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Endoscopy Mar 20211: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification....
Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021.
1: ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2: ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3-5 days.Strong recommendation, moderate quality evidence. 3: ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4: ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5: ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6: ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 : ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8: ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9: ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (A): PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (B): High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10: ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.
Topics: Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans
PubMed: 33567467
DOI: 10.1055/a-1369-5274 -
Annals of Internal Medicine Dec 2019This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous...
DESCRIPTION
This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations.
METHODS
An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.
RECOMMENDATIONS
Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.
Topics: Blood Transfusion; Cardiovascular Diseases; Endoscopy, Gastrointestinal; Gastrointestinal Hemorrhage; Hemodynamics; Hemostatic Techniques; Humans; Peptic Ulcer; Proton Pump Inhibitors; Risk Assessment; Secondary Prevention
PubMed: 31634917
DOI: 10.7326/M19-1795 -
The Korean Journal of Gastroenterology... Jun 2020Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an... (Review)
Review
Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
Topics: Anticoagulants; Embolization, Therapeutic; Endoscopy, Gastrointestinal; Erythrocyte Transfusion; Gastrointestinal Hemorrhage; Helicobacter Infections; Humans; Proton Pump Inhibitors; Upper Gastrointestinal Tract
PubMed: 32581203
DOI: 10.4166/kjg.2020.75.6.322 -
Polish Archives of Internal Medicine May 2022Obscure gastrointestinal (GI) bleeding (OGIB) is defined as small bowel bleeding of unknown etiology after negative endoscopic evaluation including... (Review)
Review
Obscure gastrointestinal (GI) bleeding (OGIB) is defined as small bowel bleeding of unknown etiology after negative endoscopic evaluation including esophagogastroduodenoscopy and colonoscopy with endoscopic evaluation of the terminal ileum. The presentation of OGIB may be either overt or occult. The former refers to persistent or recurrent visible GI bleeding (eg, melena and / or hematochezia, and rarely hematemesis), while the latter indicates the presence of persistently positive results of fecal oc-cult blood testing, iron deficiency anemia, or both, without evidence of visible GI bleeding. This review focuses exclusively on obscure‑overt GI bleeding and presents entities that should be considered as part of the differential diagnosis in patients with this type of bleeding, as well as details the role of endoscopic and radiographic techniques in the evaluation and treatment.
Topics: Colonoscopy; Gastrointestinal Hemorrhage; Humans
PubMed: 35635400
DOI: 10.20452/pamw.16253 -
Gut May 2019This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards...
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
Topics: Adult; Aged; Algorithms; Female; Gastroenterology; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Societies, Medical; United Kingdom
PubMed: 30792244
DOI: 10.1136/gutjnl-2018-317807 -
Medicine Nov 2022Acute upper gastrointestinal bleeding (UGIB) is a typical medical emergency, with an incidence of 84 to 160 cases per 100,000 individuals and a mortality rate of... (Observational Study)
Observational Study
Acute upper gastrointestinal bleeding (UGIB) is a typical medical emergency, with an incidence of 84 to 160 cases per 100,000 individuals and a mortality rate of approximately 10%. This study aimed to identify all cases of UGIB hospitalized in a tertiary gastroenterology department, to identify possible predictive factors involved in rebleeding and mortality, potential associations between different elements and the severity of bleeding, and the differences between the upper digestive hemorrhage due to nonvariceal and variceal bleeding. This was an observational, retrospective study of patients with UGIB admitted to the tertiary Department of Gastroenterology between January 2013 and December 2020. A total of 1499 patients were enrolled in the study. One thousand four hundred and ninety-nine patients were hospitalized for 7 years with active upper digestive hemorrhage, 504 variceal bleeding, and 995 nonvariceal bleeding. When comparing variceal with nonvariceal bleeding, in nonvariceal bleeding, the mean age was higher, similar sex, higher mortality rate, higher rebleeding rate, and higher hemorrhagic shock rate. Endoscopy treatment was also performed more frequently in variceal bleeding than in nonvariceal bleeding. Severe anemia was found more frequently in patients with variceal bleeding. The mortality rate was 10% in the entire study group, which was not significantly different between the 2 batches. However, the rebleeding rate is higher in patients with variceal gastrointestinal bleeding.
Topics: Humans; Gastrointestinal Hemorrhage; Esophageal and Gastric Varices; Retrospective Studies; Acute Disease; Endoscopy, Gastrointestinal; Varicose Veins
PubMed: 36397398
DOI: 10.1097/MD.0000000000031543 -
American Family Physician Feb 2020Evaluation and management of acute lower gastrointestinal bleeding focus on etiologies originating distally to the ligament of Treitz. Diverticular disease is the most...
Evaluation and management of acute lower gastrointestinal bleeding focus on etiologies originating distally to the ligament of Treitz. Diverticular disease is the most common source, accounting for 40% of cases. Hemorrhoids, angiodysplasia, infectious colitis, and inflammatory bowel disease are other common sources. Initial evaluation should focus on obtaining the patient's history and performing a physical examination, including evaluation of hemodynamic status. Subsequent evaluation should be based on the suspected etiology. Most patients should undergo colonoscopy for diagnostic and therapeutic purposes once they are hemodynamically stable and have completed adequate bowel preparation. Early colonoscopy has not demonstrated improved patient-oriented outcomes. Hemodynamic stabilization using normal saline or balanced crystalloids improves mortality in critically ill patients. For persistently unstable patients or those who cannot tolerate bowel preparation, abdominal computed tomographic angiography should be considered for localization of a bleeding source. Technetium Tc 99m-labeled red blood cell scintigraphy should not be routinely used in the evaluation of lower gastrointestinal bleeding. Surgical intervention should be considered only for patients with uncontrolled severe bleeding or multiple ineffective nonsurgical treatment attempts. Percutaneous catheter embolization should be considered for patients who are poor surgical candidates. Treatment is based on the identified source of bleeding.
