CLINICAL REVIEW
Initial Assessment and Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Emily D. Bethea, MD,* Anne C. Travis, MD, MSc,wz and John R. Saltzman, MDwz
Abstract: Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB. Key Words: upper gastrointestinal hemorrhage (UGIH), upper gastrointestinal bleeding (UGIB), risk stratification, scoring systems, restrictive transfusion strategy, hemoglobin target, international normalized ratio (INR) target, time to endoscopy
(J Clin Gastroenterol 2014;48:823–829)
at increased risk of needing endoscopic intervention, rebleeding, and death. Once adequately resuscitated, patients who are not deemed to be lowest risk should undergo upper endoscopy. An important issue to consider is the timing of endoscopy, as both urgent endoscopy (performed within 24 h of admission) and delayed endoscopy (performed at least 24 h after presentation), can both be associated with adverse patient outcomes. However, for the majority of patients, endoscopy should be performed within 24 hours.7
RESUSCITATION The first step in the management of patients with UGIB is to provide adequate fluid resuscitation. Patients should have either 2 large-bore (18 G or larger) peripheral intravenous catheters or a central venous catheter placed. Once intravenous access is established, if there are signs of active bleeding or hemodynamic instability (eg, pulse >100 beats per minute, systolic blood pressure
Initial Assessment and Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding Emily D. Bethea, MD,* Anne C. Travis, MD, MSc,wz and John R. Saltzman, MDwz
Abstract: Upper gastrointestinal bleeding (UGIB) is a substantial clinical and economic burden, with an estimated mortality rate between 3% and 15%. The initial management starts with hemodynamic assessment and resuscitation. Blood transfusions may be needed in patients with low hemoglobin levels or massive bleeding, and patients who are anticoagulated may require administration of fresh frozen plasma. Patients with significant bleeding should be started on a proton-pump inhibitor infusion, and if there is concern for variceal bleeding, an octreotide infusion. Patients with UGIB should be stratified into low-risk and high-risk categories using validated risk scores. The use of these risk scores can aid in separating low-risk patients who are suitable for outpatient management or early discharge following endoscopy from patients who are at increased risk for needing endoscopic intervention, rebleeding, and death. Upper endoscopy after adequate resuscitation is required for most patients and should be performed within 24 hours of presentation. Key to improving outcomes is appropriate initial management of patients presenting with UGIB. Key Words: upper gastrointestinal hemorrhage (UGIH), upper gastrointestinal bleeding (UGIB), risk stratification, scoring systems, restrictive transfusion strategy, hemoglobin target, international normalized ratio (INR) target, time to endoscopy
(J Clin Gastroenterol 2014;48:823–829)
at increased risk of needing endoscopic intervention, rebleeding, and death. Once adequately resuscitated, patients who are not deemed to be lowest risk should undergo upper endoscopy. An important issue to consider is the timing of endoscopy, as both urgent endoscopy (performed within 24 h of admission) and delayed endoscopy (performed at least 24 h after presentation), can both be associated with adverse patient outcomes. However, for the majority of patients, endoscopy should be performed within 24 hours.7
RESUSCITATION The first step in the management of patients with UGIB is to provide adequate fluid resuscitation. Patients should have either 2 large-bore (18 G or larger) peripheral intravenous catheters or a central venous catheter placed. Once intravenous access is established, if there are signs of active bleeding or hemodynamic instability (eg, pulse >100 beats per minute, systolic blood pressure
