Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding

Trends in Management and Outcomes of Acute Nonvariceal Upper Gastrointestinal Bleeding: 1993–2003

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).

Background. The mortality from nonvariceal upper gastrointestinal bleeding is still around 5%, despite the increased use of proton-pump inhibitors and the advancement of endoscopic therapeutic modalities. Aim. To review the state-of-the-art management of acute non variceal upper gastrointestinal bleeding from the presentation to the emergency department, risk stratification, endoscopic hemostasis, and postendoscopic consolidation management to reduce the risk of recurrent bleeding from peptic ulcers. Methods. A PubMed search was performed using the following key words acute management, non variceal upper gastrointestinal bleeding, and bleeding peptic ulcers. Results. Risk stratifying patients with acute non variceal upper gastrointestinal bleeding allows the categorization into low risk versus high risk of rebleeding, subsequently safely discharging low risk patients early from the emergency department, while achieving adequate hemostasis in high-risk lesions followed by continuous proton-pump inhibitors for 72 hours. Dual endoscopic therapy still remains the recommended choice in controlling bleeding from peptic ulcers despite the emergence of new endoscopic modalities such as the hemostatic powder. Conclusion. The management of nonvariceal upper gastrointestinal bleeding involves adequate resuscitation, preendoscopic risk assessment, endoscopic hemostasis, and post endoscopic pharmacological and nonpharmacological treatment.

Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

Artificial Neural Network (ANN) vs. Rockall Score for Prediction of Mortality in Patients with Non Variceal Upper Gastro Intestinal Bleeding (UGIB)

Background and Aim: Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency and carries high morbidity and mortality. There are multiple risk factors for poorer outcomes, including malnutrition. Ascorbic acid is a water-soluble vitamin present in most plant foods. Dietary deficiency leads to scurvy, which may alter the natural history of UGIB through impaired tissue and mucosal integrity. Traditionally thought to be rare in developed countries, vitamin C deficiency (VCD) is now well described in patients with pneumonia, sepsis, and coronavirus disease 2019. There is a paucity of literature investigating the prevalence and clinical significance of VCD in patients with UGIB;interim findings reported by our group suggested a prevalence of >30%. The aim of this study was to establish the prevalence of VCD in patients presenting with UGIB and its association with clinical outcomes. Methods: We conducted a prospective cohort study of adult patients presenting with UGIB to two metropolitan tertiary hospitals in Melbourne, Australia, over a 12-month period (March 2020 to March 2021). Fasting vitamin C levels were obtained on admission. Patients were risk-stratified using the AIMS65 score, and baseline demographic data and outcomes were recorded. The primary outcome was the prevalence of VCD (serum vitamin C level < 23 μmol/L) and severe VCD (<12 μmol/L). Secondary outcomes included a composite endpoint of adverse events (AE), comprising inpatient death, intensive care unit (ICU) admission, rebleeding, surgery, angioembolization, or massive transfusion (≥4 units of red cells). Multivariate logistic regression was used to determine the association between vitamin C levels and the secondary endpoints. Subgroup analyses were performed in variceal and non-variceal UGIB and high-risk (AIMS65, ≥2) and low-risk (AIMS65, 0-2) UGIB. Results: A total of 227 patients were included. The median age was 65 years (IQR, 54-78), 145 (63.9%) were male, and the median AIMS65 score was 1 (IQR, 1-2). The etiology of UGIB was variceal bleeding in 20.3%, peptic ulcer disease in 44.1%, and other causes in 35.7%. The mean vitamin C level was 40 ± 26 μmol/L. In terms of patient outcomes, inpatient mortality was 4%, ICU admission occurred for 11.9%, and mean length of stay (LOS) was 7.7 ± 9.7 days. Red cell transfusion was required in 63.4% of patients, with a mean requirement of 2.2 ± 2.8 units. VCD was identified in 74 patients (32.6%), with severe deficiency in 32 (14.1%). VCD was associated with significantly higher in-hospital mortality (9.5% vs 1.3%, P = 0.01), prolonged LOS (10.8 vs 6.2 days, P < 0.01), rebleeding (17.6% vs 7.88%, P = 0.05), and a higher composite endpoint of AE (77% vs 54.9%, P < 0.01). On multivariate logistic regression, high-risk UGIB (odds ratio [OR], 3.24;95% CI, 1.42-7.42), VCD (OR, 2.28;95% CI, 1.11-4.71), and chronic liver disease (OR, 11.66;95% CI, 2.92-46.64) were all independently associated with the composite endpoint of AE. In subgroup analysis, VCD was associated with a significantly increased composite endpoint of AE in patients with non-variceal (74% vs 51%, P < 0.01) and low-risk (66% vs 44%, P = 0.04) UGIB. Conclusion: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding, and LOS. Interventional studies are required to determine the impact of early vitamin C supplementation on clinical outcomes.

