Sunteți pe pagina 1din 16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

ThecontentontheUpToDatewebsiteisnotintendednorrecommendedasasubstituteformedicaladvice,
diagnosis,ortreatment.Alwaysseektheadviceofyourownphysicianorotherqualifiedhealthcare
professionalregardinganymedicalquestionsorconditions.Theuseofthiswebsiteisgovernedbythe
UpToDateTermsofUse2015UpToDate,Inc.
Approachtoacuteuppergastrointestinalbleedinginadults
Author
JohnRSaltzman,MD,
FACP,FACG,FASGE,
AGAF

SectionEditor
MarkFeldman,MD,
MACP,AGAF,FACG

DeputyEditor
AnneCTravis,MD,MSc,
FACG,AGAF

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Apr2015.|Thistopiclastupdated:Jan20,2015.
INTRODUCTIONPatientswithacuteuppergastrointestinal(GI)bleedingcommonlypresentwith
hematemesis(vomitingofbloodorcoffeegroundlikematerial)and/ormelena(black,tarrystools).Theinitial
evaluationofpatientswithacuteupperGIbleedinginvolvesanassessmentofhemodynamicstabilityand
resuscitationifnecessary.Diagnosticstudies(usuallyendoscopy)follow,withthegoalofbothdiagnosis,and
whenpossible,treatmentofthespecificdisorder.
Thediagnosticandinitialtherapeuticapproachtopatientswithclinicallysignificant(ie,thepassageofmore
thanascantamountofblood)acuteupperGIbleedingwillbereviewedhere.Thisapproachisconsistentwith
amultidisciplinaryinternationalconsensusstatementupdatedin2010,a2012guidelineissuedbytheAmerican
SocietyforGastrointestinalEndoscopy,anda2012guidelineissuedbytheAmericanCollegeof
Gastroenterology[14].ThecausesofupperGIbleeding,theendoscopicmanagementofacuteupperGI
bleeding,andthemanagementofactivevaricealhemorrhagearediscussedseparately.(See"Majorcausesof
uppergastrointestinalbleedinginadults"and"Overviewofthetreatmentofbleedingpepticulcers"and
"Generalprinciplesofthemanagementofvaricealhemorrhage"and"Methodstoachievehemostasisin
patientswithacutevaricealhemorrhage".)
Atableoutliningtheemergencymanagementofacutesevereuppergastrointestinalbleedingisprovided(table
1).
INITIALEVALUATIONTheinitialevaluationofapatientwithasuspectedclinicallysignificantacuteupper
GIbleedincludesahistory,physicalexamination,laboratorytests,andinsomecases,nasogastriclavage.
Thegoaloftheevaluationistoassesstheseverityofthebleed,identifypotentialsourcesofthebleed,and
determineifthereareconditionspresentthatmayaffectsubsequentmanagement.Theinformationgatheredas
partoftheinitialevaluationisusedtoguidedecisionsregardingtriage,resuscitation,empiricmedicaltherapy,
anddiagnostictesting.
FactorsthatarepredictiveofableedcomingfromanupperGIsourceidentifiedinametaanalysisincludeda
patientreportedhistoryofmelena(likelihoodratio[LR]5.15.9),melenicstoolonexamination(LR25),bloodor
coffeegroundsdetectedduringnasogastriclavage(LR9.6),andaratioofbloodureanitrogentoserum
creatininegreaterthan30(LR7.5)[5].Ontheotherhand,thepresenceofbloodclotsinthestoolmadean
upperGIsourcelesslikely(LR0.05).Factorsassociatedwithseverebleedingincludedredblooddetected
duringnasogastriclavage(LR3.1),tachycardia(LR4.9),orahemoglobinleveloflessthan8g/dL(LR4.56.2).
BleedingmanifestationsHematemesis(eitherredbloodorcoffeegroundemesis)suggestsbleeding
proximaltotheligamentofTreitz.Thepresenceoffranklybloodyemesissuggestsmoderatetosevere
bleedingthatmaybeongoing,whereascoffeegroundemesissuggestsmorelimitedbleeding.
Themajorityofmelena(black,tarrystool)originatesproximaltotheligamentofTreitz(90percent),thoughit
mayalsooriginatefromthesmallbowelorrightcolon[6].Melenamaybeseenwithvariabledegreesofblood
loss,beingseenwithaslittleas50mLofblood[7].
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

1/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

Hematochezia(redormaroonbloodinthestool)isusuallyduetolowerGIbleeding.However,itcanoccur
withmassiveupperGIbleeding[8],whichistypicallyassociatedwithorthostatichypotension.(See'Physical
examination'below.)
PastmedicalhistoryPatientsshouldbeaskedaboutpriorepisodesofupperGIbleeding,sinceupto60
percentofpatientswithahistoryofanupperGIbleedarebleedingfromthesamelesion[9].Inaddition,the
patient'spastmedicalhistoryshouldbereviewedtoidentifyimportantcomorbidconditionsthatmayleadto
upperGIbleedingormayinfluencethepatient'ssubsequentmanagement.
Potentialbleedingsourcessuggestedbyapatient'spastmedicalhistoryinclude:
Varicesorportalhypertensivegastropathyinapatientwithahistoryofliverdiseaseoralcoholabuse
Aortoentericfistulainapatientwithahistoryofanabdominalaorticaneurysmoranaorticgraft
Angiodysplasiainapatientwithrenaldisease,aorticstenosis,orhereditaryhemorrhagictelangiectasia
PepticulcerdiseaseinapatientwithahistoryofHelicobacterpylori,nonsteroidalantiinflammatorydrug
(NSAIDs)use,orsmoking
Malignancyinapatientwithahistoryofsmoking,alcoholabuse,orH.pyloriinfection
Marginalulcers(ulcersatananastomoticsite)inapatientwithagastroentericanastomosis
ComorbidillnessesmayinfluencepatientmanagementinthesettingofanacuteupperGIbleed.Comorbid
illnessesmay:
Makepatientsmoresusceptibletohypoxemia(eg,coronaryarterydisease,pulmonarydisease).Such
patientsmayneedtobemaintainedathigherhemoglobinlevelsthanpatientswithoutthesedisorders.
(See'Bloodtransfusions'below.)
Predisposepatientstovolumeoverloadinthesettingoffluidresuscitationorbloodtransfusions(eg,renal
disease,heartfailure).Suchpatientsmayneedmoreinvasivemonitoringduringresuscitation.(See
'Generalsupport'below.)
Resultinbleedingthatismoredifficulttocontrol(eg,coagulopathies,thrombocytopenia,significant
hepaticdysfunction).Suchpatientsmayneedtransfusionsoffreshfrozenplasmaorplatelets.(See
'Bloodtransfusions'below.)
Predisposetoaspiration(eg,dementia,hepaticencephalopathy).Endotrachealintubationshouldbe
consideredinsuchpatients.(See'Generalsupport'below.)
MedicationhistoryAthoroughmedicationhistoryshouldbeobtained,withparticularattentionpaidtodrugs
that:
Predisposetopepticulcerformation,suchasaspirinandothernonsteroidalantiinflammatorydrugs
(NSAIDs)(see"NSAIDs(includingaspirin):Pathogenesisofgastroduodenaltoxicity")
Areassociatedwithpillesophagitis(see"Medicationinducedesophagitis")
Promotebleeding,suchasantiplateletagents(eg,clopidogrel)andanticoagulants
Mayaltertheclinicalpresentation,suchasbismuthandiron,whichcanturnthestoolblack
SymptomassessmentPatientsshouldbeaskedaboutsymptomsaspartoftheassessmentofthe
severityofthebleedandasapartoftheevaluationforpotentialbleedingsources.Symptomsthatsuggestthe
bleedingissevereincludeorthostaticdizziness,confusion,angina,severepalpitations,andcold/clammy
extremities.
SpecificcausesofupperGIbleedingmaybesuggestedbythepatient'ssymptoms[6]:
Pepticulcer:Epigastricorrightupperquadrantpain
Esophagealulcer:Odynophagia,gastroesophagealreflux,dysphagia
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

2/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

MalloryWeisstear:Emesis,retching,orcoughingpriortohematemesis
Varicealhemorrhageorportalhypertensivegastropathy:Jaundice,weakness,fatigue,anorexia,
abdominaldistention
Malignancy:Dysphagia,earlysatiety,involuntaryweightloss,cachexia
PhysicalexaminationThephysicalexaminationisakeycomponentoftheassessmentofhemodynamic
stability.Signsofhypovolemiainclude[6]:
Mildtomoderatehypovolemia:Restingtachycardia
Bloodvolumelossofatleast15percent:Orthostatichypotension(adecreaseinthesystolicblood
pressureofmorethan20mmHgand/oranincreaseinheartrateof20beatsperminutewhenmoving
fromrecumbencytostanding)
Bloodvolumelossofatleast40percent:Supinehypotension
Examinationofthestoolcolormayprovideacluetothelocationofthebleeding,butitisnotareliable
indicator.Inaseriesof80patientswithseverehematochezia(redormaroonbloodinthestool),74percenthad
acoloniclesion,11percenthadanupperGIlesion,9percenthadapresumedsmallbowelsource,andnosite
wasidentifiedin6percent[8].Nasogastriclavagemaybecarriedoutifthereisdoubtastowhetherableed
originatesfromtheupperGItract.(See'Nasogastriclavage'below.)
Thepresenceofabdominalpain,especiallyifsevereandassociatedwithreboundtendernessorinvoluntary
guarding,raisesconcernforperforation.Ifanysignsofanacuteabdomenarepresent,furtherevaluationto
excludeaperforationisrequiredpriortoendoscopy.(See"Diagnosticapproachtoabdominalpaininadults",
sectionon'Surgicalabdomen'.)
Finally,aswiththepastmedicalhistory,thephysicalexaminationshouldincludeasearchforevidenceof
significantcomorbidillnesses.(See'Pastmedicalhistory'above.)
LaboratorydataLaboratoryteststhatshouldbeobtainedinpatientswithacuteuppergastrointestinal
bleedingincludeacompletebloodcount,serumchemistries,livertests,andcoagulationstudies.Inaddition,
serialelectrocardiogramsandcardiacenzymesmaybeindicatedinpatientswhoareatriskforamyocardial
infarction,suchasolderadults,patientswithahistoryofcoronaryarterydisease,orpatientswithsymptoms
suchaschestpainordyspnea.(See"Criteriaforthediagnosisofacutemyocardialinfarction".)
TheinitialhemoglobininpatientswithacuteupperGIbleedingwilloftenbeatthepatient'sbaselinebecause
thepatientislosingwholeblood.Withtime(typicallyafter24hoursormore)thehemoglobinwilldeclineasthe
bloodisdilutedbytheinfluxofextravascularfluidintothevascularspaceandbyfluidadministeredduring
resuscitation.Itshouldbekeptinmindthatoverhydrationcanleadtoafalselylowhemoglobinvalue.The
initialhemoglobinlevelismonitoredeverytwotoeighthours,dependingupontheseverityofthebleed.
Patientswithacutebleedingshouldhavenormocyticredbloodcells.Microcyticredbloodcellsoriron
deficiencyanemiasuggestchronicbleeding.Becausebloodisabsorbedasitpassesthroughthesmallbowel
andpatientsmayhavedecreasedrenalperfusion,patientswithacuteupperGIbleedingtypicallyhavean
elevatedbloodureanitrogen(BUN)tocreatinineorureatocreatinineratio(>20:1or>100:1,respectively)
[10,11].Thehighertheratio,themorelikelythebleedingisfromanupperGIsource[10].
NasogastriclavageWhetherallpatientswithsuspectedacuteupperGIbleedingrequirenasogastrictube
(NGT)placementiscontroversial,inpartbecausestudieshavefailedtodemonstrateabenefitwithregardto
clinicaloutcomes[12].Asanexample,aretrospectivestudylookedatwhethertherewereclinicalbenefits
fromNGTlavagein632patientsadmittedwithgastrointestinalbleeding[13].PatientswhounderwentNGT
lavagewerematchedwithpatientswithsimilarcharacteristicswhodidnotundergoNGTlavage.NGTlavage
wasassociatedwithashortertimetoendoscopy.However,therewerenodifferencesbetweenthosewho
underwentNGTlavageandthosewhodidnotwithregardtomortality,lengthofhospitalstay,surgery,or
transfusionrequirement.
Moreoften,NGTlavageisusedwhenitisunclearifapatienthasongoingbleedingandthusmightbenefitfrom
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

3/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

anearlyendoscopy.Inaddition,nasogastrictubelavagecanbeusedtoremoveparticulatematter,freshblood,
andclotsfromthestomachtofacilitateendoscopy.(See"Nasogastricandnasoenterictubes",sectionon
'Tubeplacement'.)
ThepresenceofredbloodorcoffeegroundmaterialintheaspiratealsoconfirmsanupperGIsourceof
bleedingandpredictswhetherthebleedingiscausedbyalesionatincreasedriskforongoingorrecurrent
bleeding[13,14].However,lavagemaynotbepositiveifbleedinghasceasedorarisesbeyondaclosed
pylorus.Thepresenceofnonbloodybiliousfluidsuggeststhatthepylorusisopenandthatthereisnoactive
upperGIbleedingdistaltothepylorus[8].
WesuggestthatpatientsonlyundergoNGTlavageifparticulatematter,freshblood,orclotsneedtobe
removedfromthestomachtofacilitateendoscopy.
GENERALMANAGEMENT
TriageAllpatientswithhemodynamicinstability(shock,orthostatichypotension)oractivebleeding
(manifestedbyhematemesis,brightredbloodpernasogastrictube,orhematochezia)shouldbeadmittedtoan
intensivecareunitforresuscitationandcloseobservationwithautomatedbloodpressuremonitoring,
electrocardiogrammonitoring,andpulseoximetry.
Atableoutliningtheemergencymanagementofacutesevereuppergastrointestinalbleedingisprovided(table
1).
Otherpatientscanbeadmittedtoaregularmedicalward,thoughwesuggestthatalladmittedpatientswiththe
exceptionoflowriskpatientsreceiveelectrocardiogrammonitoring.Outpatientmanagementmaybe
appropriateforsomelowriskpatients.(See'Riskstratification'below.)
GeneralsupportPatientsshouldreceivesupplementaloxygenbynasalcannulaandshouldreceivenothing
permouth.Twolargecaliber(16gaugeorlarger)peripheralintravenouscathetersoracentralvenousline
shouldbeinsertedandplacementofapulmonaryarterycathetershouldbeconsideredinpatientswith
hemodynamicinstabilityorwhoneedclosemonitoringduringresuscitation.(See"Pulmonaryartery
catheterization:Indications,contraindications,andcomplicationsinadults".)
Electiveendotrachealintubationinpatientswithongoinghematemesisoralteredrespiratoryormentalstatus
mayfacilitateendoscopyanddecreasetheriskofaspiration.
FluidresuscitationAdequateresuscitationandstabilizationisessentialpriortoendoscopytominimize
treatmentassociatedcomplications[15].Patientswithactivebleedingshouldreceiveintravenousfluids(eg,
500mLofnormalsalineorlactatedRinger'ssolutionover30minutes)whilebeingtypedandcrossmatchedfor
bloodtransfusion.Patientsatriskoffluidoverloadmayrequireintensivemonitoringwithapulmonaryartery
catheter.
Ifthebloodpressurefailstorespondtoinitialresuscitationefforts,therateoffluidadministrationshouldbe
increased.
BloodtransfusionsThedecisiontoinitiatebloodtransfusionsmustbeindividualized.Ourapproachisto
initiatebloodtransfusionsifthehemoglobinis<7g/dL(70g/L)formostpatients(includingthosewithstable
coronaryarterydisease),withagoalofmaintainingthehemoglobinatalevel7g/dL(70g/L)[4,1618].
However,ourgoalistomaintainthehemoglobinatalevelof9g/dL(90g/L)forpatientsatincreasedriskof
sufferingadverseeventsinthesettingofsignificantanemia,suchasthosewithunstablecoronaryartery
disease.Wedonothaveanagecutofffordeterminingwhichpatientsshouldhaveagoalhemoglobinof9
g/dL(90g/L),andinsteadbasethedecisiononthepatient'scomorbidconditions.However,patientswith
activebleedingandhypovolemiamayrequirebloodtransfusiondespiteanapparentlynormalhemoglobin.(See
'Laboratorydata'above.)
Itisparticularlyimportanttoavoidovertransfusioninpatientswithsuspectedvaricealbleeding,asitcan
precipitateworseningofthebleeding[17,1922].Transfusingpatientswithsuspectedvaricealbleedingtoa
hemoglobin>10g/dL(100g/L)shouldbeavoided.(See"Generalprinciplesofthemanagementofvariceal
hemorrhage",sectionon'Hemodynamicresuscitation'.)
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

