1. Management of patients with nonvariceal upper gastrointestinal bleeding

2. Introduction Upper gastrointestinal bleeding (UGIB)
Incidence : 50 to 160 cases per 100,000 adult
mortality : 10% to 14%
Hospital stay and costs ( With/without complication)
: 4.4/2.7 days & $5632/3402
Decreasing annual incidence of UGIB with unchanging or decreasing incidence of peptic ulcer bleeding  Increased use of NSAID or Aspirin

3. Introduction Upper gastrointestinal bleeding (UGIB)
Resuscitation, risk assessment, and preendoscopy management
Endoscopic management
Pharmacologic management
Nonendoscopic and nonpharmacologic in-hospital management
Postdischarge, ASA, and NSAIDs

4. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Resuscitation, risk assessment, and preendoscopy management
A1 & A4. Vital stablization & transfusion if Hb < 7mg/dL.
Target Hb < 10g/dl
< N Engl J Med. 999;340: >

5. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Resuscitation, risk assessment, and preendoscopy management
A2 ,A3 & A7. Low risk Vs high risk patient.
Glasgow-Blatchford bleeding score
Low risk patient selection (Score 0)
 possible outpatient management without early endoscopy
High risk : Age>65years, Cr ↑, alcoholism, active cancer, APACHE>11,
Detection of red blood from NG tube  poor outcome as an predictor of rebleeding and need emergency endoscopy
Low risk of rebleeding among ulcer patient after endoscopy
: promt discharge

6. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Resuscitation, risk assessment, and preendoscopy management
A5. coagulopathy & endoscopy.
: low platelet and prolonged INR ratio  not predict rebleeding
Prolonged INR(>1.5) - predictor of mortality in UGIB
Do not delay endoscopy from coagulopathy

7. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Resuscitation, risk assessment, and preendoscopy management
A6. Promotility agents
No routine use
: Only for short NPO time & suspected large amount of blood and clots in stomach

8. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Resuscitation, risk assessment, and preendoscopy management
A8. Preendoscopic PPI therapy
PreendoscopicPPI
: downstage the endoscopic lesion

9. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B1 & B2 . institution-specific protocols, skillful endoscopist and support staff
B3. Endoscopy, ..When..?
Barkun A, et al.
: early endoscopy(< within 24 hours of presentation)
 safe and prompt discharge at low risk
improve patient outcome (mortality…) at high risk
--Ann Intern Med. 2003;139:843-57

10. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B3. Endoscopy, ..When..?
Target time to endoscopy
: within 24hrs except 12hrs in active bleeding

11. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B4 & 7. How to manage endoscopically
Forrest IIc & III (Minor SRH)
 No endoscopic therapy
Forrest I & IIa (Major SRH)
 Endoscopic therapy

12. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B5 & 6. if clots on the ulcer bed..?
: First, vigorous targeted irrigation….but still adherent ?
Sung JJ, et al. – No rebleeding in both PPI + endoscopic therapy and PPI alone
-- Ann Intern Med. 2003;139:237-43
Laine L, et al. – various rebleeding rate (5~35%) without endoscopic therapy
high risk of rebleeding(concurrent illness)
 Endoscopic therapy + high dose PPI
Low risk of bleeding : high dose PPI therapy
-- Clin Gastroenterol Hepatol. 2009;7:33-47

13. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B8. Epinephrine injection.
 single agent injection in combination with other endoscopic hemostasis
B9. What endoscopic coaptive therapy to choose.
Bardou M, Youssef – No superior endoscopic coaptive method over another

14. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
B. Endoscopic management
B10. how to combine…(Clip, thermocoagulaton, sclerosant, & epinephrine)
: Efficacy, especially in high risk stigmata
 Medical therapy < Epinephrine injection < Monotherapy ± Epi. injection
B11. Second-look endoscopy.
Improvement of hemostatic devices
PPI use
Cost reduction
B12. If rebleeding occurs…
 Endoscopic therapy first
high risk of rebleeding
에서만 고려

15. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
C. Pharmacologic management
C1. Histamine-2 receptor antagonists & Somatostatin and octreotide
H2RA & somatostatin
: Not recommended

16. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
C. Pharmacologic management
C3 & C4. Proton pump inhibitor
: Pivotal role in management of UGIB
High dose PPI ( 80mg bolus ) + 8mg/hr infusion
 reduce rebleeding, surgery, mortality(in high risk group) and cost

17. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
D. Nonendoscopic and nonpharmacologic in-hospital management
D1 & 2 . Feeding & in-hospital care
Laine L, Cohen - Time of refeeding : No influence on the hospital course of
patients with a low risk of recurrent bleeding.
-- Gastroenterology. 1992;102:314-6.
Low risk stigmata : feeding within 24hours
High risk stigmata :
admission for at least 3 days with NPO
Second look endoscopy
feeding if trasition to low risk

18. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
D. Nonendoscopic and nonpharmacologic in-hospital management
D3 & D4. If endoscopic therapy fails
: Don’t hesitate to Seek surgery and percutaneous embolization

19. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
D. Nonendoscopic and nonpharmacologic in-hospital management
D5 & D6. Helicobacter pylori
H. Pylori (+)  irradication therapy and confirmation
(-)  repeat

20. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
E. Postdischarge, ASA, and NSAIDs
E1. NSAID use
<N Engl J Med. 2002;347: >.

21. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
E. Postdischarge, ASA, and NSAIDs
E1. NSAID use
E3. ASA Use
Gastroenterology. 2008;130:A44
Restart on individual basis ( About 7 days)

22. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
E. Postdischarge, ASA, and NSAIDs
E4. Clopidogrel(Plavix) use
PPI  CYP2C19  clopidogrel
Increased CVA & GI event
Staggered schedule of medication

23. Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding