-
A
PAGE 2| Discussion Of The Guidelines For The Evaluation
Guidelines: Upper
Gastrointestinal Bleeding And Management Of
Upper Gastrointestinal Bleeding
PAGE 4| Methodology Of The
A
Guidelines cute upper gastrointestinal (GI) bleeding is a relatively
common and high-risk clinical presentation in the emer-
gency department (ED) that leads over a quarter of a mil-
PAGE 5 | Guideline Recommenda-
tions And Editorial lion hospitalizations in the United States annually. Three recently
Comments published guidelines on the evaluation and management of up-
per GI bleeding are reviewed in this issue. Although not intended
specifically for emergency physicians, the guidelines present
PAGE 9 | References recommendations relevant to emergency medicine, focusing
on the medical management, risk stratification, and disposition
PAGE 9 | CME Questions of patients presenting with symptoms consistent with upper GI
bleeding.
Editors Note: To read more about this publication
and the background and methodologies for practice Practice Guideline Impact
guideline development, go to:
http://www.ebmedicine.net/introduction
Patients should be risk stratified using the Blatchford score,
which is based on features including hemodynamic status,
comorbidities, and laboratory test results. Low-risk patients
(Blatchford score of 0) can be considered for early discharge
from the ED without endoscopy.
The risks of overtransfusion as well as undertransfusion of
packed red blood cells should be recognized. A restrictive
transfusion policy, targeting a hemoglobin of 7 g/dL, may be
appropriate. Higher transfusion targets should be considered
for high-risk groups with evidence of intravascular volume
depletion or cardiovascular comorbidities.
A pre-endoscopic proton pump inhibitor may be used to
decrease the need for endoscopic therapy, but it does not
improve clinical outcomes.
June 2013
Volume 5, Number 6
Author
Hector L. Caraballo, MD
Assistant Professor of Emergency Medicine, Department of Emergency Medicine,
University of Texas Health Science Center San Antonio, San Antonio, TX
Editors-In-Chief
Luke K. Hermann, MD
Associate Professor of Emergency Medicine, Director of Quality and Finance,
Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai,
New York, NY
Sigrid Hahn, MD
Associate Professor of Emergency Medicine, Department of Emergency
Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Editorial Board
Nicole C. Bouchard, MD, FRCPC
Assistant Clinical Professor, Assistant Site Director; Director of Medical
Toxicology, New York-Presbyterian Hospital, Columbia University Medical
Center, New York, NY
Andy Jagoda, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Icahn School of
Medicine at Mount Sinai, New York, NY
Erik Kulstad, MD, MS
Research Director, Department of Emergency Medicine, Advocate Christ
Medical Center, Oak Lawn, IL
Eddy S. Lang, MDCM, CCFP (EM), CSPQ
Senior Researcher, Alberta Health Services; Associate Professor, University of
Calgary; Adjunct Professor, McGill University, Montreal, Quebec, Canada
Lewis S. Nelson, MD
Associate Professor of Emergency Medicine, New York University School of
Medicine; Director, Fellowship in Medical Toxicology, New York City Poison
Control Center, New York, NY
Gregory M. Press, MD, RDMS
Assistant Professor, Director of Emergency Ultrasound, Emergency Ultrasound
Fellowship Director, Department of Emergency Medicine, University of Texas at
Houston Medical School, Houston, TX
Maia S. Rutman, MD
Medical Director, Pediatric Emergency Services, Dartmouth-Hitchcock Medical
Center; Assistant Professor of Pediatric Emergency Medicine, Dartmouth
Medical School, Lebanon, NH
Scott M. Silvers, MD
Chair, Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
Scott D. Weingart, MD, FCCM
Associate Professor, Department of Emergency Medicine, Director, Division of
ED Critical Care, Icahn School of Medicine at Mount Sinai, New York, NY
Prior to beginning this activity, see CME Information
on page 10.
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Risk Stratification: There are a number of issues important to the

Discussion Of The Guidelines: emergency clinician managing a patient with upper GI bleeding. One
relevant clinical question is how to risk stratify patients upon presenta-
Upper Gastrointestinal Bleeding tion to identify those who can be safely discharged home versus those
who are anticipated to need an intervention (blood transfusion, endos-

