COMMENTARY

Making Upper GI Bleeding More Manageable

David A. Johnson, MD

Disclosures

February 12, 2020

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Upper gastrointestinal (GI) bleeding is a common problem for gastroenterologists and emergency room physicians as well. Such bleeding affects about 1 in 1000 people annually, so it's something that we deal with all the time. New recommendations for nonvariceal upper GI bleeding were recently published in the Annals of Internal Medicine, from an international group who obtained a consensus using a modified Delphi process. And in recognition of how upper GI bleeding requires a multidisciplinary approach, the group included gastroenterologists, a surgeon, an emergency medicine specialist, a cardiologist, a hematologist, and a radiologist.

Making Assessment as Simple as Knowing Your ABCs

The group first recommends using a validated instrument called the Glasgow Blatchford score for the pre-endoscopic assessment of upper GI bleeding. This is something that may make most clinicians cringe because, although we use these scores in liver disease, they are somewhat cumbersome and not routinely used for GI bleeding. But I would encourage you to think about this as something that's easy to perform and to use in in a proactive way to see if patients need to be admitted for urgent endoscopy. An online Glasgow-Blatchford score calculator is available.

The Glasgow-Blatchford score is something that I remember in my own mind with the following mnemonic tool: A-B-C-D-E-F. This is used to represent the considerations, the presence of which will increase a patient's score:

  • A is for "active"; patients with syncope or who have melena get a score for that.

  • B is for a "blood urea nitrogen" elevation of ≥ 7 mg/dL.

  • C is for "circulation," indicating a systolic blood pressure of ≥ 110 mm Hg.

  • D is for a "drop" in hemoglobin; for men and women, this is ≤ 12.9 g/dL and ≤ 11.9 g/dL, respectively.

  • E is for "elevated"—in this case, an elevated pulse rate of ≥ 100 pulses/min.

  • F is for "failure," meaning in the presence of cardiovascular or liver disease.

The Glasgow-Blatchford score goes from 0 to 23. Those with scores of 0 experience virtually no complications when they're evaluated in a proactive way. A prospective study indicated that approximately 16.5% of patients present with a score of 0. This group recommended a value of 1 or less as the threshold for considering outpatient management or at least no need for urgent endoscopy as an inpatient.

Always think about classification in this manner. This has been proven to be a cost-effective, reliable, and efficient resource. Its utilization has been validated across a number of different populations, and it may spare the patient from having to undergo the dreaded nasogastric lavage.

Limited Findings on Resuscitation

When it comes to the issue of resuscitation, the group could not offer anything beyond an effective hemodynamic recommendation. There were various studies comparing interventions (eg, Ringer lactate vs saline), but there wasn't anything that they identified to offer guidance here.

Different Strategies for Managing Upper GI Bleeding

The next recommendation is that proton pump inhibitors (PPIs) should be given to patients with ulcers at a high risk of rebleeding and who have undergone endoscopic therapy; an intravenous bolus followed by an 8-mg/hr maintenance dose should be continued for 3 days. That's not new advice, but for these high-risk patients, the recommendations also call for oral, twice-daily PPI therapy for another 11 days, so 14 days in total. They should then be given oral, once-daily PPI therapy to completion of therapy. It is this recommendation of a high-dose continuation and deceleration/tapering down that is new.

The group kind of hedged a bit on the recommendation for transfusion. They said the threshold for blood transfusions should be a hemoglobin level of < 8 g/dL. However, they recommend transfusion at a higher hemoglobin threshold when the patients have underlying cardiovascular disease. It should be noted this was not a strong recommendation and was based on low-quality evidence.

As far as endoscopic therapy, the group's recommendations were that thermocoagulation, sclerosant injection, or even over-the-scope clips are all very effective. They did not come out and suggest one over the other. Some emerging data support over-the-scope clips; however, it wasn't a part of this consensus, as the evidence base for which featured studies only published until 2018.

The next recommendation relates to hemospray (hemostatic powder). The group noted that it's very important to recognize that hemospray is a temporizing agent and not defined as a definitive treatment. It gives you a very short window of about 24 hours, and it's only effective in active bleeding. Therefore, it should be coupled with something—an intervention or a second-look endoscopy—to provide definitive therapy.

The other area that caught my attention was the recommendation that PPI therapy should be recommended for patients on dual-antiplatelet or anticoagulant therapy. This group cited the evolving data of the COMPASS trial (which was published subsequent to their recommendations) that looked at rivaroxaban plus low-dose aspirin (100 mg once daily) and found that PPI therapy did not make a difference. But we must recognize that the COMPASS trial was conducted in patients defined as being at a low risk for bleeding. I think the standard still remains that patients who are at a high risk for bleeding and taking dual-antiplatelet or anticoagulation therapy should be put on a PPI therapy until we have some validation studies.

One last recommendation that I should not overlook dealt with the issue of when to scope patients. The group recommends doing so within 24 hours for patients with nonvariceal upper GI bleeding. They could not come up with a recommendation saying that you must do it sooner. Although it wasn't within the scope of this report, the group did cite a consensus statement and the American Association for the Study of Liver Diseases guideline—both of which are admittedly somewhat dated—that for suspected variceal bleeding, the recommendation remains to perform endoscopy within 12 hours of presentation.

Hopefully these recommendations have provided you with some new guidance for the next time you consider nonvariceal upper GI bleeding in patients, which is not an uncommon problem.

I'm Dr David Johnson. Thanks again for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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