ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy (On-Demand) | October 2022-4 BARKUN Risk Stratification and Treatment of UGI Bleeding

4 BARKUN Risk Stratification and Treatment of UGI Bleeding

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This State of the Art Lecture summarized the current knowledge and recommendations for the risk stratification and treatment of upper gastrointestinal bleeding (UGIB), specifically focusing on non-variceal UGIB and peptic ulcer bleeding (PUB). <br /><br />Key findings and recommendations include:<br /><br />- Mortality from UGIB has decreased over the past 10 years and is primarily related to co-morbid illnesses rather than bleeding itself.<br />- The Glasgow Blatchford Score (GBS) can help determine whether a patient should be admitted or discharged with outpatient follow-up. Patients with a GBS of 0 or 1 can be discharged safely.<br />- Nasogastric tubes are generally not required in patients with UGIB as they do not improve visualization or risk stratification.<br />- A restrictive red blood cell transfusion policy (hemoglobin threshold of 7 g/dL) is recommended for UGIB patients.<br />- Prokinetic therapy with erythromycin before endoscopy can improve visualization and reduce the need for a second-look endoscopy in UGIB patients.<br />- The use of pre-endoscopic proton pump inhibitor (PPI) therapy is not strongly recommended or discouraged due to mixed evidence.<br />- Patients with UGIB should undergo endoscopy within 24 hours of presentation, unless variceal bleeding is suspected (in which case endoscopy should be done within 12 hours).<br />- Endoscopic therapy is recommended for ulcers with active bleeding or non-bleeding visible vessels, while the use of endoscopic therapy for ulcers with adherent clots is uncertain.<br />- Various hemostatic modalities, including bipolar electrocoagulation, heater probe, injection of absolute ethanol, through-the-scope clips, and argon plasma coagulation, can be used to treat bleeding ulcers.<br />- Hemostatic powder spray TC-325 (HemosprayTM) can be considered for actively bleeding ulcers, but only if other therapies are not readily available due to its high cost.<br />- Over-the-scope clips may be used for patients who develop recurrent bleeding from ulcers after successful endoscopic therapy.<br />- High-dose PPI therapy should be given continuously or intermittently for three days after successful endoscopic hemostatic therapy of a bleeding ulcer and should be continued for at least two weeks for high-risk patients.<br />- Patients with recurrent bleeding after endoscopic therapy should undergo repeat endoscopy and endoscopic therapy rather than surgery or transcatheter arterial embolization, although alternative forms of therapy may be considered in some cases.<br />- Management of patients on anticoagulants or antiplatelet agents in the setting of acute GI bleeding requires careful consideration of the severity of bleeding and the type of anticoagulant/antiplatelet agent being used.<br />- Secondary prophylaxis with H. pylori eradication and PPI therapy is recommended for patients with a history of ulcer bleeding.<br /><br />Overall, this lecture provides valuable insights into the current state of risk stratification and treatment of UGIB and PUB, assisting clinicians in making informed decisions for optimal patient management.

Keywords

upper gastrointestinal bleeding

Glasgow Blatchford Score

endoscopy

hemostatic therapy

prokinetic therapy

PPI therapy

recurrent bleeding

anticoagulants

antiplatelet agents

H. pylori eradication