International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding

  1. Alan N. Barkun, MD, MSc (Clinical Epidemiology);
  2. Marc Bardou, MD, PhD;
  3. Ernst J. Kuipers, MD;
  4. Joseph Sung, MD;
  5. Richard H. Hunt, MD;
  6. Myriam Martel, BSc;
  7. Paul Sinclair, MSc; and
  8. for the International Consensus Upper Gastrointestinal Bleeding Conference Group*
  1. From McGill University, Montreal, Quebec, Canada; INSERM CIC-P 803 and Service de Pharmacologie, Centre Hospitalier Universitaire de Dijon, Dijon, France; Erasmus MC University Medical Center, Rotterdam, the Netherlands; Chinese University of Hong Kong, Sha Tin, Hong Kong, China; McMaster University Health Science Centre, Hamilton, Ontario, Canada; and Canadian Association of Gastroenterology, Oakville, Ontario, Canada.

Abstract

Description: A multidisciplinary group of 34 experts from 15 countries developed this update and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding (UGIB) from 2003.

Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) process and independent ethics protocols were used. Sources of data included original and published systematic reviews; randomized, controlled trials; and abstracts up to October 2008. Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Recommendations: Recommendations emphasize early risk stratification, by using validated prognostic scales, and early endoscopy (within 24 hours). Endoscopic hemostasis remains indicated for high-risk lesions, whereas data support attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. Clips or thermocoagulation, alone or with epinephrine injection, are effective methods; epinephrine injection alone is not recommended. Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended. Preendoscopy proton-pump inhibitor (PPI) therapy may downstage the lesion; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata. Although selected patients can be discharged promptly after endoscopy, high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. For patients with UGIB who require a nonsteroidal anti-inflammatory drug, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding. Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days); ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding.

Article and Author Information

  • Note: This consensus conference, organized by the Canadian Association of Gastroenterology, was held in Vienna, Austria, on 23–24 October 2008. These consensus recommendations are endorsed by the Canadian Association of Gastroenterology, the Asian Pacific Society of Digestive Endoscopy, and the European Association for Gastroenterology and Endoscopy. Since the consensus conference, the following professional societies have reviewed and also endorsed the recommendations: European Society of Gastrointestinal Endoscopy, Hong Kong Society of Digestive Endoscopy, Italian Society of Digestive Endoscopy, Asociación Española de Gastroenterología, Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas, and Sociedad de Gastroenterologia del Uruguay.

  • Acknowledgment: The authors thank Pauline Lavigne for editorial assistance; Anoush Rhazzagi, Alexandra Shingina, and Aurélie Fichet for research assistance; and Sandra Daniels and Andres Gardeazabal for organization of the consensus conference.

  • Grant Support: By the Canadian Association of Gastroenterology; European Association for Gastroenterology and Endoscopy; Asian Pacific Society of Digestive Endoscopy; and Institute of Diabetes, Metabolism, and Nutrition (of the Canadian Institutes of Health Research), and at-arms-length contributions to these societies from AstraZeneca Mölndal, Abbott Canada, and Olympus Canada.

  • Potential Conflicts of Interest: Consultancies: A.N. Barkun (Astra Zeneca), R.H. Hunt (Schering-Plough), P. Sinclair (AstraZeneca). Honoraria: M. Bardou (AstraZeneca), E.J. Kuipers (AstraZeneca), J. Sung (Nycomed), R.H. Hunt (Nycomed). Grants pending: A.N. Barkun (AstraZeneca, Olympus), E.J. Kuipers (AstraZeneca), J. Sung (AstraZeneca). Patents pending: A.N. Barkun (Abbott). Other: E.J. Kuipers (AstraZeneca).

  • Requests for Single Reprints: Alan Barkun, MD, MSc (Clinical Epidemiology), Division of Gastroenterology, Montreal General Hospital Site, The McGill University Health Centre, 1650 Cedar Avenue, Room D7.148, Montreal, Quebec H3G 1A4, Canada.

  • Current Author Addresses: Dr. Barkun: Division of Gastroenterology, Montreal General Hospital Site, The McGill University Health Centre, 1650 Cedar Avenue, Room D7.148, Montreal, Quebec H3G 1A4, Canada.

  • Dr. Bardou: INSERM CIC-P 803, CHU de Dijon, 2 boulevard de Lattre de Tassigny, 21000 Dijon, France.

  • Dr. Kuipers: Erasmus University Medical Centre, Room Ba-391, Box 2040, 3000 CA Rotterdam, the Netherlands.

  • Dr. Sung: Department of Medicine and Therapeutics, 9/F Clinical Science Building, Prince of Wales Hospital, Chinese University of Hong Kong, Sha Tin NT, Hong Kong.

  • Dr. Hunt: Division of Gastroenterology, McMaster University Health Science Centre, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

  • Ms. Martel: 1299 Rue Prospect, Sherbrooke, Quebec J1J 1J4, Canada.

  • Mr. Sinclair: Canadian Association of Gastroenterology, #224, 1540 Cornwall Road, Oakville, Ontario L6J 7W5, Canada.

  • Author Contributions: Conception and design: A.N. Barkun, E.J. Kuipers, J. Sung, P. Sinclair.

  • Analysis and interpretation of the data: A.N. Barkun, M. Bardou, E.J. Kuipers, J. Sung, R.H. Hunt, M. Martel, P. Sinclair.

  • Drafting of the article: A.N. Barkun, E.J. Kuipers, J. Sung, R.H. Hunt, P. Sinclair.

  • Critical revision of the article for important intellectual content: A.N. Barkun, M. Bardou, J. Sung, P. Sinclair.

  • Final approval of the article: A.N. Barkun, M. Bardou, E.J. Kuipers, J. Sung, R.H. Hunt, P. Sinclair.

  • Provision of study materials or patients: J. Sung.

  • Statistical expertise: A.N. Barkun, M. Martel.

  • Obtaining of funding: E.J. Kuipers, P. Sinclair.

  • Administrative, technical, or logistic support: A.N. Barkun, E.J. Kuipers, P. Sinclair.

  • Collection and assembly of data: M. Bardou, E.J. Kuipers, M. Martel, P. Sinclair.

  • ↵* For a list of voting participants, see Appendix 1.

Summary for Patients

  • Summaries for Patients: Management of Nonvariceal Upper Gastrointestinal Bleeding Ann Intern Med January 19, 2010 152:I-48; doi:10.1059/0003-4819-152-2-201001190-00003
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  1. Ann Intern Med January 19, 2010 vol. 152 no. 2 101-113
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