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KMID : 1048120120010010053
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International Journal of Gastrointestinal Intervention
2012 Volume.1 No. 1 p.53 ~ p.57
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Evidence-based management of patients with acute non-variceal upper gastrointestinal bleeding
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Lau James Y.W.
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Abstract
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The management of patients with acute upper gastrointestinal bleeding should consist of early assessment and volume resuscitation. Endoscopy should be performed in all patients within 24 hours of their presentation. The Glasgow Blatchford score requires validation in different centers. It is accurate in identifying those at low risk of requiring intervention. The risk score is less specific in identifying those who require urgent endoscopic intervention. During endoscopy, the presence of active bleeding and a non-bleeding visible vessel mandate endoscopic hemostatic treatment. There is also evidence that clots overlying ulcers should be unveiled and hemostatic treatment offered to underlying stigmata. Injection therapy using diluted epinephrine alone is considered inadequate. A second treatment should be added to induce thrombosis of the bleeding artery. The use of thermo-coagulation with a thermal device or hemo-clips alone or after pre-injection with epinephrine is equally efficacious. Second look endoscopy should be performed in selected high risk or re-bleeding patients. Proton pump inhibitor (PPI) should administer as an adjunctive therapy. The dose of PPI use continues to be controversial. Angiographic embolization compares favorably to surgery as a rescue therapy where endoscopic therapy fails. Helicobacter pylori should be tested and treated in the presence of infection. In those who require aspirin for cardiovascular prophylaxis, aspirin should be resumed early. A low dose PPI should be added for secondary prophylaxis. In those who continue to require an analgesic, co-therapy of PPI with traditional non-steroidal anti-inflammatory agent and the use of COX-II inhibitor alone are associated with a small risk of recurrent bleeding. A combination of COX-II inhibitor and PPI is preferred in those with very high risk of gastrointestinal events. In patients on dual antiplatelet agents, PPI appears to reduce gastrointestinal events without increasing cardiovascular events.
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KEYWORD
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Hematemesis, Melena, Peptic ulcer hemorrhage
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