This is the current release of the guideline.

Definitions for the Quality of Evidence (I, II-1, II-2, II-3, and III), the Classification of Recommendations (A, B, C, D, and E), and the Voting Schema (a, b, c, d, e) are provided at the end of the "Major Recommendations" field.

Initial Management

Recommendation 1: Hospitals should develop institution-specific protocols for multidisciplinary management, which should include access to an endoscopist with training in endoscopic hemostasis. Recommendation: C (vote: a, 100%); Evidence: III

Recommendation 2: Support staff trained to assist in endoscopy should be available for urgent endoscopy. Recommendation: C (vote: a, 92%; b, 8%); Evidence: III

Recommendation 3: Immediate evaluation and appropriate resuscitation are critical to proper management. Recommendation: C (vote: a, 96%; b, 4%); Evidence: III

Recommendation 4: In selected patients, the placement of a nasogastric tube can be considered because the findings may have prognostic value. Recommendation: B (vote: a, 40%; b, 36%; c, 24%); Evidence: II-3

Risk Stratification

Recommendation 5.1: Clinical (nonendoscopic) stratification of patients into low- and high-risk categories for rebleeding and mortality is important for proper management. Available prognostic scales may be used to assist in decision-making. Recommendation: B (vote: a, 76%; b, 24%); Evidence: II-2

Recommendation 5.2: Early stratification of patients into low- and high-risk categories for rebleeding and mortality, based on clinical and endoscopic criteria, is important for proper management. Available prognostic scales may be used to assist in decision making. Recommendation: A (vote: a, 96%; b, 4%); Evidence: I

Endoscopic Therapy

Recommendation 6: Early endoscopy (within the first 24 hours) with risk classification by clinical and endoscopic criteria allows for safe and prompt discharge of patients classified as low risk (Recommendation: A [vote: a, 92%; b, 8%]; Evidence: I); improves patient outcomes for patients classified as high risk (Recommendation: C [vote: a, 64%; b, 36%]; Evidence: II-2); and reduces resource utilization of patients classified as either low or high risk (Recommendation: A [vote: a, 88%; b, 12%]; Evidence: I).

Recommendation 7: A finding of low-risk endoscopic stigmata (a clean-based ulcer or a nonprotuberant pigmented dot in an ulcer bed) is not an indication for endoscopic hemostatic therapy (Recommendation: A [vote: a, 100%]; Evidence: I). A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgment, with appropriate treatment of the underlying lesion (Recommendation: A [vote: a, 72%; b, 28%]; Evidence: I). A finding of high-risk endoscopic stigmata (active bleeding or a visible vessel in an ulcer bed) is an indication for immediate endoscopic hemostatic therapy (Recommendation: A [vote: a, 100%]; Evidence: I).

Recommendation 8: No single solution for endoscopic injection therapy is superior to another for hemostasis. Recommendation: A (vote: a, 92%; b, 8%); Evidence: I

Recommendation 9: No single method of endoscopic thermal coaptive therapy is superior to another. Recommendation: A (vote: a, 100%); Evidence: I

Recommendation 10: Monotherapy, with injection or thermal coagulation, is an effective endoscopic hemostatic technique for high-risk stigmata; however, the combination is superior to either treatment alone. Recommendation: B (vote: a, 48%; b, 48%; c, 4%); Evidence: I

Recommendation 11: The placement of clips is a promising endoscopic hemostatic therapy for high-risk stigmata. Recommendation: B (vote: a, 44%; b, 52%; c, 4%); Evidence: I

Recommendation 12: Routine second-look endoscopy is not recommended. Recommendation: E (vote: a, 92%; b,8%); Evidence: I

Recommendation 13: In cases of rebleeding, a second attempt at endoscopic therapy is generally recommended. Recommendation: A (vote: a, 100%); Evidence: I

Recommendation 14: Surgical consultation should be sought for patients who have failed endoscopic therapy. Recommendation: B (vote: a, 100%); Evidence: II-2

Pharmacotherapy

Recommendation 15: H₂-receptor antagonists are not recommended in the management of patients with acute upper gastrointestinal (GI) bleeding. Recommendation: D (vote: a, 92%; b, 8%); Evidence: I

Recommendation 16: Somatostatin and octreotide are not recommended in the routine management of patients with acute nonvariceal upper GI bleeding. Recommendation: C (vote: a, 96%; b, 4%); Evidence: I

Recommendation 17: An intravenous bolus followed by continuous-infusion proton-pump inhibitor is effective in decreasing rebleeding in patients who have undergone successful endoscopic therapy. Recommendation: A (vote: a, 100%); Evidence: I

Recommendation 18: In patients awaiting endoscopy, empirical therapy with a high-dose proton pump inhibitor should be considered. Recommendation: C (vote: a, 40%; b, 32%; c, 16%; d, 12%); Evidence: III

Recommendation 19: Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours. Recommendation: A (vote: a, 88%; b, 12%); Evidence: I

Recommendation 20: Patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present. Recommendation: A (vote: a, 96%; b, 4%); Evidence: I

Definitions

Quality of evidence

I Evidence obtained from at least 1 properly randomized, controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than 1 center or research group

II-3 Evidence obtained from comparisons between times or places with or without the intervention, or dramatic results in uncontrolled experiments

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Classification of recommendations

A There is good evidence to support the procedure or treatment.

B There is fair evidence to support the procedure or treatment.

C There is poor evidence to support the procedure or treatment, but recommendations may be made on other grounds.

D There is fair evidence that the procedure or treatment should not be used.

E There is good evidence that the procedure or treatment should not be used.

Voting schema*

1. Accept completely.
2. Accept with some reservation.
3. Accept with major reservation.
4. Reject with reservation.
5. Reject completely.

* Statements for which more than 50% of participants voted a, b, or c were accepted.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2003 Nov 18

Canadian Association of Gastroenterology - Medical Specialty Society

The Canadian Association of Gastroenterology administered all aspects of the meeting and secured multipartner funding from industry sponsors. Additional funds were obtained through a peer-review grant received by the Canadian Institutes of Health Research and an internal award from the Research Institute of the McGill University Health Centre.

Nonvariceal Upper Gastrointestinal Bleeding Consensus Conference Group

Authors: Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; John K. Marshall, MD, MSc

Statements of conflicts of interest were obtained from all voting participants, and additional ethical information was collected.

Potential Financial Conflicts of Interest: Consultancies: A. Barkun (Altana Pharma Canada Inc.); Honoraria: A. Barkun (Altana Pharma Canada Inc.); Grants received: A. Barkun (Altana Pharma Canada Inc.).

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on May 5, 2004. The information was verified by the guideline developer on May 20, 2004.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.