UGIB Guidelines
Joey Sweeney, PharmD, BCPS
The International Consensus Group recently updated the 2010 recommendations for managing nonvariceal upper GI bleeding (UGIB). The guidelines, which focus on resuscitation, assessment, bleed management, and secondary prophylaxis for recurrences, are presented as 15 statements with 38 corresponding recommendations based on the quality of evidence evaluated by voting participants.1
The guideline authors evaluated studies published prior to mid-May 2018. Specific patient population, intervention, comparator, and outcome (PICO) questions were developed and finalized through a consensus process of iterative discussions among all voting participants.
The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was then used to assess limitations of the studies included in the review. Overall quality of evidence (QoE) was graded as very low, low, moderate, or high for each recommendation.
Participants in the multidisciplinary consensus group were from 11 countries and included gastroenterologists, a cardiologist, a hematologist, a radiologist, a surgeon, and an emergency medicine specialist.
Evidence profiles (GRADE tables) were prepared for each PICO question; the profiles, systematic reviews, and meta-analyses were made available to voting participants prior to the 2-day consensus meeting for review and reflection.
Consensus was reached if 75% of the voters agreed on a direction. If consensus was reached, the strength of the recommendation was then discussed, with another 75% needed to garner a “strong” recommendation.
Consensus was not reached on 4 of the 15 PICO questions because fewer than 75% of the participants voted either yes or no. No corresponding statements were developed for these questions, but the pertinent evidence and discussions are summarized briefly in the text. Table 1 within the guideline contains a concise summary of all 38 recommendations.
Pharmacologic recommendations
Of the 38 recommendations, some are directly related to pharmacologic therapy and prophylaxis:
- For patients with hemodynamically unstable UGIB, fluid resuscitation is recommended.
- For patients receiving anticoagulants, the recommendation for acute UGIB is to not delay endoscopy.
- For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, the guidelines also recommend high-dose PPI therapy and do not recommend histamine-2 antagonist therapy.
- For patients with a bleeding ulcer at high risk for rebleed, the guidelines recommend twice-daily oral PPI therapy for 14 days, followed by once-daily thereafter.
- For patients with a history of bleeding ulcer and concurrent anticoagulant for cardiovascular (CV) prophylaxis, the guidelines recommend PPI therapy. This includes antiplatelet agents, aspirin, warfarin, and direct-acting oral anticoagulants.
Other recommendations
In addition to pharmacologic recommendations, the updated guidelines include the following relevant recommendations:
- For patients with UGIB, using the Glasgo Blatchford score to determine risk of rebleed or mortality is conditionally recommended, while using the pre-endoscopic Rockall prognostic scale failed to garner a consensus recommendation. The guideline recommends against using the AIMS65 prognostic score as a conditional recommendation.
- For patients with UGIB without underlying CV disease and A1C less than 80 g/L, and for patients with UGIB, underlying CV disease, and A1C less than 100 g/L, the guideline recommends giving blood transfusion as a conditional recommendation.
- For patients admitted with acute UGIB, early endoscopy (within 24 hours of presentation) is suggested as a conditional recommendation.
- For patients at high risk of rebleed or mortality, the group could not reach consensus on recommending an even earlier endoscopy cutoff (within 12 hours of presentation).
- For patients with acute bleeding ulcers with high-risk stigmata, the guideline recommends thermocoagulation, sclerosant injection, or endoscopic therapy with clips.
Use of TC-325 (a hemostatic powder) alone as a temporizing agent is recommended only if the three previous options are not available or if they fail.
The group could not reach consensus on the use of a doppler endoscopic probe (DEP) versus no DEP for patients with an acute bleeding ulcer who have undergone endoscopic therapy.
Further studies
The authors indicated that although UGIB management has improved substantially, areas remain in which more data are needed.
In particular, additional studies are needed to evaluate the benefits of specific prognostic scales, infusion strategies in patients with CV disease, optimal PPI dosing regimens, and optimal endoscopic therapies.
Reference:
1. Barkun AN, et al. Ann Intern Med. 2019;[Epub ahead of print 22 October 2019]