4/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

Arandomizedtrialsuggeststhatusingalowerhemoglobinthresholdforinitiatingtransfusionimproves
outcomes.Inthetrial,921adultswithacuteupperGIbleedingwereassignedtoeitherarestrictivetransfusion
strategy(transfusiononlywhenthehemoglobinfellto<7g/dL[70g/L])oraliberaltransfusionstrategy
(transfusionwhenthehemoglobinfellto<9g/dL[90g/L])[17].
Patientswereexcludediftheyhadmassiveexsanguinatingbleeding,anacutecoronarysyndrome,
symptomaticperipheralvasculopathy,stroke,transientischemicattack,transfusionwithintheprior90days,
recenttraumaorsurgery,aRockallscoreof0withahemoglobinlevelhigherthan12g/dL(120g/L,patientsat
lowriskoffurtherbleeding),oriftheattendingclinicianpreviouslydecidedthatapatientshouldavoidaspecific
medicaltherapy.Olderagewasnotanexclusioncriterion,andthemeanageofpatientswas64yearsinthe
restrictivegroupand66yearsintheliberalgroup.Inaddition,cirrhosiswasnotanexclusioncriterion(31
percentofthepatientsinthestudyhadcirrhosis).Themajorityofpatientsintherestrictiveandliberal
transfusiongroupshadbleedingduetoapepticulcer(51and47percent,respectively),followedbyvariceal
bleeding(23and24percent,respectively).
Patientsintherestrictivegroupweremorelikelythanthoseintheliberalgrouptoavoidtransfusion(51versus
14percent)andreceivedfewerunitsofblood(mean1.5versus3.8units).Mortalitywaslowerintherestrictive
strategygroup(5versus9percent,adjustedhazardratio0.55,95%CI0.330.92).Patientsintherestrictive
groupwerealsolesslikelytohavefurtherbleedingortosuffercomplications.Amongpatientswithcirrhosis,
therisksofdeathandfurtherbleedingwerelowerwiththerestrictivestrategyforpatientswithChildAorB
cirrhosis,butweresimilarforpatientwithChildCcirrhosis.
Itisimportanttonote,however,thatallthepatientsinthisstudyunderwentemergentupperendoscopywitha
meandurationfromadmissiontoupperendoscopyof5hours.Endoscopictherapywasgiventothosewith
activebleeding,anonbleedingvisiblevessel,anadherentclot,orbleedingesophagealvarices.Itisnotclear
whethersimilarresultswouldbeseeninpatientswhodonotreceiveanupperendoscopyandendoscopic
therapyasquicklyasthepatientsincludedinthisstudy.Theoretically,patientstreatedwitharestrictive
transfusionstrategymayhaveworseoutcomesinthesettingofdelayedendoscopywithongoingbleeding.
Aretrospectivestudyalsosuggestedthatoutcomesmaybeworseinpatientswhoreceivebloodtransfusions.
Thestudyincluded1677patientswithnonvaricealupperGIbleeding[23].Whilenotassociatedwithmortality,
bloodtransfusionwithinthefirst24hoursofpresentationwasindependentlyassociatedwithanincreasedrisk
ofrebleedingafteradjustingforfactorssuchashemodynamicinstability,endoscopictherapy,highrisk
stigmataofrecurrenthemorrhage,initialhemoglobinvalue,andthepresenceofbloodonrectalexaminationor
inthenasogastrictubeaspirate(OR1.8,95%CI1.22.8).
Patientswithactivebleedingandacoagulopathy(prolongedprothrombintimewithINR>1.5)orlowplatelet
count(<50,000/microL)shouldbetransfusedwithfreshfrozenplasma(FFP)orplatelets,respectively.
Providedthepatientishemodynamicallystable,urgentendoscopycanusuallyproceedsimultaneouslywith
transfusionandshouldnotbepostponeduntilthecoagulopathyiscorrected.However,inpatientswithanINR
3,weattempttocorrecttheINRto<3priortostartinganendoscopy,withadditionalFFPbeinggivenafter
theendoscopyifhighriskstigmataforrecurrentbleedingwerefoundorifendoscopictherapywasperformed
andtheINRisstill>1.5.Thisapproachisbasedondatathatsuggestendoscopyissafeinpatientswhoare
mildlytomoderatelyanticoagulated[24].Inaddition,becausepackedredbloodcellsdonotcontaincoagulation
factors,transfusionofaunitofFFPshouldbeconsideredaftereveryfourunitsofpackedredbloodcells[25].
Platelettransfusionsshouldalsobeconsideredinpatientswithlifethreateningbleedingwhohavereceived
antiplateletagentssuchasaspirinorclopidogrel[26].Ifthepatientistakingthemedicationsbecauseofa
recent(lessthanoneyear)vascularstentplacementoracutecoronarysyndrome,whenpossible,a
cardiologistshouldbeconsultedpriortostoppingtheagentorgivingaplatelettransfusion.
Medications
AcidsuppressionPatientsadmittedtothehospitalwithacuteupperGIbleedingaretypicallytreated
withaprotonpumpinhibitor(PPI).WesuggestthatpatientswithacuteupperGIbleedingbestartedempirically
onanintravenous(IV)PPI(eg,omeprazole40mgIVtwicedaily).Itcanbestartedatpresentationand
continueduntilconfirmationofthecauseofbleeding.Oncethesourceofthebleedinghasbeenidentifiedand
treated(ifpossible),theneedforongoingacidsuppressioncanbedetermined.(See"Overviewofthetreatment
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

5/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

ofbleedingpepticulcers",sectionon'Acidsuppression'.)
Severalstudieshaveexaminedtheroleofacidsuppressiongivenbeforeorafterendoscopy(withorwithout
therapeuticintervention)[27].InthesettingofactiveupperGIbleedingfromanulcer,acidsuppressivetherapy
withH2receptorantagonistshasnotbeenshowntosignificantlylowertherateofulcerrebleeding[2830].By
contrast,highdoseantisecretorytherapywithanintravenousinfusionofaPPIsignificantlyreducestherateof
rebleedingcomparedwithstandardtreatmentinpatientswithbleedingulcers[31].OralandintravenousPPI
therapyalsodecreasethelengthofhospitalstay,rebleedingrate,andneedforbloodtransfusioninpatients
withhighriskulcerstreatedwithendoscopictherapy.(See"Overviewofthetreatmentofbleedingpeptic
ulcers",sectionon'Acidsuppression'.)
PPIsmayalsopromotehemostasisinpatientswithlesionsotherthanulcers.Thislikelyoccursbecause
neutralizationofgastricacidleadstothestabilizationofbloodclots[32].
ProkineticsBotherythromycinandmetoclopramidehavebeenstudiedinpatientswithacuteupperGI
bleeding.Thegoalofusingaprokineticagentistoimprovegastricvisualizationatthetimeofendoscopyby
clearingthestomachofblood,clots,andfoodresidue.Wesuggestthaterythromycinbeconsideredinpatients
whoarelikelytohavealargeamountofbloodintheirstomach,suchasthosewithseverebleeding.A
reasonabledoseis3mg/kgintravenouslyover20to30minutes,30to90minutespriortoendoscopy.
Erythromycinpromotesgastricemptyingbaseduponitsabilitytobeanagonistofmotilinreceptors.Using
erythromycintoimprovegastricvisualizationhasbeenstudiedinatleastfourrandomizedcontrolledtrials[33
36].Thestudiessuggestedthatasingledoseofintravenouserythromycingiven20to120minutesbefore
endoscopycansignificantlyimprovevisibility,shortenendoscopytime,andreducetheneedforsecondlook
endoscopy.Treatmentappearstobesafe.
Ametaanalysisexaminedfivetrialswith316patientswhowereassignedtoerythromycin,metoclopramide,or
placebo[37].Theanalysisfoundthattheuseofaprokineticagentdecreasedtheneedforsecondlook
endoscopy,butdidnotaffectthenumberofunitsofbloodtransfused,lengthofhospitalstay,orneedfor
surgery.Insubgroupanalyses,erythromycincontinuedtoshowabenefitwithregardtotheneedforsecond
lookendoscopy,butmetoclopramidedidnot.
Asecondmetaanalysisexaminedfourtrialswith335patientswhowereassignedtoeithererythromycinora
controlgroup[38].Themetaanalysisfoundthatpatientswhoreceivederythromycinweresignificantlymore
likelytohaveanemptystomachatthetimeofendoscopycomparedwithpatientsinthecontrolgroup(69
versus37percent).Patientstreatedwitherythromycinalsohadsignificantreductionsintheneedforsecond
endoscopy,volumeofbloodtransfused,andlengthofhospitalstay.Finally,therewasatrendtowardshorter
endoscopicproceduretimesanddecreasedmortalityforpatientstreatedwitherythromycin.
Erythromycinhasalsobeencomparedwithnasogastriclavage.Arandomizedtrialwith253patientsthat
comparederythromycinalonewithnasogastriclavagealoneandnasogastriclavagepluserythromycinfound
thatthequalityofvisualizationdidnotdiffersignificantlyamongthethreegroups[39].Inaddition,therewere
nodifferencesamongthegroupswithregardtoprocedureduration,rebleedingrates,needforsecond
endoscopy,numberoftransfusedunitsofblood,andmortality.
SomatostatinanditsanalogsSomatostatin,oritsanalogoctreotide,isusedinthetreatmentof
varicealbleedingandmayalsoreducetheriskofbleedingduetononvaricealcauses[40].Inpatientswith
suspectedvaricealbleeding,octreotideisgivenasanintravenousbolusof20to50mcg,followedbya
continuousinfusionatarateof25to50mcgperhour.(See"Methodstoachievehemostasisinpatientswith
acutevaricealhemorrhage",sectionon'Somatostatinanditsanalogs'.)
OctreotideisnotrecommendedforroutineuseinpatientswithacutenonvaricealupperGIbleeding,butitcan
beusedasadjunctivetherapyinsomecases.Itsroleisgenerallylimitedtosettingsinwhichendoscopyis
unavailableorasameanstohelpstabilizepatientsbeforedefinitivetherapycanbeperformed.(See"Overview
ofthetreatmentofbleedingpepticulcers",sectionon'Somatostatinandoctreotide'.)
AntibioticsforpatientswithcirrhosisBacterialinfectionsarepresentinupto20percentofpatients
withcirrhosiswhoarehospitalizedwithgastrointestinalbleedinguptoanadditional50percentdevelopan
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

