Original article Hemostatic powder application for control of acute upper gastrointestinal bleeding in patients with gastric malignancy Authors Yeong Jin Kim, Jun Chul Park, Eun Hye Kim, Sung Kwan Shin,

More information

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP

Proton Pump Inhibitors- Questions & Controversies. Farah Kablaoui, PharmD, BCPS, BCCCP Proton Pump Inhibitors- Questions & Controversies Farah Kablaoui, PharmD, BCPS, BCCCP Disclosure Information Proton Pump Inhibitors: Questions & Controversies Farah Kablaoui I have no financial relationship

More information

Continuation of Low-Dose Aspirin Therapy with Either PR or PO Administration in Patients with Peptic Ulcer Bleeding

Continuation of Low-Dose Aspirin Therapy with Either PR or PO Administration in Patients with Peptic Ulcer Bleeding Continuation of Low-Dose Aspirin Therapy with Either PR or PO Administration in Patients with Peptic Ulcer Bleeding IRB Protocol Lucian Iancovici February 4, 2010 A. Study Design and Purpose Aspirin has

More information

Clinical and Endoscopic Features of Peptic Ulcer Bleeding in Malaysia

Clinical and Endoscopic Features of Peptic Ulcer Bleeding in Malaysia Clinical and Endoscopic Features of Peptic Ulcer Bleeding in Malaysia * P Kandasami, FRCS, ** K Harjit, FRCS, *** H Hanafiah, FRCS * Department of Surgery, International Medical University, ** Department

More information

Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding

Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding ORIGINAL INVESTIGATION Simple Clinical Predictors May Obviate Urgent Endoscopy in Selected Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding Joseph Romagnuolo, MScEpid, MD, FRCPC; Alan N.

More information

Retrospective evaluation of the rockall risk scoring system in patients with nonvariceal upper gastrointestinal hemorrhage at a community hospital

Retrospective evaluation of the rockall risk scoring system in patients with nonvariceal upper gastrointestinal hemorrhage at a community hospital Eastern Michigan University DigitalCommons@EMU Master's Theses and Doctoral Dissertations Master's Theses, and Doctoral Dissertations, and Graduate Capstone Projects 2006 Retrospective evaluation of the

More information

Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU

Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU Stressed Out: Evaluating the Need for Stress Ulcer Prophylaxis in the ICU Josh Arnold, PharmD PGY1 Pharmacy Resident Pharmacy Grand Rounds November 8, 2016 2016 MFMER slide-1 Objectives Identify the significance

More information

GASTROINESTINAL BLEEDING. Dr.Ammar I. Abdul-Latif

GASTROINESTINAL BLEEDING. Dr.Ammar I. Abdul-Latif GASTROINESTINAL BLEEDING Dr.Ammar I. Abdul-Latif CLASSIFICATION OF G.I.BLEEDING GIB Appearance Acuity Site Apparent Acute Upper Obscure Chronic Lower UPPER&LOWER G.I.BLEEDING CAUSES OF UPPER G.I. BLEEDING

More information

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

Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (Review) Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, Moayyedi P This

More information

Peptic ulcer bleeding patients with Rockall scores 6 are at risk of long-term ulcer rebleeding: A 3.5-year prospective longitudinal study

Peptic ulcer bleeding patients with Rockall scores 6 are at risk of long-term ulcer rebleeding: A 3.5-year prospective longitudinal study bs_bs_banner doi:10.1111/jgh.13822 GASTROENTEROLOGY Peptic ulcer bleeding patients with Rockall scores 6 are at risk of long-term ulcer rebleeding: A 3.5-year prospective longitudinal study Er-Hsiang Yang,*,,1

More information

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding

Endoclips vs large or small-volume epinephrine in peptic ulcer recurrent bleeding Online Submissions: http://www.wjgnet.com/1007-9327office wjg@wjgnet.com doi:10.3748/wjg.v18.i18.2219 World J Gastroenterol 2012 May 14; 18(18): 2219-2224 ISSN 1007-9327 (print) ISSN 2219-2840 (online)

More information

Lei Gu 1, Fei Xu 2,3 and Jie Yuan 1*

Lei Gu 1, Fei Xu 2,3 and Jie Yuan 1* Gu et al. BMC Gastroenterology (2018) 18:98 https://doi.org/10.1186/s12876-018-0828-5 RESEARCH ARTICLE Open Access Comparison of AIMS65, Glasgow Blatchford and Rockall scoring approaches in predicting

More information

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic. bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published.

