practice guidelines
International Consensus Group Issues Recommendations for Management of Upper GI Bleeding
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he clinical and economic burden of upper gastrointestinal (GI) bleeding is considerable, with the annual incidence ranging from 48 to 160 cases per 100,000 adults and mortality rates ranging from 10 to 14 percent. In response to new data that may lead to improved patient outcomes, the International Consensus Upper Gastrointestinal Bleeding Conference Group-a multidisciplinary group of 34 experts from 15 countries-developed international guidelines for managing nonvariceal upper GI bleeding. The guidelines include new recommendations, as well as updates to the 2002 guidelines from the British Society of Gastroenterology and the 2003 consensus guidelines from the Nonvariceal Upper GI Bleeding Consensus Conference Group. The evidence rating system implemented is defined as follows: 1A = strong recommendation, highquality evidence; 1B = strong recommendation, moderate-quality evidence; 1C = strong recommendation, low- or very low-quality evidence; 2A = weak recommendation, high-quality evidence; 2B = weak recommendation, moderate-quality evidence; 2C = weak recommendation, low- or very lowquality evidence. Grade 1 recommendations should be interpreted as “do it” or “do not do it”; grade 2 recommendations should be interpreted as “probably do it” or “probably do not do it.” Resuscitation, Risk Assessment, and Pre-endoscopy Management Revised recommendation: Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. (Grade: 1C) Early identification of high-risk patients can facilitate appropriate intervention, which minimizes morbidity and mortality. Stratification should be based on clinical, laboratory, and endoscopic criteria. Predictors of increased risk of rebleeding include age older than 65 years; shock; poor overall health; comorbid illnesses; low initial hemoglobin (Hgb) levels; melena; transfusion requirement; fresh 240
red blood on rectal examination, in the emesis, or in the nasogastric aspirate; sepsis; and elevated urea, creatinine, or serum transaminase levels. New recommendation: Blood transfusions should be administered in patients with an Hgb level of 7 g per dL (70 g per L) or less. (Grade: 1C) Patients should be considered for transfusion based on their underlying condition, hemodynamic status, and markers of tissue hypoxia in acute situations. Red blood cell transfusion is rarely needed in patients with an Hgb level greater than 10 g per dL (100 g per L) and is usually needed when the Hgb level is less than 6 g per dL (60 g per L). New recommendation: In patients receiving anticoagulants, correction of coagulopathy is recommended, but should not delay endoscopy. (Grade: 2C) Available data suggest that it may not be necessary to delay endoscopy in patients with mild to moderate coagulopathy. One study of patients undergoing endoscopy found no difference in rebleeding, surgery, mortality, or complication rates between patients receiving warfarin (Coumadin) and those not receiving anticoagulants. New recommendation: Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. (Grade: 2B) Although promotility agents may be useful in selected patients with suspected blood in the stomach, they are not recommended for routine use in patients with upper GI bleeding. Revised recommendation: Selected patients with acute ulcer bleeding who are at low risk of rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. (Grade: 1A) One randomized controlled trial (RCT) assessing the role of early discharge in low-risk patients found no difference in rates of recurrent bleeding. None of the patients who were discharged early experienced serious adverse events, underwent surgery, or died during the 30-day follow-up. Asian Journal of Clinical Cardiology, Vol. 14, No. 7, November 2011