6/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

infectionwhilehospitalized.Suchpatientshaveincreasedmortality.
Multipletrialsevaluatingtheeffectivenessofprophylacticantibioticsincirrhoticpatientshospitalizedfor
bleedingsuggestanoverallreductionininfectiouscomplicationsandpossiblydecreasedmortality.Antibiotics
mayalsoreducetheriskofrecurrentbleedinginhospitalizedpatientswhobledfromesophagealvarices.A
reasonableconclusionfromthesedataisthatpatientswithcirrhosiswhopresentwithacuteupperGIbleeding
(fromvaricesorothercauses)shouldbegivenprophylacticantibiotics,preferablybeforeendoscopy(although
effectivenesshasalsobeendemonstratedwhengivenafterendoscopy).(See"Generalprinciplesofthe
managementofvaricealhemorrhage",sectionon'Infectionanduseofprophylacticantibiotics'.)
TranexamicacidTranexamicacidisanantifibrinolyticagentthathasbeenstudiedinpatientswith
upperGIbleeding.Ametaanalysisthatincludedeightrandomizedtrialsoftranexamicacidinpatientswith
upperGIbleedingfoundabenefitwithregardtomortalitybutnotwithregardtobleeding,surgery,ortransfusion
requirements[41].Whenonlystudiesthatusedantiulcerdrugsand/orendoscopictherapywereincluded,there
wasnobeneficialeffect.ThissuggeststhatthereisnorolefortranexamicacidinthetreatmentofupperGI
bleeding,sincethecurrentstandardofcareistotreatpatientswithprotonpumpinhibitorsandendoscopic
therapy(ifindicated).
AnticoagulantsandantiplateletagentsWhenpossible,anticoagulantsandantiplateletagentsshould
beheldinpatientswithupperGIbleeding.However,thethromboticriskofreversinganticoagulationshouldbe
weighedagainsttheriskofcontinuedbleedingwithoutreversal,andthusthedecisiontodiscontinue
medicationsoradministerreversalagentsneedstobeindividualized.Insomecases(eg,stoppinga
nonsteroidalantiinflammatorydruginapatientwhoistakingitformildjointpain),thedecisiontostopthese
agentsmaybestraightforward.However,inmorecomplicatedcases,consultationwiththeproviderwho
prescribedtheanticoagulant/antiplateletmedicationshouldbeconsidered.(See"Managementofanticoagulants
inpatientsundergoingendoscopicprocedures",sectionon'Urgentproceduresinanticoagulatedpatients'and
"Endoscopicproceduresinpatientswithdisordersofhemostasis"and"Managementofantiplateletagentsin
patientsundergoingendoscopicprocedures",sectionon'Urgentproceduresinpatientsonantiplateletagents'
and"Correctingexcessanticoagulationafterwarfarin".)
Whentoresumethesemedicationsoncehemostasishasbeenachievedwillalsodependonthepatient'srisks
forthrombosisandrecurrentbleeding.(See"Managementofanticoagulantsinpatientsundergoingendoscopic
procedures",sectionon'Resumptionofanticoagulants'and"Overviewofthetreatmentofbleedingpeptic
ulcers",sectionon'Riskfactorsforpersistentorrecurrentbleeding'.)
ConsultationsGastroenterologicalconsultationshouldbeobtainedinallpatientswithsuspectedclinically
significantacuteupperGIbleeding.Thedecisiontoobtainsurgicalandinterventionalradiologyconsultations
priortoendoscopyshouldbebaseduponthelikelihoodofpersistentorrecurrentbleeding,or
risks/complicationsstemmingfromendoscopictherapy(perforation,precipitationofmassivebleeding).
Asageneralrule,weobtainsurgicalandinterventionalradiologyconsultationifendoscopictherapyisunlikely
tobesuccessful,ifthepatientisdeemedtobeathighriskforrebleedingorcomplicationsassociatedwith
endoscopy,orifthereisconcernthatthepatientmayhaveanaortoentericfistula.Inaddition,asurgeonand
aninterventionalradiologistshouldbepromptlynotifiedofallpatientswithsevereacuteupperGIbleeding[42].
DIAGNOSTICSTUDIESAlgorithmsprovidinganoverviewofthediagnosticapproachtopatientswith
suspecteduppergastrointestinalbleedingareprovided(algorithm1andalgorithm2).
UpperendoscopyUpperendoscopyisthediagnosticmodalityofchoiceforacuteupperGIbleeding
[43,44].Endoscopyhasahighsensitivityandspecificityforlocatingandidentifyingbleedinglesionsinthe
upperGItract.Inaddition,onceableedinglesionhasbeenidentified,therapeuticendoscopycanachieve
acutehemostasisandpreventrecurrentbleedinginmostpatients.Earlyendoscopy(within24hours)is
recommendedformostpatientswithacuteUGIbleeding,thoughwhetherearlyendoscopyaffectsoutcomes
andresourceutilizationisunsettled.(See'Earlyendoscopy'belowand"Methodstoachievehemostasisin
patientswithacutevaricealhemorrhage",sectionon'Initialmanagement'and"Overviewofthetreatmentof
bleedingpepticulcers",sectionon'Endoscopictherapy'.)
EndoscopicfindingsinpatientswithpepticulcersmaybedescribedusingtheForrestclassification[45].
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

7/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

Findingsincludespurtinghemorrhage(classIa)(picture1),oozinghemorrhage(classIb),anonbleedingvisible
vessel(classIIa)(picture2),anadherentclot(classIIb)(picture3),aflatpigmentedspot(classIIc),anda
cleanulcerbase(classIII).Theendoscopicappearancehelpsdeterminewhichlesionsrequireendoscopic
therapy.(See"Overviewofthetreatmentofbleedingpepticulcers",sectionon'Endoscopictherapy'.)
Itmaybehelpfultoirrigatethestomachpriortoendoscopytohelpremoveresidualbloodandothergastric
contents.However,despiteirrigation,thestomachcanbeobscuredwithblood,potentiallymakingitdifficultto
establishacleardiagnosisand/orperformtherapeuticmaneuvers.Inpatientsinwhombloodobscuresthe
sourceofbleeding,asecondendoscopymayberequiredtoestablishadiagnosisandtopotentiallyapply
therapy,butroutinesecondlookendoscopyisnotrecommended.(See'Nasogastriclavage'aboveand
"Overviewofthetreatmentofbleedingpepticulcers",sectionon'Secondlookendoscopy'.)
RisksofendoscopyRisksofupperendoscopyincludeaspiration,adversereactionstoconscious
sedation,perforation,andincreasingbleedingwhileattemptingtherapeuticintervention.Patientsneedtobe
hemodynamicallystablepriortoundergoingendoscopy.
However,whilepatientsneedtobehemodynamicallystable,datasuggestthatmostpatientsdonotneedto
haveanormalhematocritinordertosafelyundergoendoscopy[46].Inaddition,endoscopyappearstobesafe
inpatientswhoaremildlytomoderatelyanticoagulated[24].Inaretrospectivestudyof920patientswithupper
GIbleedingundergoingupperendoscopy,patientswithlowhematocrits(<30percent)weresimilartothose
withhighhematocrits(>30percent)withregardtocardiovascularcomplicationsandmortality[46].Inanother
retrospectivestudywith233patientswithupperGIbleedingwhoreceivedendoscopictherapy,anelevated
INRwasnotassociatedwithanincreasedriskofrebleeding,transfusionrequirement,surgery,lengthofstay,
ormortality[24].TheINRwasbetween1.3and2.7in95percentofthepatients,sotheauthorscautionthat
theresultsofthestudymayonlyapplytopatientswhoaremildlytomoderatelyanticoagulated.
Therisksversusbenefitsofupperendoscopyshouldbeconsideredinhighriskpatients,suchasthosewho
havehadarecentmyocardialinfarction.Inonestudy,forexample,200patientswhounderwentendoscopy
within30daysaftermyocardialinfarction(MI)werecomparedwith200controlsmatchedforage,sex,and
endoscopicindication[47].Complications(includingfatalventriculartachycardia,nearrespiratoryarrest,and
mildhypotension)occurredmoreofteninpatientswhohadarecentMI(8versus2percent).Complications
occurredmoreoften(21versus2percent)inpatientswhowereveryill(ApacheIIscore>16orhypotension
priortoendoscopy).However,suchpatientsareatincreasedriskforcomplicationsevenwithoutendoscopy
andmaybeparticularlyvulnerabletocomplicationsfromcontinuedbleedingwithoutendoscopy.(See
"Predictivescoringsystemsintheintensivecareunit".)
OtherdiagnostictestsOtherdiagnostictestsforacuteupperGIbleedingincludeangiographyandatagged
redbloodcellscan,whichcandetectactivebleeding[48,49].UpperGIbariumstudiesarecontraindicatedin
thesettingofacuteupperGIbleedingbecausetheywillinterferewithsubsequentendoscopy,angiography,or
surgery[43].Thereisalsointerestinusingwirelesscapsuleendoscopyforpatientswhohavepresentedtothe
emergencydepartmentwithsuspectedupperGIbleeding.Anesophagealcapsule(whichhasarecordingtime
of20minutes)canbegivenintheemergencydepartmentandreviewedimmediatelyforevidenceofbleeding.
Confirmingthepresenceofbloodinthestomachorduodenummayaidwithpatienttriageandidentifypatients
morelikelytobenefitfromearlyendoscopy[5053].(See"Angiographiccontrolofnonvaricealgastrointestinal
bleedinginadults"and"Evaluationofobscuregastrointestinalbleeding"and"Wirelessvideocapsule
endoscopy",sectionon'Esophagealcapsuleendoscopy'.)
Acolonoscopyisgenerallyrequiredforpatientswithhematocheziaandanegativeupperendoscopyunlessan
alternativesourceforthebleedinghasbeenidentified.Inaddition,patientswithmelenaandanegativeupper
endoscopyfrequentlyundergocolonoscopytoruleoutarightsidedcolonicsourceforthebleeding,assuch
lesionsmaypresentwithmelena.Inastudythatincluded1743colonoscopiesperformedfortheevaluationof
melenafollowinganondiagnosticupperendoscopy,asuspectedbleedingsourcewasidentifiedin5percentof
patients,aratethatwashigherthanthatseenin194,979averageriskscreeningcontrols(1percent).Despite
therelativelylowyieldinpatientswithmelena,weroutinelyperformacolonoscopyinpatientswithmelenaand
anegativeupperendoscopy,aswellasinpatientswithhematochezia.(See"Approachtoacutelower
gastrointestinalbleedinginadults",sectionon'Colonoscopy'.)
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

8/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

RISKSTRATIFICATIONEndoscopic,clinical,andlaboratoryfeaturesmaybeusefulforriskstratification
ofpatientswhopresentwithacuteupperGIbleeding(table2andpicture4)[5463],andtheuseofrisk
stratificationtoolsisrecommendedbytheInternationalConsensusUpperGastrointestinalBleeding
ConferenceGroup[2].Factorsassociatedwithrebleedingidentifiedinametaanalysisincluded[64]:
Hemodynamicinstability(systolicbloodpressurelessthan100mmHg,heartrategreaterthan100beats
perminute)
Hemoglobinlessthan10g/L
Activebleedingatthetimeofendoscopy
Largeulcersize(greaterthan1to3cminvariousstudies)
Ulcerlocation(posteriorduodenalbulborhighlessergastriccurvature)
Severalinvestigatorshavedevelopeddecisionrulesandpredictivemodelsthatpermitidentificationofpatients
whoareatlowriskforrecurrentorlifethreateninghemorrhage[65].Suchpatientsmaybesuitableforearly
hospitaldischargeorevenoutpatientcare.Theeffectivenessofsuchruleshasbeenevaluatedinavarietyof
clinicalsettings,withmoststudiessuggestingthatpatientsdeemedtobelowriskcansafelybedischarged
earlyortreatedasoutpatients[5460,6573].Inaddition,thisapproachisassociatedwithreducedresource
utilizationcomparedwithuniversalhospitalizationofpatientswithacuteupperGIbleeding.
RiskscoresTwocommonlycitedscoringsystemsaretheRockallscoreandtheBlatchfordscore:
TheRockallscoreisbaseduponage,thepresenceofshock,comorbidity,diagnosis,andendoscopic
stigmataofrecenthemorrhage(calculator1)[54].Inonevalidationstudy,only32of744patients(4
percent)whoscored2orless(outofamaximumof11)rebledandonlyonedied.
Ontheotherhand,inalaterstudyof247patientswhounderwentendoscopictherapyforbleedingpeptic
ulcers,themodelperformedpoorlywhenpredictingrecurrentbleeding,underscoringtheneedfor
validationofthesemodels[74].
TheBlatchfordscore(alsoknownastheGlasgowBlatchfordscore),unliketheRockallscore,doesnot
takeendoscopicdataintoaccountandthuscanbeusedwhenthepatientfirstpresents(calculator2)
[59].Thescoreisbaseduponthebloodureanitrogen,hemoglobin,systolicbloodpressure,pulse,and
thepresenceofmelena,syncope,hepaticdisease,and/orcardiacfailure.Thescorerangesfromzeroto
23andtheriskofrequiringendoscopicinterventionincreaseswithincreasingscore.Onemetaanalysis
foundthataBlatchfordscoreofzerowasassociatedwithalowlikelihoodoftheneedforurgent
endoscopicintervention(likelihoodratio0.02,95%confidenceinterval[CI]00.05)[5].
Asimplerversionofthescore,knownasthemodifiedGlasgowBlatchfordscore,iscalculatedusingonly
thebloodureanitrogen,hemoglobin,systolicbloodpressure,andpulse.Thescorerangesfrom0to16.A
prospectivestudyofthemodifiedscorefoundthatitperformedaswellasthefullBlatchfordscoreand
thatitoutperformedtheRockallscorewithregardtopredictingtheneedforclinicalintervention,
rebleeding,andmortality[75].
AIMS65isanotherscoringsystemthatusesdataavailablepriortoendoscopy.Studiessuggestithashigh
accuracyforpredictinginpatientmortalityamongpatientswithupperGIbleeding[63,76].Thescorewas
derivedusingdatafromadatabasethatcontainedinformationfrom187UnitedStateshospitals.Thederivation
cohortuseddatafrom29,222hospitaladmissions.Thescorewasthenvalidatedusingaseparatedataset
containinginformationfrom32,504admissions.Thestudyfoundthatfivefactorswereassociatedwith
increasedinpatientmortality:

Albuminlessthan3.0g/dL(30g/L)
INRgreaterthan1.5
AlteredMentalstatus(Glasgowcomascorelessthan14,disorientation,lethargy,stupor,orcoma)
Systolicbloodpressureof90mmHgorless
Ageolderthan65years

http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=prin

9/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

Inthevalidationcohort,themortalityrateincreasedsignificantlyasthenumberofriskfactorspresent
increased:

Zeroriskfactors:0.3percent
Oneriskfactor:1percent
Tworiskfactors:3percent
Threeriskfactors:9percent
Fourriskfactors:15percent
Fiveriskfactors:25percent

Inadditiontopredictingmortality,anincreasingscorewasalsoassociatedwithincreasedlengthofstay(from
3.4daysforzeroriskfactorsto8.1daysforfiveriskfactors)andincreasedcost(averagecostof$5647USD
withzeroriskfactorsto$15,776USDwithfiveriskfactors).Prospectivestudiesareneededtoconfirmthe
abilityofthescoretopredictmortality,lengthofstay,andcost.Inaddition,itisnotyetknownifthescore
predictsrebleedingfollowingendoscopictherapy.
EarlyendoscopyStudieshavereachedvariableconclusionswhendeterminingwhethertheapplicationof
earlyendoscopyforriskstratificationandtreatmentreducesresourceutilizationoraffectspatientoutcomes
[68,7780].Whereassomestudieshavedemonstratedreducedresourceutilizationandimprovedoutcomes
fromearlyendoscopy[79,80],otherstudies,includingarandomizedtrial,didnot[68,77]:
Intherandomizedtrial,93outpatientswithacuteupperGIbleedingwereassignedtourgentendoscopy
(beforehospitalization)orelectiveendoscopyafteradmission[68].Resultsoftheurgentendoscopyanda
recommendationregardingpatientdispositionwereprovidedtotheattendingclinicianwhomadethefinal
decisionregardingpatientdisposition.
Thetimingofendoscopydidnotaffectresourceutilizationorpatientoutcomes.Lengthofstaywas
similar(fourversusfivedaysintheurgentanddelayedgroups,respectively),aswasthemeannumberof
daysintheintensivecareunit(1.2).Outpatientcarewasrecommendedfor19patients(40percent)inthe
urgentendoscopygroup.However,theattendingclinicianswhowereresponsibleformakingthe
dischargedecisionsonlyfollowedtherecommendationforoutpatientcareinfourpatients.
Thistrialsuggeststhatinorderforearlyendoscopytoreduceresourceutilization,stratificationneedsto
translateintochangesinpatientmanagement.Studiesshowingreducedutilizationhaveincorporated
processesbywhichpatientdispositionwaslinkeddirectlytotheriskstratificationsystem.
Abenefitforearlyendoscopy(definedasendoscopywithinonedayofadmission)wassuggestedbya
largeretrospectivestudyusingadatabaseofhospitalinpatientadmissions(NationwideInpatientSample)
[80].Thestudylookedat35,747adultswithacutevaricealbleedingand435,765adultswithnonvariceal
upperGIbleeding.Amongpatientswithacutevaricealhemorrhage,inpatientmortalitywas8.3percentfor
thosewhounderwentupperendoscopywithinonedayofadmissionandwas15.3percentforthosewho
didnot(adjustedoddsratio[OR]1.1895%CI1.081.31).ForpatientswithnonvaricealupperGI
bleeding,thecorrespondingmortalityrateswere2.5and6.6percent,respectively(adjustedOR1.32
95%CI1.261.38).
However,alimitationofthestudyisthatitdidnotdifferentiatepatientswhowereadmittedwithupperGI
bleedingfromthosewhodevelopedupperGIbleedingwhilehospitalizedforotherreasons(mostofwhom
wouldpresumablyundergoendoscopymorethanonedayfollowinghospitaladmission).Thiscouldskew
theresultstowardincreasedmortalityinthepatientswhodidnotundergoearlyendoscopysincepatients
whodevelopbleedingasinpatientsareknowntohavehighermortalityrates[81,82].
Anotherstudythatsuggestedabenefitwithregardtomortalityincluded8222patientswithupperGI
bleeding[79].Patientswhodiedhadasignificantlylongerwaitingtimetoendoscopythanthosewho
survived(1.65versus0.95daysadjustedOR1.10,95%CI1.061.14).
ImplementationThedatapresentedabovesuggestthatriskstratificationisfeasibleandpermits
identificationofpatientswhocanbemanagedsafelywithouthospitalization.However,forthesesystemstobe
successful,theriskstratificationsystemmustbetieddirectlytodecisionsregardingpatientdischarge.Noneof
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

