About 10% of the population in the Western world will experience peptic ulcer disease at some point during their lives. Individuals with peptic ulcer disease may present with a variety of gastrointestinal (GI) symptoms including abdominal pain, vomiting, and bleeding. Indeed, peptic ulcer disease is the most common cause of conditions such as upper GI hemorrhage and perforation, which are associated with high mortality and morbidity [
Acute upper gastrointestinal bleeding (AUGIB) is one of the commonest causes for hospitalization worldwide. In the United States, there are 250,000 to 300,000 hospital admissions and 15,000 to 30,000 deaths each year resulting from acute upper GI hemorrhage [
Our paper will focus on the state-of-the-art management of bleeding peptic ulcer disease. There are five cornerstone elements critical to the appropriate management of patients with NVUGIB. They are resuscitation, risk assessment, preendoscopic care, endoscopic management, and postendoscopic care including pharmacological and nonpharmacological therapies. The issue of secondary prophylaxis will not be addressed in this particular paper, but readers are referred to a recent narrative review on the topic [
Patients presenting with upper gastrointestinal bleeding are at risk of hemodynamic shock and airway compromise therefore, the first priority is to assess the adequacy of the airway, as well as the patient’s breathing and circulation. Venous access should be achieved with at least 2 large-bore cannulae, and patients with active bleeding should be monitored in a high-dependency unit with pulse oximetry, cardiac monitoring, automated blood pressure readings, close monitoring of urine output, and, ideally, central venous pressure monitoring. As a minimum, all patients should be blood typed and cross-matched for an appropriate number of units of packed red blood cells with blood sent for hemoglobin, hematocrit, platelets, coagulation time, and electrolytes [
Acute upper gastrointestinal bleeding (AUGIB) is a very common indication for transfusion of blood components. A study from the United Kingdom found that this indication alone accounts for 14% of the national red cell supply [
The prognostic value of the international normalized ratio (INR) following presentation with NVUGIB is poorly characterized. In the Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE) cohort of 1869 patients with NVUGIB, a presenting INR of greater than 1.5 was associated with almost a two-fold increased risk of mortality (OR 1.95, 95% CI 1.13–3.41) after adjustment for confounders, but not an increased risk of rebleeding [
The role of the nasogastric tube (NGT) in the initial assessment of patients presenting with NVUGIB remains controversial. It carries a prognostic value in identifying high-risk lesions [
The clinical predictors of increased risk for rebleeding or mortality include age greater than 65 years, shock, poor overall health status, comorbid illnesses, low initial hemoglobin levels, melena, transfusion requirement, fresh red blood on rectal examination, in the emesis, or in the nasogastric aspirate, sepsis, and elevated urea, creatinine, or serum aminotransferase levels [
The most extensively validated scores are the Rockall (Table
Points scheme allocation for the complete Rockall score.
Score | 0 | 1 | 2 | 3 |
| ||||
Age | <60 | 60–79 | ≥80 | |
Vital signs | No shock | Tachycardia HR > 100 | Hypotension SBP < 100 | |
Comorbidities | none | Cardiac failure/ischemic disease/other conditions | Liver, renal failure, and advanced malignancy | |
Diagnosis | Mallory Weiss tear, no bleeding or lesions identified | Other diagnosis | Malignancy of upper GI tract | |
Stigmata of bleeding | None or dark spot only | Blood in GI tract, active bleeding or visible vessel, or adherent clot |
Rockall score [
Points scheme allocation for the Blatchford score.
Parameter | Points |
---|---|
Urea mmol/L | |
6.5–7.9 | 2 |
8–9.9 | 3 |
10–25 | 4 |
>25 | 6 |
Haemoglobin g/L (for men) | |
120–129 | 1 |
110–119 | 3 |
<110 | 6 |
Haemoglobin g/L (for women) | |
100–119 | 1 |
<110 | 6 |
SBP mm Hg | |
100–109 | 1 |
90–99 | 2 |
<90 | 3 |
Others | |
Pulse > 100 | 1 |
Melena on presentation | 1 |
Syncope on presentation | 2 |
Hepatic disease | 2 |
Cardiac failure | 2 |
Blatchford score [
Mortality and bleeding rates according to the complete Rockall score.
The complete Rockall score has been said to be superior to both the preendoscopy clinical Rockall scores and Blatchford score in predicting mortality and rebleeding [
The Blatchford score is more useful than the clinical Rockall score in identifying low-risk patients who do not require therapeutic endoscopy, and specifically those patients with a score of zero may be safely triaged from the ED to outpatient management [
Endoscopically, the following features predict the increased risk of rebleeding: active bleeding at the time of endoscopy, large ulcer size >2 cm, bleeding ulcers located on the lesser curvature or posterior duodenal wall, and high-risk stigmata classified according to the Forrest classification (Table
The Forrest classification.