T
copy, or surgery). Two of the guidelines reviewed in this issue recom-
his issue of EM Practice Guidelines Update reviews 3 recently mend using the Blatchford score (see Table 1) to risk stratify patients
published guidelines on the evaluation and management of up- prior to endoscopy and to consider discharging low-risk patients (ie,
per GI bleeding. These include: Blatchford score of 0). Be aware that these recommendations are
based on a low level of evidence. The Blatchford score can also be
1. Acute Upper Gastrointestinal Bleeding: Management. NICE Clini- used to help communicate risk to patients in order to facilitate their
cal Guideline 141. Published by the (United Kingdom) National participation in the clinical and disposition decision making.
Health Service (NHS) National Institute for Health and Clinical
Excellence (NICE).1 Available at: http://guidance.nice.org.uk/CG141 Table 1. The Blatchford Scoring System
2. "The Role Of Endoscopy In The Management Of Acute Non- Risk Marker at Admission Score
Blood Urea (mmol/L)
Variceal Upper GI Bleeding. Published by the American Society 6.5 but < 8.0 2
for Gastrointestinal Endoscopy (ASGE). 2 Available at: http:// 8 but < 10 3
www.asge.org/assets/0/71542/71544/b4349a10-9b72-463e-ac70- 10 but < 25 4
25 6
f394c7aa20b4.pdf
Hemoglobin (g/L) for Men
3. Management Of Patients With Ulcer Bleeding. Published by the
120 but < 130 1
American College of Gastroenterology (ACG).3 Available at: http:// 100 but < 120 3
www.guidelines.gov/content.aspx?id=38023#Section405 < 100 6
Hemoglobin (g/L) for Women
Although the United States-based organization guidelines (#2 and #3) 100 but < 120 1
< 100 6
discuss only nonvariceal upper GI bleeding (a distinction that may not Systolic Blood Pressure (mm Hg)
be clear at the time of presentation), and each guideline did not ad- 100-109 1
dress every topic, many of the recommendations are still relevant to 90-99 2
emergency medicine practice. Only the relevant recommendations < 90 3
Other Markers
have been abstracted and discussed in this issue. These guidelines Pulse 100 beats/min 1
and this review are not intended to represent the standard of care. Presentation with melena 1
Presentation with syncope 2
The annual incidence of acute upper GI bleeding that results in hospi- Hepatic disease 2
Cardiac failure 2
talization is approximately 100 per 100,000 adults.4 Overall, the most
common cause of upper GI bleeding is a bleeding peptic ulcer. There For a patient with acute upper gastrointestinal bleeding, add scores for each risk marker to derive
has been a slight downward trend in the occurrence of upper GI bleed- a total score ranging from 0 to 23. If no value applies for a particular marker, score 0. A score of 0
is the clinical cutoff above which patients are considered to be at risk of needing an intervention.
ing in the past decade, but 28-day mortality of nonvariceal hemorrhage
is still 13% and that of variceal hemorrhage is 21%.5 Reprinted from The Lancet, Vol. 356, Blatchford O, Murray WR, Blatchford M. A risk score to
predict need for treatment for upper gastrointestinal haemorrhage. Pages 1318-1321. Copyright
2000, used with permission from Elsevier.