Topics: Acute Disease; Colonoscopy; Computed Tomography Angiography; Digestive System Surgical Procedures; Embolization, Therapeutic; Gastrointestinal Hemorrhage; Humans
PubMed: 32053333
DOI: No ID Found -
World Journal of Gastroenterology Feb 2017There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show... (Review)
Review
There are many causes of gastrointestinal bleeding (GIB) in children, and this condition is not rare, having a reported incidence of 6.4%. Causes vary with age, but show considerable overlap; moreover, while many of the causes in the pediatric population are similar to those in adults, some lesions are unique to children. The diagnostic approach for pediatric GIB includes definition of the etiology, localization of the bleeding site and determination of the severity of bleeding; timely and accurate diagnosis is necessary to reduce morbidity and mortality. To assist medical care providers in the evaluation and management of children with GIB, the "Gastro-Ped Bleed Team" of the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition (SIGENP) carried out a systematic search on MEDLINE PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) to identify all articles published in English from January 1990 to 2016; the following key words were used to conduct the electronic search: "upper GIB" and "pediatric" [all fields]; "lower GIB" and "pediatric" [all fields]; "obscure GIB" and "pediatric" [all fields]; "GIB" and "endoscopy" [all fields]; "GIB" and "therapy" [all fields]. The identified publications included articles describing randomized controlled trials, reviews, case reports, cohort studies, case-control studies and observational studies. References from the pertinent articles were also reviewed. This paper expresses a position statement of SIGENP that can have an immediate impact on clinical practice and for which sufficient evidence is not available in literature. The experts participating in this effort were selected according to their expertise and professional qualifications.
Topics: Adolescent; Child; Child, Preschool; Diagnostic Imaging; Endoscopy; Gastroenterology; Gastrointestinal Diseases; Gastrointestinal Hemorrhage; Hemodynamics; Humans; Infant; Infant, Newborn; Italy; Pediatrics; Recurrence; Societies, Medical
PubMed: 28293079
DOI: 10.3748/wjg.v23.i8.1328 -
Alimentary Pharmacology & Therapeutics Jan 2014Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality. (Review)
Review
BACKGROUND
Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and -rarely - mortality.
AIM
To provide an up-to-date comprehensive summary of the literature evaluating this disease entity with a particular focus on pathogenesis as well as current and emerging diagnostic and therapeutic modalities. Recommendations for treatment will be made on the basis of the current available evidence and consensus opinion of the authors.
METHODS
A systematic literature search was performed. The search strategy used the keywords 'angiodysplasia' or 'arteriovenous malformation' or 'angioectasia' or 'vascular ectasia' or 'vascular lesions' or 'vascular abnormalities' or 'vascular malformations' in the title or abstract.
RESULTS
Most AD lesions (54-81.9%) are detected in the caecum and ascending colon. They may develop secondary to chronic low-grade intermittent obstruction of submucosal veins coupled with increased vascular endothelial growth factor-dependent proliferation. Endotherapy with argon plasma coagulation resolves bleeding in 85% of patients with colonic AD. In patients who fail (or are not suitable for) other interventions, treatment with thalidomide or octreotide can lead to a clinically meaningful response in 71.4% and 77% of patients respectively.
CONCLUSIONS
Angiodysplasia is a rare, but important, cause of both overt and occult GI bleeding especially in the older patients. Advances in endoscopic imaging and therapeutic techniques have led to improved outcomes in these patients. The choice of treatment should be decided on a patient-by-patient basis. Further research is required to better understand the pathogenesis and identify potential therapeutic targets.
Topics: Angiodysplasia; Electrocoagulation; Gastrointestinal Hemorrhage; Humans; Octreotide; Thalidomide
PubMed: 24138285
DOI: 10.1111/apt.12527 -
Gut Mar 1996The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage, and to formulate a simple...
The aim of this study was to establish the relative importance of risk factors for mortality after acute upper gastrointestinal haemorrhage, and to formulate a simple numerical scoring system that categorizes patients by risk. A prospective, unselected, multicentre, population based study was undertaken using standardised questionnaires in two phases one year apart. A total of 4185 cases of acute upper gastrointestinal haemorrhage over the age of 16 identified over a four month period in 1993 and 1625 cases identified subsequently over a three month period in 1994 were included in the study. It was found that age, shock, comorbidity, diagnosis, major stigmata of recent haemorrhage, and rebleeding are all independent predictors of mortality when assessed using multiple logistic regression. A numerical score using these parameters has been developed that closely follows the predictions generated by logistical regression equations. Haemoglobin, sex, presentation (other than shock), and drug therapy (non-steroidal anti-inflammatory drugs and anticoagulants) are not represented in the final model. When tested for general applicability in a second population, the scoring system was found to reproducibly predict mortality in each risk category. In conclusion, a simple numerical score can be used to categorize patients presenting with acute upper gastrointestinal haemorrhage by risk of death. This score can be used to determine case mix when comparing outcomes in audit and research and to calculate risk standardised mortality. In addition, this risk score can identify 15% of all cases with acute upper gastrointestinal haemorrhage at the time of presentation and 26% of cases after endoscopy who are at low risk of rebleeding and negligible risk of death and who might therefore be considered for early discharge or outpatient treatment with consequent resource savings.
Topics: Acute Disease; Aged; Aged, 80 and over; Comorbidity; Female; Forecasting; Gastrointestinal Hemorrhage; Humans; Male; Medical Audit; Middle Aged; Models, Statistical; Prospective Studies; Recurrence; Regression Analysis; Risk Factors; Severity of Illness Index
PubMed: 8675081
DOI: 10.1136/gut.38.3.316