10/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

thepublishedriskscoreshasyetbeenadoptedwidely.
Asageneralrule,wedischargepatientswhomeetthefollowingcriteria:
Havenocomorbidities
Havestablevitalsigns
Haveanormalhemoglobin
Havealikelybleedingsourceidentifiedonupperendoscopy
Haveasourceofbleedingthatisnotassociatedwithahighriskofrebleeding(eg,varicealbleeding,
activebleeding,bleedingfromaDieulafoy'slesion,orulcerbleedingwithhighriskstigmata)(table2)
However,thedecisiontodischargeapatientalsodependsuponindividualpatientfactors,suchasreliabilityfor
followupandconfidenceinthediagnosisinsomecases,weadmitpatientswhoappeartobelowriskfor
observation.
Ifpatientsdonotmeetthesecriteriaweadmitthemtoamonitoredsettingorintensivecareunit(depending
upontheseverityofbleeding,comorbidities,andstabilityofvitalsigns).Mostpatientswhohavereceived
endoscopictreatmentforhighriskstigmatashouldbehospitalizedfor72hourstomonitorforrebleeding,since
mostrebleedingoccursduringthistime[2].
TREATMENTThetreatmentofpatientswithupperGIbleedingduetovariouscausesisdiscussed
separately.(See"Overviewofthetreatmentofbleedingpepticulcers"and"Contactthermaldevicesforthe
treatmentofbleedingpepticulcers"and"Methodstoachievehemostasisinpatientswithacutevariceal
hemorrhage".)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,"TheBasics"
and"BeyondtheBasics."TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoread
materials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.
Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowantindepth
informationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
"patientinfo"andthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Upperendoscopy(TheBasics)"and"Patientinformation:GI
bleed(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Upperendoscopy(BeyondtheBasics)"and"Patient
information:Pepticulcerdisease(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Atableoutliningtheemergencymanagementofacutesevereuppergastrointestinalbleedingisprovided
(table1).(See'Introduction'above.)
AcarefulhistoryshouldbeobtainedtoidentifypotentialsourcesoftheupperGIbleed,assessthe
severityofthebleed,andtoidentifycomorbidconditionsthatmayinfluencethepatient'ssubsequent
management.(See'Initialevaluation'above.)
Thephysicalexaminationshouldfocusonsignsthatindicatetheseverityofbloodloss,helplocalizethe
sourceofthebleeding,andsuggestcomplications.(See'Physicalexamination'above.)
Thepresenceofabdominalpain,especiallyifsevereandassociatedwithreboundtendernessor
involuntaryguardingraisesconcernforperforation.Ifanysignsofanacuteabdomenarepresent,further
evaluationtoexcludeaperforationisrequiredpriortoendoscopy.(See'Physicalexamination'above.)
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

11/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

Laboratorytestsobtainedinpatientswithacuteuppergastrointestinalbleedingincludeacompleteblood
count,serumchemistries,livertests,andcoagulationstudies.Inaddition,wesuggestrulingouta
myocardialinfarctioninolderadultpatientsandthosewithknowncardiovasculardiseasewhohave
severebleeding,especiallyiftherehasbeenhemodynamicinstability.(See'Laboratorydata'above.)
WesuggestthatpatientsonlyundergoNGTlavageifparticulatematter,freshblood,andclotsneedtobe
removedfromthestomachtofacilitateendoscopy.(See'Nasogastriclavage'above.)
Patientswhorequirehospitalizationshouldbeadmittedtoamonitoredbedorintensivecareunit
dependingupontheseverityofbleeding.(See'Triage'above.)
Wesuggestincorporationofavalidatedriskscoreforuppergastrointestinalbleedingintoroutineclinical
practicetofacilitateoptimaltriagedecisions.(See'Riskscores'above.)
Generalsupportivemeasuresinclude:
Provisionofsupplementaloxygenbynasalcannula
Nothingpermouth
Twolargecaliber(16gaugeorlarger)peripheralcathetersoracentralvenousline
Placementofapulmonaryarterycathetershouldbeconsideredinpatientswithhemodynamic
instabilityorwhoneedclosemonitoringduringresuscitation
Forthemajorityofpatientswithacuteuppergastrointestinalbleedingwhodonothavesignificant
comorbidillnesses,werecommendgivingbloodtransfusionstomaintainthehemoglobinat7g/dL(70
g/L)ratherthan9g/dL(90g/L)(Grade1B).However,patientswithactivebleedingandhypovolemia
mayrequirebloodtransfusiondespiteanapparentlynormalhemoglobin.Forpatientsatincreasedriskof
sufferingadverseeventsinthesettingofsignificantanemia,suchasthosewithunstablecoronaryartery
disease,wesuggesttransfusingtomaintainthehemoglobinat9g/dL(90g/L)ratherthan7g/dL(70
g/L)(Grade2C).(See'Bloodtransfusions'aboveand"Overviewofthenonacutemanagementof
unstableanginaandnonSTelevationmyocardialinfarction",sectionon'Redcelltransfusion'.).
Inpatientswithsuspectedvaricealbleeding,wesuggesttransfusingtoahemoglobinofnomorethan10
g/dL(100g/L)(Grade2C).Itisparticularlyimportanttoavoidovertransfusioninpatientswithsuspected
varicealbleeding,asitcanprecipitateworseningofthebleeding.(See'Bloodtransfusions'above.)
WesuggestthatpatientswithacuteupperGIbleedingbetreatedwithanintravenousPPIatpresentation
untilconfirmationofthecauseofbleeding,afterwhichtheneedforspecifictherapyandthedurationof
PPIusecanbedetermined(Grade2B).(See'Acidsuppression'aboveand"Overviewofthetreatmentof
bleedingpepticulcers",sectionon'Acidsuppression'.)
Wesuggestthaterythromycinbegivenpriortoendoscopyinpatientswhoarelikelytohavealarge
amountofbloodintheirstomach,suchasthosewithseverebleeding.Areasonabledoseis3mg/kg
intravenouslyover20to30minutes,30to90minutespriortoendoscopy.(See'Prokinetics'above.)
WerecommendthatpatientsknowntohavecirrhosiswhopresentwithacuteupperGIbleedingreceive
antibiotics,preferablybeforeendoscopy(Grade1A).(See"Generalprinciplesofthemanagementof
varicealhemorrhage",sectionon'Infectionanduseofprophylacticantibiotics'.)
Werecommendupperendoscopyfortheevaluationandmanagementofclinicallysignificant(ie,more
thanascantamountofblood)acuteupperGIbleeding(Grade1A).Additionaldiagnostictestsmaybe
requiredinspecificcircumstances.Algorithmsprovidinganoverviewofthediagnosticapproachto
patientswithsuspecteduppergastrointestinalbleedingareprovided(algorithm1andalgorithm2).(See
'Diagnosticstudies'above.)
ThetreatmentofpatientswithupperGIbleedingduetovariouscausesisdiscussedseparately.(See
"Overviewofthetreatmentofbleedingpepticulcers"and"Contactthermaldevicesforthetreatmentof
bleedingpepticulcers"and"Methodstoachievehemostasisinpatientswithacutevaricealhemorrhage".)
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