EM Practice Guidelines Update 2013 2 www.ebmedicine.net June 2013

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Hemodynamic Resuscitation: Early hemodynamic resuscitation Endoscopy: Being familiar with national specialty society recom-
goals are also the subject of ongoing study, and the best approach mendations for the timing of endoscopy could allow the emergency
for all but exsanguinating bleeds is still not clear. The NICE guideline clinician to communicate more effectively with the endoscopist. While
discussed the risks of overtransfusion, but only the ACG guideline pro- the NICE guideline recommends offering endoscopy to an unstable
vided a specific target hemoglobin level (7 g/dL), reflecting a restrictive patient immediately after resuscitation, the United States-based guide-
transfusion approach unless there were signs of intravascular volume lines consider urgent endoscopy for unstable patients to be carried
depletion or cardiovascular comorbidities. All of the guidelines empha- out within 12 hours (ACG) or even 24 hours (ASGE). As there is little
sized the low levels of evidence supporting these recommendations evidence to guide the timing of endoscopy, knowledge of these recom-
and the need to take into account the full clinical picture. mendations may help to set expectations regarding the availability of
off-hours endoscopy. The recommendations also underscore the impor-
Controversies In Management: One area of disagreement among tance placed by professional GI societies on resuscitating the unstable
societies and individual practitioners is what, if any, pharmacologic patient prior to endoscopy, which may be at odds with the emergency
therapies need to be given in the ED to patients with suspected non- clinicians desire to get the patient the definitive treatment for upper GI
variceal upper GI bleeding. The controversy stems from the fact that bleeding.
most patients presenting with nonvariceal upper GI bleeding will likely
not have reduced morbidity or mortality from the initiation of proton Airway Management: None of the guidelines reviewed here pro-
pump inhibitor therapy prior to endoscopy, despite this being standard vided any recommendations for airway management, including when
practice in the United States. A recent Cochrane review concluded that and how to intubate the bleeding patient for airway protection or
the risk of 30-day mortality was unchanged (odds ratio [OR], 1.1; 95% indications for intubation prior to endoscopy.
confidence interval [CI], 0.8-1.7), as was the risk of rebleeding (OR,
0.8; 95% CI, 0.6-1.1) or surgery (OR, 1.0; 95% CI, 0.7-1.4).6 Initia-
tion of proton pump inhibitor therapy prior to endoscopy significantly
reduced endoscopic therapy at index endoscopy (OR, 0.7; 95% CI,
0.5-0.9). These guidelines recommendations differ because of the
relative weight that the guideline development committees placed on
different outcomes, including cost-effectiveness. The British NICE
guideline, which EM Practice Guidelines Update editors scored as
the highest-quality guideline of the 3 (using the AGREE II instrument),
recommended against the initiation of proton pump inhibitors prior to
endoscopy. The ACG guideline, which we also gave moderately high
scores for methodology, conditionally recommended the use of pro-
ton pump inhibitor therapy to reduce rates of endoscopic therapy but
not to reduce morbidity or mortality. The emergency clinicians decision
to use proton pump inhibitors can be made in conjunction with local
consultants.

EM Practice Guidelines Update 2013 3 www.ebmedicine.net June 2013

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Relevant portions of the 3 guidelines are abstracted and compared, by

Methodology Of The Guidelines specific recommendations, beginning on page 5.

Table 2. Comparison Of Upper Gastrointestinal Bleeding Management

T
he author of this issue of EM Practice Guidelines Update graded Guideline Methodologies, According To AGREE II Criteria*
and compared for strength of methodology the 3 guidelines
using the Appraisal of Guidelines for Research and Evaluation AGREE Guideline Quality Domains NICE ASGE ACG
(AGREE) II instrument.7 (See Table 2.) (For more information on the Scope and purpose 7 6 6
AGREE II instrument, go to the AGREE Trust website at http://www. Stakeholder involvement 7 3 2
agreetrust.org/). Overall, the NICE guideline is notable for its use of Rigor of development 7 4 4
a rigorous and transparent approach and for basing recommenda-
Clarity of presentation 7 5 6
tions (where possible) on meta-analyses and the balance of benefits,
harms, and cost. Although the NICE guideline carefully presents the Applicability 7 1 1
evidence used to derive the recommendation, it does not actually rate Editorial independence 7 4 5
the strength of the recommendation. The guidelines development was Overall guideline quality 7 4 5
commissioned and funded by the National Clinical Guideline Centre (a EM Practice Guidelines Update Quality Domains
government agency in the United Kingdom) and was written by a large Relevance to emergency medicine 6 4 6
interdisciplinary group.
Abbreviations: AGREE, Appraisal of Guidelines for Research and Evaluation;
The Standards of Practice Committee of the American Society for ACG, American College of Gastroenterology; ASGE, American Society for
Gastrointestinal Endoscopy (ASGE) wrote the ASGE guideline with Gastrointestinal Endoscopy; NICE, National Institute for Health and Clinical
the intent of providing practical recommendations for endoscopists. No Excellence.
other stakeholders were involved. A conflict-of-interest declaration is
*Notes:
a part of the document, and it noted that the 2 physicians involved in
The EM Practice Guidelines Update editors used the Appraisal of
producing the guideline did have consulting involvement with multiple
Guidelines for Research and Evaluation (AGREE) II instrument
medical device companies. Their development process was less well
(http://www.agreetrust.org/) to grade each guideline on 23 items in
documented than in the NICE guideline. Literature search terms and
the 6 domains.
search limitations were not revealed. The link between strength of evi-
Each item was assigned a score from 1 to 7 (with 1 = strongly
dence and strength of recommendation was not always clear.
disagree that it fulfills item criteria and 7 = strongly agree that it
The ACG guideline was developed by 2 member physicians. There is fulfills item criteria), and the editors scores were averaged. Table
no documentation of involvement of other stakeholder groups. A con- 2 displays the composite score for each domain for each guideline.
flict-of-interest declaration is included in the document, and it stated The overall guideline quality score is an aggregate of the domain
that 1 author served as a consultant with multiple pharmaceutical and scores. The scores are color-coded for easier reference, with green
medical device companies and the other author had been the recipi- representing a 6 or 7 score, yellow representing a 4 or 5 score, and
ent of several research grants from several medical device companies. red representing a 1, 2, or 3 score.
Recommendation statements are graded for both strength of evidence The score for relevance to emergency medicine (also out of 7), is
and strength of recommendation, but a strong recommendation did not not part of the AGREE instrument, but it reflects the judgment of
have to be based on a high level of evidence. the editors of EM Practice Guidelines Update.