Mo1165 Prediction for Mortality in Patients With Non-Variceal Upper Gastrointestinal Bleeding: Novel DGSG Score

Endoscopia urgente frente a endoscopia precoz: ¿tiene algún papel la endoscopia urgente en la hemorragia digestiva alta aguda no varicosa?

Acute upper gastrointestinal hemorrhage is a highly prevalent clinical condition, with the majority of cases representing acute non-variceal upper gastrointestinal hemorrhage. With the advancement of modern medicine, endoscopy has become an indispensable tool in the diagnosis and treatment of various diseases. In order to achieve optimal results in the endoscopic treatment of non-variceal upper gastrointestinal bleeding, it is essential to make an accurate and timely diagnosis and select the most appropriate treatment method. This article introduces the definition of acute non-variceal upper gastrointestinal bleeding (ANVUGIB) and the importance of endoscopic treatment for this disease. It then presents an overview of various assessment systems for ANVUGIB and an overview of endoscopic advances in thermal coagulation, mechanical hemostasis, and topical pharmacological injection hemostasis for three aspects of ANVUGIB-related bleeding. In particular, this article discusses the therapeutic efficacy and safety of different treatment options for non-variceal upper gastrointestinal bleeding, as well as the advantages and limitations of these treatment options in managing this disease.

Acute gastrointestinal (GI) bleeding is a common cause of hospitalization. There are conflicting results regarding the effectiveness of early endoscopy in patients with upper GI bleeding. The study aimed to determine the benefit of early endoscopy and the epidemiological characteristics of patients presenting to the emergency department with non-variceal acute upper GI bleeding. Patients over 18 years of age who presented to the emergency department with upper GI between 2015 and 2016 and underwent endoscopy were included in the study. The patients were divided into two groups: early endoscopy group (endoscopy within the 24 h) and late endoscopy group (endoscopy after 24 h). Of 104 patients, 57.7% were man, and the mean age was 66.27 ± 17.64 years. Of the patients who underwent endoscopy, 80 (76.9%) were in the early endoscopy group. There was no difference in blood transfusion needs (P = 0.388), re-bleeding (P = 0.137), the need for surgery, and mortality rates with regard to the timing of endoscopy. The results of the receiver-operating characteristics curve analysis revealed patients with a GBS ≥ 9 were taken as high-risk, and a prognosis analysis was performed accordingly. However, in patients undergoing early endoscopy, a difference was detected with respect to the length of hospital stay (P = 0.011) and treatment costs (P = 0.030). In the comparison with the admission time (working/non-working h) and variables, there were no significant differences in the length of hospital stay (P = 0.230), transfusion needs (P = 0.348), re-bleeding frequency (P = 0.905), and treatment costs (P = 0.094). Endoscopy within 24 h in the setting of acute upper non-variceal GI bleeding is associated with an increase in the length of hospital stay and treatment costs, but is not associated with re-bleeding, transfusion needs, need for surgery, and mortality.

Timing of endoscopy in high-risk patients with acute upper gastrointestinal bleeding: Results of a multicenter international cohort study.

Background/AimsThis study aimed to determine the performance of the AIMS65 score (AIMS65), Glasgow-Blatchford score (GBS), and Rockall score (RS) in predicting outcomes in patients with upper gastrointestinal bleeding (UGIB), and to compare the results between patients with nonvariceal UGIB (NVUGIB) and those with variceal UGIB (VUGIB).MethodsWe conducted a prospective observational study between March 2016 and December 2017. Receiver operating characteristic curve analysis was performed for all outcomes for comparison. The associations of all three scores with mortality were evaluated using multivariate logistic regression analysis.ResultsOf the total of 337 patients with UGIB, 267 patients (79.2%) had NVUGIB. AIMS65 was significantly associated (odds ratio [OR], 1.735; 95% confidence interval [CI], 1.148–2.620), RS was marginally associated (OR, 1.225; 95% CI, 0.973–1.543), but GBS was not associated (OR, 1.017; 95% CI, 0.890–1.163) with mortality risk in patients with UGIB. However, all three scores accurately predicted all other outcomes (all p<0.05) except rebleeding (p>0.05). Only AIMS65 precisely predicted mortality, the need for blood transfusion and the composite endpoint (all p<0.05) in patients with VUGIB.ConclusionsAIMS65 is superior to GBS and RS in predicting mortality in patients with UGIB, and also precisely predicts the need for blood transfusion and the composite endpoint in patients with VUGIB. No scoring system could satisfactorily predict rebleeding in all patients with UGIB.