12/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. BarkunA,BardouM,MarshallJK,NonvaricealUpperGIBleedingConsensusConferenceGroup.
Consensusrecommendationsformanagingpatientswithnonvaricealuppergastrointestinalbleeding.Ann
InternMed2003139:843.
2. BarkunAN,BardouM,KuipersEJ,etal.Internationalconsensusrecommendationsonthemanagement
ofpatientswithnonvaricealuppergastrointestinalbleeding.AnnInternMed2010152:101.
3. HwangJH,FisherDA,BenMenachemT,etal.Theroleofendoscopyinthemanagementofacutenon
varicealupperGIbleeding.GastrointestEndosc201275:1132.
4. LaineL,JensenDM.Managementofpatientswithulcerbleeding.AmJGastroenterol2012107:345.
5. SrygleyFD,GerardoCJ,TranT,FisherDA.Doesthispatienthaveasevereuppergastrointestinal
bleed?JAMA2012307:1072.
6. CappellMS,FriedelD.Initialmanagementofacuteuppergastrointestinalbleeding:frominitialevaluation
uptogastrointestinalendoscopy.MedClinNorthAm200892:491.
7. Currentdiagnosisandtreatment:Surgery,13,DohertyG(Ed),McGrawHillCompanies,2010.p.493.
8. JensenDM,MachicadoGA.Diagnosisandtreatmentofseverehematochezia.Theroleofurgent
colonoscopyafterpurge.Gastroenterology198895:1569.
9. PalmerED.Thevigorousdiagnosticapproachtouppergastrointestinaltracthemorrhage.A23year
prospectivestudyof1,4000patients.JAMA1969207:1477.
10. RichardsRJ,DonicaMB,GrayerD.Canthebloodureanitrogen/creatinineratiodistinguishupperfrom
lowergastrointestinalbleeding?JClinGastroenterol199012:500.
11. MortensenPB,NhrM,MllerPetersenJF,BalslevI.Thediagnosticvalueofserumurea/creatinine
ratioindistinguishingbetweenupperandlowergastrointestinalbleeding.Aprospectivestudy.DanMed
Bull199441:237.
12. PallinDJ,SaltzmanJR.IsnasogastrictubelavageinpatientswithacuteupperGIbleedingindicatedor
antiquated?GastrointestEndosc201174:981.
13. HuangES,KarsanS,KanwalF,etal.ImpactofnasogastriclavageonoutcomesinacuteGIbleeding.
GastrointestEndosc201174:971.
14. AljebreenAM,FalloneCA,BarkunAN.Nasogastricaspiratepredictshighriskendoscopiclesionsin
patientswithacuteupperGIbleeding.GastrointestEndosc200459:172.
15. BaradarianR,RamdhaneyS,ChapalamaduguR,etal.Earlyintensiveresuscitationofpatientswith
uppergastrointestinalbleedingdecreasesmortality.AmJGastroenterol200499:619.
16. DugganJM.Gastrointestinalhemorrhage:shouldwetransfuseless?DigDisSci200954:1662.
17. VillanuevaC,ColomoA,BoschA,etal.Transfusionstrategiesforacuteuppergastrointestinalbleeding.
NEnglJMed2013368:11.
18. QaseemA,HumphreyLL,FittermanN,etal.Treatmentofanemiainpatientswithheartdisease:a
clinicalpracticeguidelinefromtheAmericanCollegeofPhysicians.AnnInternMed2013159:770.
19. KravetzD,BoschJ,ArderiuM,etal.Hemodynamiceffectsofbloodvolumerestitutionfollowinga
hemorrhageinratswithportalhypertensionduetocirrhosisoftheliver:influenceoftheextentofportal
systemicshunting.Hepatology19899:808.
20. CerqueiraRM,AndradeL,CorreiaMR,etal.Riskfactorsforinhospitalmortalityincirrhoticpatients
withoesophagealvaricealbleeding.EurJGastroenterolHepatol201224:551.
21. KrigeJE,KotzeUK,DistillerG,etal.Predictivefactorsforrebleedinganddeathinalcoholiccirrhotic
patientswithacutevaricealbleeding:amultivariateanalysis.WorldJSurg200933:2127.
22. McCormickPA,JenkinsSA,McIntyreN,BurroughsAK.Whyportalhypertensivevaricesbleedand
bleed:ahypothesis.Gut199536:100.
23. RestelliniS,KheradO,JairathV,etal.Redbloodcelltransfusionisassociatedwithincreased
rebleedinginpatientswithnonvaricealuppergastrointestinalbleeding.AlimentPharmacolTher2013
37:316.
24. WolfAT,WasanSK,SaltzmanJR.Impactofanticoagulationonrebleedingfollowingendoscopictherapy
fornonvaricealuppergastrointestinalhemorrhage.AmJGastroenterol2007102:290.
25. MaltzGS,SiegelJE,CarsonJL.Hematologicmanagementofgastrointestinalbleeding.Gastroenterol
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

13/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

ClinNorthAm200029:169.
26. ASGEStandardsofPracticeCommittee,AndersonMA,BenMenachemT,etal.Managementof
antithromboticagentsforendoscopicprocedures.GastrointestEndosc200970:1060.
27. DorwardS,SreedharanA,LeontiadisGI,etal.Protonpumpinhibitortreatmentinitiatedpriorto
endoscopicdiagnosisinuppergastrointestinalbleeding.CochraneDatabaseSystRev2006
:CD005415.
28. GisbertJP,GonzlezL,CalvetX,etal.ProtonpumpinhibitorsversusH2antagonists:ametaanalysis
oftheirefficacyintreatingbleedingpepticulcer.AlimentPharmacolTher200115:917.
29. KavianiMJ,HashemiMR,KazemifarAR,etal.Effectoforalomeprazoleinreducingrebleedingin
bleedingpepticulcers:aprospective,doubleblind,randomized,clinicaltrial.AlimentPharmacolTher
200317:211.
30. LauJY,SungJJ,LeeKK,etal.Effectofintravenousomeprazoleonrecurrentbleedingafterendoscopic
treatmentofbleedingpepticulcers.NEnglJMed2000343:310.
31. ChanWH,KhinLW,ChungYF,etal.Randomizedcontrolledtrialofstandardversushighdose
intravenousomeprazoleafterendoscopictherapyinhighriskpatientswithacutepepticulcerbleeding.Br
JSurg201198:640.
32. GreenFWJr,KaplanMM,CurtisLE,LevinePH.Effectofacidandpepsinonbloodcoagulationand
plateletaggregation.Apossiblecontributorprolongedgastroduodenalmucosalhemorrhage.
Gastroenterology197874:38.
33. FrossardJL,SpahrL,QueneauPE,etal.Erythromycinintravenousbolusinfusioninacuteupper
gastrointestinalbleeding:arandomized,controlled,doubleblindtrial.Gastroenterology2002123:17.
34. CoffinB,PocardM,PanisY,etal.ErythromycinimprovesthequalityofEGDinpatientswithacute
upperGIbleeding:arandomizedcontrolledstudy.GastrointestEndosc200256:174.
35. AltraifI,HandooFA,AljumahA,etal.Effectoferythromycinbeforeendoscopyinpatientspresenting
withvaricealbleeding:aprospective,randomized,doubleblind,placebocontrolledtrial.Gastrointest
Endosc201173:245.
36. CarbonellN,PauwelsA,SerfatyL,etal.Erythromycininfusionpriortoendoscopyforacuteupper
gastrointestinalbleeding:arandomized,controlled,doubleblindtrial.AmJGastroenterol2006101:1211.
37. BarkunAN,BardouM,MartelM,etal.ProkineticsinacuteupperGIbleeding:ametaanalysis.
GastrointestEndosc201072:1138.
38. BaiY,GuoJF,LiZS.Metaanalysis:erythromycinbeforeendoscopyforacuteuppergastrointestinal
bleeding.AlimentPharmacolTher201134:166.
39. PateronD,VicautE,DebucE,etal.Erythromycininfusionorgastriclavageforuppergastrointestinal
bleeding:amulticenterrandomizedcontrolledtrial.AnnEmergMed201157:582.
40. ImperialeTF,BirgissonS.SomatostatinoroctreotidecomparedwithH2antagonistsandplacebointhe
managementofacutenonvaricealuppergastrointestinalhemorrhage:ametaanalysis.AnnInternMed
1997127:1062.
41. BennettC,KlingenbergSL,LangholzE,GluudLL.Tranexamicacidforuppergastrointestinalbleeding.
CochraneDatabaseSystRev201411:CD006640.
42. KolkmanJJ,MeuwissenSG.Areviewontreatmentofbleedingpepticulcer:acollaborativetaskof
gastroenterologistandsurgeon.ScandJGastroenterolSuppl1996218:16.
43. JutabhaR,JensenDM.Managementofuppergastrointestinalbleedinginthepatientwithchronicliver
disease.MedClinNorthAm199680:1035.
44. AdangRP,VismansJF,TalmonJL,etal.Appropriatenessofindicationsfordiagnosticupper
gastrointestinalendoscopy:associationwithrelevantendoscopicdisease.GastrointestEndosc1995
42:390.
45. ForrestJA,FinlaysonND,ShearmanDJ.Endoscopyingastrointestinalbleeding.Lancet19742:394.
46. BalderasV,BhoreR,LaraLF,etal.Thehematocritlevelinuppergastrointestinalhemorrhage:safetyof
endoscopyandoutcomes.AmJMed2011124:970.
47. CappellMS,IacovoneFMJr.Safetyandefficacyofesophagogastroduodenoscopyaftermyocardial
infarction.AmJMed1999106:29.
48. BarthKH.Radiologicalinterventioninupperandlowergastrointestinalbleeding.BaillieresClin
Gastroenterol19959:53.
49. EmslieJT,ZarnegarK,SiegelME,BeartRWJr.Technetium99mlabeledredbloodcellscansinthe
investigationofgastrointestinalbleeding.DisColonRectum199639:750.
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