EM Practice Guidelines Update 2013 4 www.ebmedicine.net June 2013

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Guideline Recommendations
And Editorial Comment
Strength Of Recommendation For Guideline Organizations
NICE: Strength of evidence was determined by assigning a rating by
study design and then downgrading based on specified criteria. A final
rating of very low, low, moderate, or high was assigned. The guideline de-
velopment group did not explicitly grade the strength of their recommen-
dations, but they did select 10 key priorities for implementation, based on
the fact that the recommendations would: (1) have a high impact on out-
comes that are important to patients, (2) have a high impact on reducing
variation in care and outcomes, (3) lead to a more efficient use of NHS
resources, (4) promote patient choice, and (5) promote equality.
ASGE: The strength of the evidence was classified as 1 of the following:
High: Further research is very unlikely to change our confidence in
the estimate of effect.
Moderate: Further research is likely to have an important impact on
our confidence in the estimate of effect and may change the estimate.
Low: Further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change
the estimate.
Very low: Any estimate of effect is very uncertain.
The strength of individual recommendations was based on both the
aggregated evidence quality and an assessment of the anticipated
benefits and harms:
Weaker recommendations are indicated by phrases such as
We suggest...
Stronger recommendations are typically stated as We recommend...
ACG: The strength of the evidence was classified as 1 of the following:
High: Further research is very unlikely to change our confidence in
the estimate of effect.
Moderate: Further research is likely to have an important impact on
our confidence in the estimate of effect and may change the estimate.
EM Practice Guidelines Update 2013 5
Current Guidelines For Management Upper GI Bleeding
Low: Further research is very likely to have an important impact
on our confidence in the estimate of effect and is likely to change
the estimate.
Very low: Any estimate of effect is very uncertain.
The strength of a recommendation was graded as 1 of the following:
Strong: The desirable effects of an intervention clearly outweigh
the undesirable effects.
Conditional: Uncertainty exists about the trade-offs.
Use Of Clinical Risk Scores For Management And Disposition
Decisions In Initial Evaluation Of Patients With Upper GI Bleeding
NICE
Use the following formal risk assessment scores for all patients
with acute upper gastrointestinal bleeding:
The Blatchford score at first assessment, and
The full Rockall score after endoscopy. (Priority recommenda-
tion, low- to very-low-quality evidence)
Consider early discharge for patients with a pre-endoscopy Blatch-
ford score of 0. (Priority recommendation, low- to very-low-
quality evidence)
ACG
Risk assessment should be performed to stratify patients into
higher-risk and lower-risk categories, and it may assist in initial
decisions such as timing of endoscopy, time of discharge, and level
of care. (Conditional recommendation, low-quality evidence)
Discharge from the ED without inpatient endoscopy may be consid-
ered in patients with urea nitrogen < 18.2 mg/dL; hemoglobin
13.0 g/dL for men,12.0 g/dL for women; systolic blood pressure
110 mm Hg; pulse < 100 beats/min; and absence of melena,
syncope, cardiac failure, and liver disease, as they have < 1%
chance of requiring intervention. (Conditional recommendation,
low-quality evidence)
Editorial Comment
All 3 guidelines discuss the use of clinical prediction rules to identify
patients who are at low or high risk of needing an intervention (transfu-
sion, endoscopy, or surgery), but only NICE and ACG provide formal
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recommendations. Based on a low level of evidence, they recommend ASGE