More information

T he aim of a scheduled second endoscopy is to detect and

T he aim of a scheduled second endoscopy is to detect and 1403 STOMACH Effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomised trial P W Y Chiu, C Y W Lam, S W Lee, K H Kwong, S H Lam, D T Y Lee, S P Y Kwok... See

More information

Erythromycin infusion prior to endoscopy for acute nonvariceal upper gastrointestinal bleeding: a pilot randomized controlled trial

Erythromycin infusion prior to endoscopy for acute nonvariceal upper gastrointestinal bleeding: a pilot randomized controlled trial ORIGINAL ARTICLE Korean J Intern Med 2017;32:1002-1009 https://doi.org/10.3904/kjim.2016.117 Erythromycin infusion prior to endoscopy for acute nonvariceal upper gastrointestinal bleeding: a pilot randomized

More information

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding

Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding Review Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding Y. Lu 1, R. Loffroy 3,J.Y.W.Lau 4 and A. Barkun 1,2 1 Division of Gastroenterology and 2 Department

More information

UPPER GASTROINTESTINAL BLEEDING STATE OF THE ART

UPPER GASTROINTESTINAL BLEEDING STATE OF THE ART FOLIA MEDICA CRACOVIENSIA Vol. LIV, 4, 2014: 59 78 PL ISSN 0015-5616 59 Mirosław Szura 1, Artur Pasternak 1,2 UPPER GASTROINTESTINAL BLEEDING STATE OF THE ART Abstract: Upper gastrointestinal (GI) bleeding

More information

AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING

AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING American Society For Gastrointestinal Endoscopy AN ANNOTATED ALGORITHMIC APPROACH TO UPPER GASTROINTESTINAL BLEEDING Algorithms for appropriate utilization of endoscopy are based on a critical review of

More information

A cute upper gastrointestinal haemorrhage is

A cute upper gastrointestinal haemorrhage is 399 BEST PRACTICE Management of haematemesis and melaena K Palmer... Acute upper gastrointestinal bleeding is a common medical emergency which carries hospital mortality in excess of 10%. The most important

More information

Definitive Surgical Treatment When Endoscopy Fails. Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept.

Definitive Surgical Treatment When Endoscopy Fails. Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept. Nonvariceal Gastrointestinal Hemorrhage: Definitive Surgical Treatment When Endoscopy Fails Erik Peltz D.O. Resident Debate February 26 th 2007 University of Colorado Dept. Surgery Non-Variceal Upper GI

More information

Research Article Outcome of Holiday and Nonholiday Admission Patients with Acute Peptic Ulcer Bleeding: A Real-World Report from Southern Taiwan

Research Article Outcome of Holiday and Nonholiday Admission Patients with Acute Peptic Ulcer Bleeding: A Real-World Report from Southern Taiwan BioMed Research International, Article ID 906531, 6 pages http://dx.doi.org/10.1155/2014/906531 Research Article Outcome of Holiday and Nonholiday Admission Patients with Acute Peptic Ulcer Bleeding: A

More information

Upper gastrointestinal (GI) bleeding represents a substantial

Upper gastrointestinal (GI) bleeding represents a substantial Clinical Guidelines Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall, MD, MSc, for the Nonvariceal

More information

MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE

MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE MANAGING GI BLEEDING IN A COMMUNITY HOSPITAL SETTING DR M. F. M. BRULE DISCLOSURES Presenter: Dr Michele Brule Relationships with commercial interests: None OBJECTIVES Assess the severity of GI bleeding

More information

Nothing to disclose. Annually ~ 300,000 hospitalizations and ~ 20,000 deaths in US*

Nothing to disclose. Annually ~ 300,000 hospitalizations and ~ 20,000 deaths in US* Gastrointestinal Bleeding Disclosures Nothing to disclose Bennie Ray Upchurch III, MD, FACP, FASGE Clinical Associate Professor of Medicine Division of Gastroenterology, Hepatology & Nutrition The Ohio

More information