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Diagnosis and management of nonvariceal upper gastrointestinal bleeding

Nature Reviews Gastroenterology & Hepatology volume 9, pages 97–104 (2012)Cite this article

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Abstract

Nonvariceal upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality worldwide. Despite the improvements in the management of this condition in western countries, mortality rates have remained at 5–10% over the past decade. This article presents the main recommendations for the management of UGIB. Pre-endoscopic management (including use of scoring scales, nasogastric tube placement and blood pressure stabilization) is crucial for triage and optimal resuscitation of patients, and should include a multidisciplinary approach at an early stage. Unless the patient has specific comorbidities, transfusion should only be considered if their hemoglobin level is ≤70 g/l. Endoscopic therapy, the cornerstone of therapeutic management of high-risk lesions, should not be delayed for more than 24 h following admission. Several endoscopic techniques, mostly using clips or thermal methods, are available and new approaches are emerging. When endoscopy fails, surgery or arterial embolization should be considered. Although the efficacy of prokinetics and high-dose intravenous PPI prior to endoscopy is controversial, the use of an intravenous PPI following endoscopy is strongly recommended. Antiplatelet therapy should be suspended and resumed in 3–5 days. Finally, all patients should be tested for Helicobacter pylori by serology in the acute setting.

Key Points

  • Resuscitation should be initiated prior to any diagnostic procedure

  • Gastrointestinal endoscopy allows visualization of the stigmata, accurate assessment of the level of risk and treatment of the underlying lesion

  • Combination of endoscopic therapies improves control of the gastrointestinal hemorrhage

  • Intravenous PPI therapy after endoscopy is crucial to decrease the risk of cardiovascular complications and to prevent recurrence of bleeding

  • Helicobacter pylori testing should be performed in the acute setting

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Figure 1: Algorithm for optimal management of nonvariceal upper gastrointestinal bleeding.

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Authors and Affiliations

  1. Department of Gastroenterology, National Institute for Health and Medical Research (INSERM), CIC-P 803, Centre Hospitalier Universitaire de Dijon, 14 rue Gaffarel, BP77908, Dijon, 21079, France

    Marc Bardou & Isabelle Le Ray

  2.  5301 McKenna, Montréal, H3T 1T9, QC, Canada

    Dalila Benhaberou-Brun

  3. Gastroenterology Department, McGill University Health Centre, Montréal General Hospital site, Room D16-157b, 1650 Cedar Avenue, Montréal, H3G 1A4, QC, Canada

    Alan N. Barkun

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  1. Marc Bardou
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All authors contributed substantially to researching data for the article, discussion of the content, writing the manuscript and editing the text.

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Correspondence to Marc Bardou.

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A. N. Barkun has acted as a consultant for AstraZeneca and Takeda Canada. The other authors declare no competing interests.

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Bardou, M., Benhaberou-Brun, D., Le Ray, I. et al. Diagnosis and management of nonvariceal upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 9, 97–104 (2012). https://doi.org/10.1038/nrgastro.2011.260

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