using the Blatchford score (see Table 1) for early risk stratification. We recommend that patients with upper GI bleeding be adequately
The utility for emergency clinicians is that the Blatchford score uses resuscitated before endoscopy. (Very low-quality evidence)
data available prior to endoscopy. The best available evidence indi-
ACG
cates that all patients who present with an acute upper GI bleed and
Hemodynamic status should be assessed immediately upon pre-
a Blatchford score > 0 merit admission for endoscopy. On the other
sentation and resuscitative measures should begin, as needed.
hand, patients with a Blatchford score of 0 have a < 1% chance of
(Strong recommendation, low-quality evidence)
requiring intervention, and a small series found no complications in this
Blood transfusions should target hemoglobin 7 g/dL, with higher
group of low-risk patients being discharged from the ED.3
hemoglobins targeted in patients with clinical evidence of intravas-
Recommendations For Fluid Resuscitation And Administration Of cular volume depletion or comorbidities such as coronary artery
Blood Products disease. (Conditional recommendation, low-to-moderate-
NICE quality evidence)
Transfuse patients with massive bleeding with blood, platelets, and
Editorial Comment
clotting factors in line with local protocols for managing massive
Evidence guiding the hemodynamic resuscitation of patients with up-
bleeding. (Consensus of guideline committee)
per GI bleeding is limited. Patients with unstable vital signs and signs
Base decisions on blood transfusion on the full clinical picture, rec-
of massive hemorrhage require immediate critical interventions, and
ognizing that overtransfusion may be as damaging as undertrans-
they do not present a conundrum for the emergency clinician. The plan
fusion. (Very low-quality evidence)
of action is less clear in other cases. Hemoglobin levels (which are not
Do not offer platelet transfusion to patients who are not actively
a real-time measure of blood loss) are only somewhat useful in deter-
bleeding and are hemodynamically stable. (Consensus of guide-
mining whether or when to transfuse a patient. Red cell transfusion is
line committee)
not a low-risk intervention, and the damages alluded to in the NICE
Offer platelet transfusion to patients who are actively bleeding and
recommendation above include a possible increased risk of rebleed-
have a platelet count of < 50 x 109/L. (Consensus of guideline
ing. This concern is further supported by a randomized controlled trial
committee)
published subsequent to these guidelines that found a higher risk of
Offer fresh frozen plasma to patients who have either:
rebleeding in the liberal-strategy transfusion group compared to the
A fibrinogen level of < 1 g/L or
restrictive-strategy group.8 The ACG guideline is the only guideline that
A prothrombin time (international normalized ratio) or activated
provides a specific target hemoglobin (7 g/dL) for transfusions, but this
partial thromboplastin time > 1.5 times normal (Consensus of
is based on low-to-moderate-quality evidence of the benefit of a re-
guideline committee)
strictive transfusion policy.
Offer prothrombin complex concentrate to patients who are taking
warfarin and actively bleeding. (Consensus of guideline committee) Use Of Proton Pump Inhibitors In Patients With Undifferentiated
Treat patients who are taking warfarin and whose upper GI bleed- Or Confirmed Nonvariceal Upper GI Bleeding
ing has stopped in line with local warfarin protocols. (Consensus NICE
of guideline committee) Do not offer acid-suppression drugs (proton pump inhibitors or H2
Do not use recombinant factor Vlla except when all other methods receptor antagonists) before endoscopy to patients with suspected
have failed. (High- to low-quality evidence) nonvariceal upper GI bleeding. (Moderate- to low-quality and
economic evidence with direct to partial applicability)