14/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

50. GralnekIM,ChingJY,MazaI,etal.Capsuleendoscopyinacuteuppergastrointestinalhemorrhage:a
prospectivecohortstudy.Endoscopy201345:12.
51. MeltzerAC,AliMA,KresibergRB,etal.Videocapsuleendoscopyintheemergencydepartment:a
prospectivestudyofacuteuppergastrointestinalhemorrhage.AnnEmergMed201361:438.
52. ChandranS,TestroA,UrquhartP,etal.RiskstratificationofupperGIbleedingwithanesophageal
capsule.GastrointestEndosc201377:891.
53. MeltzerAC,PinchbeckC,BurnettS,etal.Emergencyphysiciansaccuratelyinterpretvideocapsule
endoscopyfindingsinsuspecteduppergastrointestinalhemorrhage:avideosurvey.AcadEmergMed
201320:711.
54. RockallTA,LoganRF,DevlinHB,NorthfieldTC.Selectionofpatientsforearlydischargeoroutpatient
careafteracuteuppergastrointestinalhaemorrhage.NationalAuditofAcuteUpperGastrointestinal
Haemorrhage.Lancet1996347:1138.
55. CorleyDA,StefanAM,WolfM,etal.Earlyindicatorsofprognosisinuppergastrointestinalhemorrhage.
AmJGastroenterol199893:336.
56. StanleyAJ,RobinsonI,ForrestEH,etal.Haemodynamicparameterspredictingvaricealhaemorrhage
andsurvivalinalcoholiccirrhosis.QJM199891:19.
57. HayJA,MaldonadoL,WeingartenSR,EllrodtAG.Prospectiveevaluationofaclinicalguideline
recommendinghospitallengthofstayinuppergastrointestinaltracthemorrhage.JAMA1997278:2151.
58. HayJA,LyubashevskyE,ElashoffJ,etal.Uppergastrointestinalhemorrhageclinicalguideline
determiningtheoptimalhospitallengthofstay.AmJMed1996100:313.
59. BlatchfordO,MurrayWR,BlatchfordM.Ariskscoretopredictneedfortreatmentforupper
gastrointestinalhaemorrhage.Lancet2000356:1318.
60. CipollettaL,BiancoMA,RotondanoG,etal.OutpatientmanagementforlowrisknonvaricealupperGI
bleeding:arandomizedcontrolledtrial.GastrointestEndosc200255:1.
61. MarmoR,KochM,CipollettaL,etal.Predictingmortalityinnonvaricealuppergastrointestinalbleeders:
validationoftheItalianPNEDScoreandProspectiveComparisonwiththeRockallScore.AmJ
Gastroenterol2010105:1284.
62. PangSH,ChingJY,LauJY,etal.ComparingtheBlatchfordandpreendoscopicRockallscorein
predictingtheneedforendoscopictherapyinpatientswithupperGIhemorrhage.GastrointestEndosc
201071:1134.
63. SaltzmanJR,TabakYP,HyettBH,etal.Asimpleriskscoreaccuratelypredictsinhospitalmortality,
lengthofstay,andcostinacuteupperGIbleeding.GastrointestEndosc201174:1215.
64. GarcaIglesiasP,VilloriaA,SuarezD,etal.Metaanalysis:predictorsofrebleedingafterendoscopic
treatmentforbleedingpepticulcer.AlimentPharmacolTher201134:888.
65. DasA,WongRC.PredictionofoutcomeofacuteGIhemorrhage:areviewofriskscoresandpredictive
models.GastrointestEndosc200460:85.
66. BrulletE,CampoR,CalvetX,etal.Arandomizedstudyofthesafetyofoutpatientcareforpatientswith
bleedingpepticulcertreatedbyendoscopicinjection.GastrointestEndosc200460:15.
67. GralnekIM,DulaiGS.Incrementalvalueofupperendoscopyfortriageofpatientswithacutenon
varicealupperGIhemorrhage.GastrointestEndosc200460:9.
68. BjorkmanDJ,ZamanA,FennertyMB,etal.Urgentvs.electiveendoscopyforacutenonvaricealupper
GIbleeding:aneffectivenessstudy.GastrointestEndosc200460:1.
69. LongstrethGF,FeitelbergSP.Successfuloutpatientmanagementofacuteuppergastrointestinal
hemorrhage:useofpracticeguidelinesinalargepatientseries.GastrointestEndosc199847:219.
70. LeeJG,TurnipseedS,RomanoPS,etal.Endoscopybasedtriagesignificantlyreduceshospitalization
ratesandcostsoftreatingupperGIbleeding:arandomizedcontrolledtrial.GastrointestEndosc1999
50:755.
71. ImperialeTF,DominitzJA,ProvenzaleDT,etal.Predictingpooroutcomefromacuteupper
gastrointestinalhemorrhage.ArchInternMed2007167:1291.
72. DasA,BenMenachemT,FarooqFT,etal.Artificialneuralnetworkasapredictiveinstrumentinpatients
withacutenonvaricealuppergastrointestinalhemorrhage.Gastroenterology2008134:65.
73. StanleyAJ,AshleyD,DaltonHR,etal.Outpatientmanagementofpatientswithlowriskupper
gastrointestinalhaemorrhage:multicentrevalidationandprospectiveevaluation.Lancet2009373:42.
74. ChurchNI,DallalHJ,MassonJ,etal.ValidityoftheRockallscoringsystemafterendoscopictherapy
forbleedingpepticulcer:aprospectivecohortstudy.GastrointestEndosc200663:606.
http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

15/16

6/1/2015

Approachtoacuteuppergastrointestinalbleedinginadults

75. ChengDW,LuYW,TellerT,etal.AmodifiedGlasgowBlatchfordScoreimprovesriskstratificationin
uppergastrointestinalbleed:aprospectivecomparisonofscoringsystems.AlimentPharmacolTher
201236:782.
76. HyettBH,AbougergiMS,CharpentierJP,etal.TheAIMS65scorecomparedwiththeGlasgow
BlatchfordscoreinpredictingoutcomesinupperGIbleeding.GastrointestEndosc201377:551.
77. SarinN,MongaN,AdamsPC.Timetoendoscopyandoutcomesinuppergastrointestinalbleeding.Can
JGastroenterol200923:489.
78. TsoiKK,MaTK,SungJJ.Endoscopyforuppergastrointestinalbleeding:howurgentisit?NatRev
GastroenterolHepatol20096:463.
79. TsoiKK,ChiuPW,ChanFK,etal.Theriskofpepticulcerbleedingmortalityinrelationtohospital
admissiononholidays:acohortstudyon8,222casesofpepticulcerbleeding.AmJGastroenterol2012
107:405.
80. WysockiJD,SrivastavS,WinsteadNS.Anationwideanalysisofriskfactorsformortalityandtimeto
endoscopyinuppergastrointestinalhaemorrhage.AlimentPharmacolTher201236:30.
81. HearnshawSA,LoganRF,LoweD,etal.AcuteuppergastrointestinalbleedingintheUK:patient
characteristics,diagnosesandoutcomesinthe2007UKaudit.Gut201160:1327.
82. MarmoR,KochM,CipollettaL,etal.Predictingmortalityinpatientswithinhospitalnonvaricealupper
GIbleeding:aprospective,multicenterdatabasestudy.GastrointestEndosc201479:741.
Topic2548Version42.0

Disclosures
Disclosures:JohnRSaltzman,MD,FACP,FACG,FASGE,AGAFNothingtodisclose.Mark
Feldman,MD,MACP,AGAF,FACGNothingtodisclose.AnneCTravis,MD,MSc,FACG,AGAF
EquityOwnership/StockOptions:Proctor&Gamble[Pepticulcerdisease,esophagealreflux
(omeprazole)].
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,these
areaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsfor
referencestobeprovidedtosupportthecontent.Appropriatelyreferencedcontentisrequiredofall
authorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

http://www.uptodate.com/contents/approachtoacuteuppergastrointestinalbleedinginadults?topicKey=GAST%2F2548&elapsedTimeMs=5&view=pri

16/16

S-ar putea să vă placă și