Key points

Introduction

Acute upper gastrointestinal bleeding (UGIB) refers to gross GI blood loss originating proximal to the ligament of Treitz that usually manifests as fresh blood hematemesis, “coffee ground’’ emesis, and/or melena with or without hemodynamic compromise. Hematochezia may be the presenting sign in patients with extremely brisk UGIB, yet this clinical presentation is uncommon. Traditional negative patient outcomes include rebleeding and mortality, with patient mortality commonly associated with decompensation of preexisting comorbid medical conditions precipitated by the acute bleeding event.

In most clinical settings, the great majority (80%–90%) of episodes of acute UGIB are secondary to nonvariceal causes, the foremost being peptic ulcer bleeding. Upper endoscopy is the most accurate and practical method for diagnosing the source of acute UGIB. Subsequently, appropriate endoscopic therapy significantly reduces mortality, rebleeding, requirement for transfusion, hospital stay, and health care costs. Even in the absence of specific endoscopic hemostasis therapy, the prognostic information obtained from upper endoscopy can significantly reduce the use of health care resources.

Introduction

Acute upper gastrointestinal bleeding (UGIB) refers to gross GI blood loss originating proximal to the ligament of Treitz that usually manifests as fresh blood hematemesis, “coffee ground’’ emesis, and/or melena with or without hemodynamic compromise. Hematochezia may be the presenting sign in patients with extremely brisk UGIB, yet this clinical presentation is uncommon. Traditional negative patient outcomes include rebleeding and mortality, with patient mortality commonly associated with decompensation of preexisting comorbid medical conditions precipitated by the acute bleeding event.

In most clinical settings, the great majority (80%–90%) of episodes of acute UGIB are secondary to nonvariceal causes, the foremost being peptic ulcer bleeding. Upper endoscopy is the most accurate and practical method for diagnosing the source of acute UGIB. Subsequently, appropriate endoscopic therapy significantly reduces mortality, rebleeding, requirement for transfusion, hospital stay, and health care costs. Even in the absence of specific endoscopic hemostasis therapy, the prognostic information obtained from upper endoscopy can significantly reduce the use of health care resources.

Timing of endoscopy

The first priority in UGIB patient management is correcting fluid losses and restoring hemodynamic stability. Volume resuscitation should be initiated with crystalloid intravenous (IV) fluids with the use of large-bore IV catheters (eg, 2 peripheral catheters of 16–18 gauge or a central catheter if peripheral venous access is not attainable). To maintain adequate oxygen-carrying capacity, especially in older patients with coexisting cardiopulmonary comorbidities, the use of supplemental oxygen and transfusion of plasma expanders (eg, packed red blood cells) should be considered. When indicated, correction of coagulopathy should be undertaken but should not delay performance of upper endoscopy. This can be achieved using fresh frozen plasma and in selected cases (if the platelet count is <50,000) transfusion of platelets.

Blood transfusions should be considered in patients with a hemoglobin level below 70 g/L. Early transfusions (given within 12 hours of patient presentation) have been shown to be associated with higher rates of rebleeding and a higher 30-day mortality. Villanueva and colleagues recently reported on 921 patients with UGIB randomly assigned to either a restrictive (transfuse at a hemoglobin level of ≤70 g/L) or liberal (transfuse at a hemoglobin level of ≤90 g/L) transfusion strategy. Those who received the restrictive blood transfusion strategy had significantly lower mortality at 45 days (95% vs 91%; hazard ratio [HR], 0.55; 95% CI, 0.33–0.92), less rebleeding (10% vs 16%; HR, 0.68; 95% CI, 0.47–0.98), and fewer overall adverse events. However, in the subset of nonvariceal UGIB patients, significantly improved outcomes were limited to a reduced need for surgery and only statistical trends suggesting less rebleeding and improved survival. These blood transfusion thresholds may not necessarily apply to patients with significant medical comorbidities (ie, acute coronary syndrome, symptomatic peripheral ischemia, stroke, or transient ischemic attack). Such patients may benefit from a more liberal transfusion policy in an attempt to avoid disease exacerbations induced by significant GI blood loss.

After hemodynamic stabilization, patients should undergo “early” upper endoscopy (now routinely defined as performance within 24 hours of patient presentation). Some high-risk patients, such as those with acute coronary syndrome or a suspected bowel perforation, may benefit from deferring endoscopy until their clinical situation is more fully evaluated and stabilized. Low-risk patients, identified using a pre-endoscopy risk stratification score (eg, Glasgow-Blatchford) can be considered for outpatient management. Very early or emergent upper endoscopy, performed within 2 to 12 hours of patient presentation, has not been shown to confer any additional benefit or alter patient outcomes compared with ‘early’ endoscopy. In patients who require endoscopic hemostasis therapy, early upper endoscopy results in improved patient outcome. Cooper and colleagues reported that early endoscopy significantly reduced rebleeding and surgery in patients who required endoscopic hemostasis. It has also been shown that, compared with patients who undergo routine endoscopy, early endoscopy is safe and reduces the hospital duration of stay for all patients, regardless of need for endotherapy. Early endoscopy (performed within 24 hours of patient presentation) is performed, therefore, because of its potential to improve clinical outcomes in the subset of patients who require endoscopic hemostasis and overall reduces hospital length of stay and health care costs.

Studies of urgent endoscopy (ie, endoscopy performed within only a few hours of patient presentation) have not shown any differences in patient outcomes compared with routine timed performance of endoscopy. Several randomized, controlled trials and retrospective cohort studies have examined “very early endoscopy” at less than 2 to 3, less than 6, less than 8, or less than 12 hours compared with endoscopy performed at less than 24 to 48 hours. Very early endoscopy yielded higher rates of finding high-risk endoscopic stigmata of bleeding, and thus, higher rates of endoscopic hemostasis, but without demonstrable improved outcomes of rebleeding, need for surgery, or duration of hospitalization. In higher risk patients, 1 study randomizing patients to upper endoscopy fewer than 12 hours versus longer than 12 hours from patient presentation, detected a significantly reduced need for blood transfusions and shorter hospitalization (4 vs 14.5 days) in the subgroup of patients with coffee grounds or bloody nasogastric aspirate. Moreover, an observational study demonstrated that longer time to endoscopy predicted all-cause, “in hospital” mortality in patients with a Blatchford score of 12 or higher. The American College of Gastroenterology’s recent guidelines on peptic ulcer bleeding suggest that upper endoscopy performed within 12 hours of patient presentation may be considered in high-risk patients. Similarly, the United Kingdom UGIB toolkit produced by the Academy of Royal Medical Colleges recommends upper endoscopy within 6 to 12 hours in “urgent-risk” patients, a practice that is currently not supported by high-quality evidence for nonvariceal UGIB, although appropriate in the context of suspected variceal bleeding where upper endoscopy within 12 hours is recommended.

Data from bleeding registries show that a significant proportion of UGIB patients have a delay of greater than 24 hours before undergoing upper endoscopy. Reasons behind such delays are likely multifactorial; however, several reports from administrative databases report a “weekend effect,” whereby UGIB patients presenting on weekends are less likely to undergo early endoscopy and have higher mortality, which may or may not be owing to the delay in receiving endoscopy. Nevertheless, endoscopy within 24 hours of patient presentation should be targeted as a standalone quality indicator when managing patients with acute UGIB. The availability both of on-call GI endoscopists proficient in endoscopic hemostasis and on-call support staff with technical expertise in the usage of endoscopic devices enables performance of endoscopy on a 24/7 basis and is recommended.