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Management of Nonvariceal Upper Gastrointestinal Bleeding FREE

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The summary below is from the full report titled “International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding.” It is in the 19 January 2009 issue of Annals of Internal Medicine (volume 152, pages 101-113). The authors are A.N. Barkun, M. Bardou, E.J. Kuipers, J. Sung, R.H. Hunt, M. Martel, and P. Sinclair, for the International Consensus Upper Gastrointestinal Bleeding Conference Group.

Ann Intern Med. 2010;152(2):I-48. doi:10.7326/0003-4819-152-2-201001190-00003
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Who developed these guidelines?

A group of 34 experts from 15 countries developed the recommendations. The group's specific purpose was to update previous recommendations that had been made in 2003 for the management of patients with nonvariceal upper gastrointestinal bleeding.

What is the problem and what is known about it so far?

Nonvariceal upper gastrointestinal bleeding is bleeding that occurs from a source in the upper part of the intestine, such as an ulcer. Evidence about effective management for patients with such bleeding is evolving rapidly.

How did the panel develop these recommendations?

The panel reviewed and discussed recently published research and then voted on recommendations. They also rated the quality of evidence and the strength of each recommendation.

What did the authors find?

A fair amount of evidence convinced the authors to add 10 new recommendations and revise 11 past recommendations. They left 13 recommendations unchanged.

What does the expert panel suggest that patients and doctors do?

The panel recommends stratifying all patients into low- and high-risk categories for rebleeding and mortality. They suggest blood transfusions for patients with hemoglobin levels less than 70 g/L. They recommend early endoscopy for most patients and recommend against routine use of promotility agents before endoscopy. They advise endoscopic hemostasis treatment of high-risk lesions, intravenous high-dose proton-pump inhibitor (PPI) therapy after successful endoscopic hemostasis, and hospitalization for at least 72 hours after endoscopic hemostasis. Patients at low risk for rebleeding on the basis of clinical characteristics and endoscopic findings can be discharged promptly after endoscopy. All patients should be tested for Helicobacter pylori infection, but if negative test results are obtained in the acute setting, then tests should be repeated. Routine second-look endoscopy is not recommended. The panel advises combining a PPI with a cyclooxygenase-2 inhibitor for patients who have experienced bleeding while receiving a nonsteroidal anti-inflammatory drug (NSAID) yet require long-term NSAID therapy to reduce the risk for recurrent bleeding. They also advise restarting acetylsalicylic acid (ASA) therapy for secondary cardiovascular prophylaxis as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). Finally, they note that ASA plus a PPI is preferred over clopidogrel alone to reduce risk for recurrent bleeding.

What are the cautions related to these recommendations?

Some of the recommendations are supported by limited evidence. Recommendations may change as new studies become available.





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