Forrest class | Endoscopic appearance |
---|---|
High risk | |
1a | Active spurting bleeding |
1b | Active oozing bleeding |
2a | Non Bleeding visible vessel |
2b | Adherent clot |
Low risk | |
2c | Pigmented clot |
3 | Clean base ulcer |
Proton-pump inhibitors (PPIs) play an important role in the stabilization of clot formation in response to bleeding peptic ulcers through pH-dependent factors, by raising the pH to 6, helping in optimizing platelet aggregation [
Cost-effective scenarios optimizing the possible role of this preemptive pharmacotherapy have been identified and include a high likelihood of bleeding from a nonvariceal source and delayed access to endoscopy [
Current international recommendations state that somatostatin or octreotide are not recommended in the routine management of patients with acute NVUGIB [
The use of prokinetic agents prior to endoscopy may improve diagnostic yield in selected patients; however, they are not warranted for routine use in all patients who present with UGIB. A meta-analysis [
Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding. Early endoscopy (within the first 24 hours), using risk classification based on clinical and endoscopic criteria, has been shown to permit the safe and prompt discharge of patients classified as low risk. Furthermore, it also improves patient outcomes for patients classified as high-risk, while reducing use of resources for patients classified as either low or high-risk [
There exist many endoscopic modalities for treating bleeding peptic ulcer disease. These include mechanical devices such as endoscopic clips and thermal probes, and it is needless to say that it can inject epinephrine, saline, sclerosing agents, thrombin, and fibrin glue. More recently, hemostatic powders have also been introduced [
Endoscopic therapy is warranted for high-risk lesions that is, Forrest classification 1a, 1b, 2a, and 2b, 2b because of their greatest propensities for rebleeding if left untreated. Meta-analyses have confirmed that endoscopic hemostasis in this group of patients results in significant improvements in rebleeding, but have been underpowered to show any better improvement in the need for surgery or mortality [
The use of hemostatic powders is an emerging endoscopic hemostatic technology, part of a family of products that was recently introduced in the management of upper GI bleeding [
The role of second-look endoscopy, a preplanned repeat endoscopy performed 16–24 hours after an initial endoscopic treatment, has been a source of controversy. A recent meta-analysis suggests that in the absence of high-dose PPI, especially in PUB patients at very high-risk of rebleeding, routine second-look endoscopy appears effective. However, the generalizability of these results to the era of high-dose PPI and otherwise unselected patients with high-risk stigmata is unclear [
It has been well documented that high-risk lesions require 72 hours following endoscopic therapy to evolve from a high-risk to a low-risk stigmata, justifying the 3-day duration of the profound acid suppression [
High-dose intravenous PPI therapy (e.g., a PPI at a dose of 80 mg bolus dose followed by 8 mg/h infusion over 72 hours) should be administered to patients with high-risk stigmata who have received successful endoscopic therapy. This recommendation is based on a meta-analysis of RCTs including 5792 patients in which PPI therapy reduced the incidence of rebleeding (OR 0.45, 95% CI 0.36–0.57) and needed for surgery (OR 0.56, 95% CI 0.45–0.70), but not mortality (OR 0.90, 95% CI 0.67–1.19) [
Furthermore, PPIs improve mortality in patients with HRS, but only if they have initially undergone endoscopic hemostasis (i.e., mainly high dose IV) [
All patients with bleeding peptic ulcers should be tested for
Diagnostic test performance for
A recent RCT out of Hong Kong has shown that it is more deleterious to withhold ASA amongst patients using it for secondary cardiovascular prophylaxis than to restart it early on. Based on these data, consensus recommendations state that in patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding [
Adequate resuscitation and initial risk assessment are crucial in patients presenting with AUGIB. Early endoscopy allows for categorization of patients into low versus high-risk of rebleeding and delivery of endoscopic hemostasis. Prokinetics are helpful in visualizing bleeding lesions at the initial endoscopy. Dual endoscopic modality therapy is superior to epinephrine injection alone followed by continuous PPI infusion for 72 hours should be applied for high-risk stigmata of rebleeding.
All patients should be discharged on a single daily oral dose of a PPI the duration of PPI is determined by the underlying etiology of the bleeding ulcer, while in patients who are on antiplatelet agents, the cardiothrombotic risks should be balanced against the risk of further bleeding or rebleeding. ASA should be soon restarted in patients with high-risk of cardiothrombotic events. Finally, all patients presenting with bleeding ulcers should be tested for
Gastrointestinal
Acute upper gastroIntestinal bleeding
Nonvariceal upper gastroIntestinal bleeding
Proton-pump inhibitors
Prothrombin complex concentrate
Nasogastric tube
Nonsteriodal anti-inflammatory drugs
Aspirin
Cyclo-oxygenase 2
Peptic ulcer bleeding
High-risk stigmata
Hemoglobin
Randomized control trials.