EM Practice Guidelines Update 2013 6 www.ebmedicine.net June 2013

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Offer proton pump inhibitors to patients with nonvariceal upper GI
bleeding and stigmata of recent hemorrhage shown at endoscopy.
(Moderate- to very-low-quality evidence and economic evi-
dence with direct applicability)
ASGE
We recommend antisecretory therapy with proton pump inhibitors
for patients with bleeding caused by peptic ulcers or in patients
with suspected peptic ulcer bleeding who are awaiting endoscopy.
(High-quality evidence)
ACG
Pre-endoscopic intravenous proton pump inhibitors (eg, 80-mg
bolus followed by 8-mg/h infusion) may be considered to decrease
the proportion of patients who have higher-risk stigmata of hemor-
rhage at endoscopy and who receive endoscopic therapy. How-
ever, proton pump inhibitors do not improve clinical outcomes such
as further bleeding, surgery, or death. (Conditional recommenda-
tion, high-quality evidence)
If endoscopy will be delayed or cannot be performed, an intra-
venous proton pump inhibitor is recommended to reduce further
bleeding. (Conditional recommendation, moderate-quality
evidence)
Editorial Comment
It is important to distinguish between the 2 clinical subgroups in this
section that are considered for acid suppression therapy. These groups
include: (1) patients with suspected nonvariceal upper GI bleeding,
and (2) patients with endoscopically confirmed nonvariceal upper GI
bleeding. Each guideline group explained the rationale for their recom-
mendation, and their different priorities yielded conflicting recommen-
dations. The ASGE guideline is intended for use by clinical endosco-
pists, while the NICE guidelines are national recommendations that
take into account relative benefit and harm, including cost. The ASGE
recommendation to initiate proton pump inhibitors pre-endoscopy is
based on a meta-analysis that demonstrated a significant reduction in
rates of high-risk stigmata encountered during endoscopy and, hence,
lower rates of endoscopic intervention in patients receiving proton
EM Practice Guidelines Update 2013 7
Current Guidelines For Management Upper GI Bleeding
pump inhibitors prior to endoscopy. In contrast, the NICE recommen-
dation is based on the lack of overall mortality or morbidity reductions
(rebleeding or risk of surgery) when proton pump inhibitors are initiated
prior to endoscopy.
Pharmacologic Management Of Suspected Or Confirmed Variceal
Upper GI Bleeding
NICE
Offer terlipressin to patients with suspected variceal bleeding at
presentation. Stop treatment after definitive hemostasis has been
achieved, or after 5 days, unless there is another indication for its
use. (Very low- to moderate-quality evidence from randomized
controlled studies and economic evidence of direct applicability)
Editorial Comment
Terlipressin is not available in the United States, so there are no rec-
ommendations for its use in the United States-based ASGE and ACG
guidelines. In the UK-based NICE guideline, the clinical question they
asked was whether terlipressin (compared with placebo, somatostatin,
or octreotide) was the best strategy, and they did not find evidence of su-
periority of the somatostatin or its analogue, octreotide, over terlipressin.
Antibiotic Prophylaxis For Confirmed Or Suspected Variceal Bleeds
NICE
Offer prophylactic antibiotic treatment at presentation to patients with
suspected or confirmed variceal bleeding. (Priority recommenda-
tion, low- to very-low-quality evidence from randomized con-
trolled studies and economic evidence of partial applicability)
Editorial Comment
Mortality from variceal-related upper GI bleeding is approximately
20%, and secondary bacterial infections in this group of immuno-
compromised patients are believed to be an important contributor to
mortality. A recent Cochrane review that included 12 trials (n = 1241)
found that administration of antibiotics at the time of endoscopy was
associated with both fewer infections (bacteremia, pneumonia, sponta-
neous bacterial peritonitis, and urinary tract infections) and an overall
decrease in mortality.9
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Timing Of Endoscopy In Acute Upper GI Bleeding
NICE
Offer endoscopy to unstable patients with severe, acute upper GI
bleeding immediately after resuscitation. (Priority recommenda-
tion, consensus of the guideline committee)
Offer endoscopy within 24 hours of admission to all other patients
with upper GI bleeding. (Priority recommendation)
ASGE
We recommend endoscopy to diagnose the etiology of acute upper
GI bleeding. (Moderate-quality evidence) The timing of endos-
copy should depend on clinical factors. Urgent endoscopy (within
24 h of presentation) is recommended for patients with a history of
malignancy or cirrhosis, presentation with hematemesis, and signs
of hypovolemia (including hypotension, tachycardia, and shock)