Although acute upper gastrointestinal bleeding (UGIB) can lead to anemia, evidence regarding the effects of oral iron supplementation on UGIB-induced anemia following discharge remains lacking. The present study aimed to investigate the effects of oral iron supplementation on hemoglobin response and iron storage in patients with anemia secondary to nonvariceal UGIB. This randomized controlled trial included 151 patients with nonvariceal UGIB who had anemia at discharge. Patients were assigned to a 1:1 block in which they were either administered 6weeks of 600mg/d oral ferrous fumarate (treatment group, n=77) or treated without iron supplementation (control group, n=74). The primary outcome was composite hemoglobin response (hemoglobin elevation greater than 2g/dL or no anemia at the end of treatment [EOT]). The proportion of patients achieving composite hemoglobin response was greater in the treatment group than in the control group (72.7% vs 45.9%; adjusted risk ratio [RR], 2.980; P=0.004). At EOT, the percentage change in the hemoglobin level (34.2±24.8% vs 19.4±19.9%; adjusted coefficient, 11.543; P<0.001) was significantly higher in the treatment group than in the control group; however, the proportions of patients with a serum ferritin level <30μg/L and a transferrin saturation <16% were lower in the treatment group (all P<0.05). No significant differences in treatment-associated adverse effects and adherence rates were observed between the groups. Oral iron supplementation exerts beneficial effects on anemia and iron storage following nonvariceal UGIB without significantly impacting rates of adverse effects or adherence.

Non-variceal upper gastrointestinal bleeding is a common gastroenterological emergency associated with significant morbidity and mortality. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment. As historically played a limited role in the diagnosis of acute non-variceal upper gastrointestinal bleeding, multidetector-row computed tomography angiography is emerging as a promising tool in the diagnosis of non-variceal upper gastrointestinal bleeding, especially for severe cases. However, to date, evidence concerning the role of multidetector-row computed tomography angiography in the non-variceal upper gastrointestinal bleeding diagnosis is still lacking. The purpose of this study was to retrospectively investigate the diagnostic performance of emergent multidetector-row computed tomography angiography performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site, and the underlying etiology of severe non-variceal upper gastrointestinal bleeding. Institutional databases were reviewed in order to identify severe acute non-variceal upper gastrointestinal bleeding patients who were admitted to our bleeding unit and were referred for emergent multidetector-row computed tomography angiography prior to any hemostatic treatment (< 3h) or following (< 3h) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of multidetector-row computed tomography angiography to detect the status, the site, and the etiology of severe non-variceal upper gastrointestinal bleeding with endoscopy, digital subtraction angiography, surgery, pathology, or a combination of them as reference standards. A total of 68 patients (38 men, median age 69years [range 25-96]) were enrolled. The overall multidetector-row computed tomography angiography sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively. Finally, the overall multidetector-row computed tomography angiography sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively. Although esophagogastroduodenoscopy is the mainstay in the diagnosis and treatment of most non-variceal upper gastrointestinal bleeding cases, multidetector-row computed tomography angiography seems to be a feasible and effective modality in detecting the site, the status, and the etiology of severe acute non-variceal upper gastrointestinal bleeding. It may play a crucial role in the management of selected cases of non-variceal upper gastrointestinal bleeding, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of multidetector-row computed tomography angiography in the diagnostic process of acute non-variceal upper gastrointestinal bleeding.

Background and aimsThis study aimed to determine the performance of AIMS65, Rockall score, and Glasgow-Blatchford score (GBS) in patients presenting with upper gastrointestinal bleeding (UGIB) and to compare results between patients with nonvariceal UGIB (NVUGIB) and variceal UGIB (VUGIB).MethodsWe conducted a single-center prospective cohort study between December 2021 and December 2022. A total of 400 patients who met the inclusion criteria were included in the study, out of which 232 patients (58%) had NVUGIB and 168 patients (42%) had VUGIB. Receiver operating characteristic curve analysis was performed for all outcomes for comparison.ResultsOf the total of 400 patients with UGIB, 232 patients (58%) had NVUGIB, and 168 patients (42%) had VUGIB. The present study showed that GBS (AUROC 0.729, 95% CI: 0.598–0.859, p = 0.001) and RS (AUROC 0.693, 95% CI: 0.579–0.807, p = 0.005) but not AIMS65 (AUROC, 0.545, 95% CI: 0.412–0.679, p = 0.500) predicted in-hospital and overall 6-week mortality in patients with UGIB. All the three scores predicted need for blood transfusion and poor composite outcomes (p < 0.05). The need for endoscopic intervention was predicted by all the three scores in overall UGIB (OUGIB) patients (p < 0.05), only GBS and RS in NVUGIB patients (p < 0.05). Rebleeding was best predicated by RS in both OUGIB and NVUGIB patients (p < 0.05). None of the scores predicted the need for endoscopic intervention, rebleeding, need for surgical and radiological intervention, and composite outcomes in VUGIB patients (p > 0.05).ConclusionsGBS and RS were superior to AIMS65 in predicted in-hospital and overall 6-week mortality in all the three categories: OUGIB, NVUGIB, and VUGIB patients.