Management of nonvariceal upper gastrointestinal bleeding

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Abstract

Nonvariceal upper gastrointestinal bleeding is unique from variceal bleeding in terms of patient characteristics, management, rebleeding rates, and prognosis, and should be managed differently. The majority of nonvariceal upper gastrointestinal bleeds will not rebleed once treated successfully. The incidence is 80 to 90% of all upper gastrointestinal bleeds and the mortality is between 5 to 10%. The causes include nonacid-related ulceration from tumors, infections, inflammatory disease, Mallory-Weiss tears, erosions, esophagitis, dieulafoy lesions, angiodysplasias, gastric antral vascular ectasia, and portal hypertensive gastropathy. Rarer causes include hemobilia, hemosuccus pancreaticus, and aortoenteric fistulas. Hematemesis and melena are the key features of bleeding from the upper gastrointestinal tract, but fresh per rectal bleeding may be present in a rapidly bleeding lesion. Resuscitation and stabilization before endoscopy leads to improved outcomes. Fluid resuscitation is essential to avoid hypotension. Though widely practiced, there is currently insufficient evidence to show that routine red cell transfusion is beneficial. Coagulopathy requires correction, but the optimal international normalized ratio has not been determined yet. Risk stratification scores such as the Rockall and Glasgow-Blatchford scores are useful to predict rebleeding, mortality, and to determine the urgency of endoscopy. Evidence suggests that high-dose proton pump inhibitors (PPI) should be given as an infusion before endoscopy. If patients are intolerant of PPIs, histamine-2 receptor antagonists can be given, although their acid suppression is inferior. Endoscopic therapy includes thermal methods such as coaptive coagulation, argon plasma coagulation, and hemostatic clips. Four quadrant epinephrine injections combined with either thermal therapy or clipping reduces mortality. In hypoxic patients, endoscopy masks allow high-flow oxygen during upper gastrointestinal endoscopy. The risk of rebleeding reduces after 72 hours. In rebleeding, repeat endoscopy is useful and persistent failure of endoscopic therapy mandates either embolization or surgery. In this review, we analyze the management of nonvariceal upper gastrointestinal bleeding with evidence from the currently published clinical trials.

Author-supplied keywords

  • *gastrointestinal hemorrhage/di [Diagnosis]
  • *gastrointestinal hemorrhage/dt [Drug Therapy]
  • *gastrointestinal hemorrhage/su [Surgery]
  • *gastrointestinal hemorrhage/th [Therapy]
  • *nonvariceal upper gastrointestinal bleeding/di [D
  • *nonvariceal upper gastrointestinal bleeding/dt [D
  • *nonvariceal upper gastrointestinal bleeding/su [S
  • *nonvariceal upper gastrointestinal bleeding/th [T
  • Glasgow Blatchford score
  • Mallory Weiss syndrome
  • adrenalin/dt [Drug Therapy]
  • anticoagulant agent
  • argon plasma coagulation
  • blood clot
  • blood clotting disorder
  • clinical assessment
  • comorbidity
  • congestive heart failure
  • coronary stent
  • digestive system cancer/di [Diagnosis]
  • drug eluting stent
  • drug hypersensitivity
  • electrocoagulation
  • endoscopic clipping
  • endoscopic therapy
  • endoscopy
  • erosive gastritis/di [Diagnosis]
  • erythrocyte concentrate
  • erythromycin/dt [Drug Therapy]
  • erythromycin/iv [Intravenous Drug Administration]
  • esomeprazole/do [Drug Dose]
  • esomeprazole/dt [Drug Therapy]
  • esomeprazole/iv [Intravenous Drug Administration]
  • esophagitis/di [Diagnosis]
  • fresh frozen plasma/dt [Drug Therapy]
  • health care cost
  • heart disease
  • heart tamponade
  • heart ventricle arrhythmia
  • hematemesis
  • hemodynamics
  • hemoglobin/ec [Endogenous Compound]
  • hemostasis
  • hemostatic agent/dt [Drug Therapy]
  • histamine H2 receptor antagonist/cm [Drug Comparis
  • hospitalization
  • human
  • hypotension
  • hypovolemic shock
  • incidence
  • infusion
  • injection
  • international normalized ratio
  • intubation
  • ischemic heart disease
  • kidney failure
  • laser coagulation
  • liver disease
  • liver failure
  • loading drug dose
  • long QT syndrome
  • melena
  • metastasis
  • metoclopramide/dt [Drug Therapy]
  • metoclopramide/iv [Intravenous Drug Administration
  • mortality
  • named inventories, questionnaires and rating scale
  • occlusive cerebrovascular disease
  • omeprazole/do [Drug Dose]
  • omeprazole/dt [Drug Therapy]
  • omeprazole/iv [Intravenous Drug Administration]
  • oxygen
  • oxygen mask
  • oxygen therapy
  • pantoprazole/do [Drug Dose]
  • pantoprazole/dt [Drug Therapy]
  • pantoprazole/iv [Intravenous Drug Administration]
  • patient care
  • peptic ulcer/di [Diagnosis]
  • plasma substitute
  • prognosis
  • prokinetic agent
  • prophylaxis
  • proton pump inhibitor/cm [Drug Comparison]
  • proton pump inhibitor/do [Drug Dose]
  • proton pump inhibitor/dt [Drug Therapy]
  • proton pump inhibitor/iv [Intravenous Drug Adminis
  • randomized controlled trial (topic)
  • ranitidine/do [Drug Dose]
  • ranitidine/dt [Drug Therapy]
  • ranitidine/iv [Intravenous Drug Administration]
  • respiratory distress
  • resuscitation
  • review
  • risk assessment
  • risk benefit analysis
  • risk reduction
  • shock
  • stomach pH
  • syncope
  • systolic blood pressure
  • tachycardia
  • therapy
  • thrombocyte transfusion
  • transfusion
  • treatment contraindication
  • treatment failure
  • urea nitrogen blood level
  • urea/ec [Endogenous Compound]
  • vasoconstriction
  • vitamin K group/dt [Drug Therapy]
  • warfarin

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