and a hemoglobin < 8 g/dL.
ACG
Patients with upper GI bleeding should generally undergo endos-
copy within 24 hours of admission, following resuscitative efforts to
optimize hemodynamic parameters and other medical problems.
(Conditional recommendation, low-quality evidence)
In patients who are hemodynamically stable and without serious
comorbidities, endoscopy should be performed as soon as pos-
sible in a nonemergent setting to identify the substantial proportion
of patients with low-risk endoscopic findings who can be safely
discharged. (Conditional recommendation, moderate-quality
evidence)
In patients with higher-risk clinical features (eg, tachycardia, hypo-
tension, bloody emesis, or nasogastric aspirate in hospital) en-
doscopy within 12 hours may be considered to potentially improve
clinical outcomes. (Conditional recommendation, low-quality
evidence)
Editorial Comment
Early endoscopy has been defined as occurring within 2 to 24 hours
of presentation. Evidence is limited, but the AGE guideline surmises
that the lack of clinical benefit argues against the need for endoscopy
EM Practice Guidelines Update 2013 8
Current Guidelines For Management Upper GI Bleeding
in an emergent setting (eg, during the night) for low-risk patients, citing
observational data suggesting that higher-risk patients (Blatchford score
> 12) may have a higher mortality with delays to endoscopy > 13 hours.
Use Of Prokinetic Agents In Nonvariceal Upper GI Bleeding
ASGE
We suggest prokinetic agents in patients with a high probability
of having fresh blood or a clot in the stomach when undergoing
endoscopy. (Low-quality evidence)
ACG
Intravenous infusion of erythromycin (250 mg approximately 30
min before endoscopy) should be considered to improve diagnos-
tic yield and decrease the need for repeat endoscopy. However,
erythromycin has not consistently been shown to improve clinical
outcomes. (Conditional recommendation, moderate-quality
evidence)
Editorial Comment
Prokinetic agents can help the endoscopist obtain better views dur-
ing the procedure and locate the source of the bleed. The evidence is
better for erythromycin than metoclopramide, but there is no effect on
clinical outcomes. The prokinetic agent is most effective when admin-
istered within 2 hours of the procedure, and the decision to administer
these agents should be made in conjunction with the endoscopist.
Nasogastric Tube Placement With Gastric Lavage
ACG
Nasogastric or orogastric lavage is not required in patients with up-
per GI bleeding for diagnosis, prognosis, visualization, or therapeu-
tic effect. (Conditional recommendation, low-quality evidence)
Editorial Comment
Nasogastric tube placement with gastric lavage is a painful procedure
and is not useful for diagnosis or prognosis in upper GI bleeding. The
use of an nasogastric tube for other reasons (eg, to decompress the
stomach prior to intubation to reduce the risk of aspiration) was not ad-
dressed in these guidelines.
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7. Brouwers M, Kho ME, Browman GP, et al for the AGREE Next b. 5 g/dL
Steps Consortium. AGREE II: Advancing guideline develop- c. 6 g/dL
ment, reporting and evaluation in healthcare. Can Med As- d. 7 g/dL
soc J. 2010. Dec 2010;182:E839-842; doi:10.1503/090449.
(Guideline assessment tool)
4. Which therapy has been shown to decrease mortality in upper
8. Villaneuva C, Colomo A, Bosch A, et al. Transfusion strate- GI bleeding?
gies for acute upper gastrointestinal bleeding. New Engl J Med. a. Prokinetic agents in nonvariceal upper GI bleeding
2013;368(1):11-21. (Randomized controlled trial; 921 patients)
b. Proton pump inhibitors in nonvariceal upper GI bleeding
9. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. c. Antibiotic prophylaxis in variceal upper GI bleeding
Antibiotic prophylaxis for cirrhotic patients with upper gastro- d. Nasogastric lavage prior to endoscopy in nonvariceal upper GI
intestinal bleeding. Cochrane Database Syst Rev. 2010 Sep bleeding
8;(9):CD002907. (Systematic review)

EM Practice Guidelines Update 2013 9 www.ebmedicine.net June 2013

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EM Practice Guidelines Update 2013 10
Current Guidelines For Management Upper GI Bleeding
CME information for EM Practice Guidelines Update
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Date of Original Release: June 1, 2013. Date of most recent review: May 1, 2013. Termination date: June
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In Children

EM Practice Guidelines Update 2013 11 www.ebmedicine.net June 2013

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EM
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EM Practice Guidelines
Practice Guidelines Update
Update 2013
Guidelines Update 2009
2009 11 12 EBMedicine.net
ebmedicine.net November
www.ebmedicine.net
EBMedicine.net November 2009
June 2013
2009