Diagnostic And Therapeutic Approaches For Non-Variceal Upper Gastrointestinal Bleeding

Abstract

Upper gastrointestinal bleeding (UGIB) is a common, life-threatening medical condition. Non-variceal causes account for more than 90% of bleeding episodes. Peptic ulcer disease is the most frequent cause of non-variceal UGIB. Patients present with hematemesis and/or melena but hematochezia might be present in patients with severe bleeding. Despite advances in diagnostic and therapeutic methods, mortality remains high in the elderly and patients with comorbidities. Endoscopy is the primary procedure that should be performed to identify the etiology of UGIB and for treatment purposes following adequate resuscitation of patients. Early endoscopy (within the first 24 hours) has considerably improved the clinical outcomes. A number of scoring systems are being used in patients with UGIB to identify the risk of complications, rebleeding risk, the need for interventional procedures and the risk of death. The most commonly used scoring tools are the Rockall score, Glasgow-Blatchford score and AIMS65 score. Primary treatment modalities include adequate resuscitation, intravenous fluid support, transfusion of red blood cell suspension, acid suppression therapy and administration of prokinetic agents. In general, angiography, computed tomography, technetium-99m-labeled red blood cell scintigraphy and capsule endoscopy may be used in patients whose bleeding cannot be detected endoscopically. Interventional radiological procedures should be initially performed for hemorrhages that cannot be stopped endoscopically and surgical options should be considered when interventional radiological procedures are out of reach or unsuccessful.

Keywords

• Upper gastrointestinal bleeding
• Endoscopy
• Non-variceal

References

1. 1. Hunt, R.H., et al.,1995. Critical issues in the pathophysiology and management of peptic ulcer disease. European Journal of Gastroenterology & Hepatology. 7,685-699.
2. 2. Hwang, J.H., et al.,2012. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointestinal endoscopy. 75,1132-1138.
3. 3. Wilcox, C.M. and W.S. Clark.,1999. Causes and outcome of upper and lower gastrointestinal bleeding: the Grady Hospital experience. Southern medical journal. 92, 44-50.
4. 4. Van Leerdam, M., et al.,2003. Acute upper GI bleeding: did anything change?: Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. The American journal of gastroenterology. 98, 1494-1499.
5. 5. Rockall, T., et al.,1995. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Bmj. 311, 222-226.
6. 6. Laine, L., et al.,2012. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. American Journal of Gastroenterology. 107, 1190-1195.
7. 7. Vergara, M., et al.,2014. Epinephrine injection versus epinephrine injection and a second endoscopic method in high‐risk bleeding ulcers. Cochrane Database of Systematic Reviews, (10).
8. 8. Alzoubaidi, D. L.B. Lovat, and R. Haidry.,2019. Management of non-variceal upper gastrointestinal bleeding: where are we in 2018? Frontline Gastroenterology. 10,35-42.

9. 9. Gralnek, I., et al.,2015. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 47, a1-46-a46.
10. 10. Naseer, M., et al.,2020. Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review. World Journal of Gastrointestinal Endoscopy. 12, 1.
11. 11. Da Costa, N., et al.,2001. Bleeding reflux esophagitis: a prospective 1-year study in a university hospital. The American journal of gastroenterology. 96, 47-51.
12. 12. Guntipalli, P., et al.,2014. Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome. Digestive diseases and sciences. 59, 2997-3003.
13. 13. Marangoni, G., et al.,2009. An uncommon cause of life-threatening gastrointestinal bleeding: 2 synchronous Dieulafoy lesions. Journal of pediatric surgery. 44, 441-443.
14. 14. Jabbari, M., et al.,1984. Gastric antral vascular ectasia: the watermelon stomach. Gastroenterology. 87, 1165-1170.
15. 15. Rawla, P. and J. Devasahayam.,2019. Mallory Weiss Syndrome, in StatPearls [Internet]. StatPearls Publishing.
16. 16. Kortas, D.Y., et al.,2001. Mallory-Weiss tear: predisposing factors and predictors of a complicated course. The American journal of gastroenterology. 96, 2863-2865.
17. 17. Kim, Y.-I. and I.J. Choi., 2015. Endoscopic management of tumor bleeding from inoperable gastric cancer. Clinical Endoscopy. 48, 121.
18. 18. Adler, D.G., et al.,2004. ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointestinal endoscopy. 60, 497-504.
19. 19. Lanas, A.,2010. Upper GI Bleeding–Associated Mortality: challenges to improving a resistant outcome. American Journal of Gastroenterology. 105, 90-92.
20. 20. Barkun, A.N., et al.,2010. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Annals of internal medicine. 152, 101-113.
21. 21. Baradarian, R., et al.,2004. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. American Journal of Gastroenterology. 99, 619-622.
22. 22. Perel, P. and I. Roberts.,2012. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database of Systematic Reviews,(6).
23. 23. Crooks, C., T. Card, and J. West.,2011. Reductions in 28-day mortality following hospital admission for upper gastrointestinal hemorrhage. Gastroenterology. 141,62-70.
24. 24. Odutayo, A., et al.,2017. Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials. The Lancet Gastroenterology & Hepatology. 2, 354-360.
25. 25. Dunne, P.D., et al.,2019. Previous use of antithrombotic agents reduces mortality and length of hospital stay in patients with high-risk upper gastrointestinal bleeding. Clinical Gastroenterology and Hepatology. 17, 440-447.
26. 26. Chang, H.-Y., et al.,2015. Risk of gastrointestinal bleeding associated with oral anticoagulants: population based retrospective cohort study. bmj. 350.
27. 27. Acosta, R.D., et al.,2016. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointestinal endoscopy. 83, 3-16.
28. 28. Maltz, G.S., J.E. Siegel, and J.L. Carson.,2000. Hematologic management of gastrointestinal bleeding. Gastroenterology Clinics of North America. 29, 169-187.
29. 29. Veitch, A.M., et al.,2016. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut.. 65, 374-389.
30. 30. Laine, L. and K.R. McQuaid.,2009. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clinical Gastroenterology and Hepatology. 7, 33-47.
31. 31. Frossard, J.L., et al.,2002 Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology. 123, 17-23.
32. 32. Roberts, I., et al.,2020. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 395, 1927-1936.
33. 33. Nahon, S., et al.,2012. Epidemiological and prognostic factors involved in upper gastrointestinal bleeding: results of a French prospective multicenter study. Endoscopy. 44, 998-1008.
34. 34. Monteiro, S., et al.,2016. Upper gastrointestinal bleeding risk scores: Who, when and why? World journal of gastrointestinal pathophysiology. 7, 86.
35. 35. Van Leerdam, M.,2008. Epidemiology of acute upper gastrointestinal bleeding. Best practice & research Clinical gastroenterology. 22, 209-224.
36. 36. Forrest, J.H., N. Finlayson, and D. Shearman.,1974. Endoscopy in gastrointestinal bleeding. The Lancet. 304, 394-397.
37. 37. Rockall, T., et al.,1996. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 38, 316-321.
38. 38. Stanley, A., et al.,2009. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. The Lancet. 373, 42-47.
39. 39. Blatchford, O., W.R. Murray, and M. Blatchford.,2000 A risk score to predict need for treatment for uppergastrointestinal haemorrhage. The Lancet. 356, 1318-1321.
40. 40. Saltzman, J.R., et al.,2011. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointestinal endoscopy. 74, 1215-1224.
41. 41. Sung, J.J., et al.,2011. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut. 60, 1170-1177.
42. 42. Lau, J.Y., et al.,2020 Timing of endoscopy for acute upper gastrointestinal bleeding. New England Journal of Medicine. 382, 1299-1308.