Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding (UGIB) remains a common and challenging emergency for gastroenterologists and general physicians. The annual incidence is 50 to 150 per 100,000 of the population, and, even though there have been significant improvements in endoscopic and supportive therapies, the overall mortality stubbornly remains around 10%, and may even reach 35% in hospitalised patients with serious co-morbidity. Patients aged over 80 years of age now account for around 25% of all UGIB and 33% of UGIB occurring in hospitalized patients and therefore tend to account for much of the poor outcome of this condition.1 The causes of non-variceal UGIB are shown in (Table I), although the commonly quoted figure of 50% for peptic ulcer bleeding may be overestimated. In a recent large CORI (Clinical Outcome Research Initiative) study of UGIB, peptic ulcer was the probable cause of UGIB in only 20% of cases.2 The incidence of peptic ulcer disease is expected to continue to decline with more widespread helicobacter pylori eradication and proton pump inhibitor (PPI) usage. Table I Causes of non-variceal UGIB RISK ASSESSMENT AND INITIAL MANAGEMENT Several clinical scoring systems e.g. Rockall score, the Baylor bleeding score, the Cedars-Sinai Medical Centre Predictive Index and the Blatchford score, have been developed to direct appropriate patient management and enable cost effective use of resources. These systems weigh a combination of clinical, laboratory and endoscopic variables to produce a score that predicts the risk of mortality, recurrent haemorrhage, need for clinical intervention or suitability for early discharge. Factors commonly associated with poor outcome from UGIB may be related to the patient's presentation and co-morbidities, or to the behaviour of the ulcer (Table II). Risk stratification using non-endoscopic parameters has the advantage that it can be performed readily on initial presentation in the emergency department, and appropriate initial risk assessment is still possible, even if early endoscopy, which requires skilled staff and resources, is not always available. Table II Predictors of adverse outcome from UGIB Inclusion of endoscopic stigmata of recent haemorrhage (SRH) that relate to increased risk of re-bleeding and death into scoring systems increases the sensitivity for predicting patients at high or low risk compared to non-endoscopic assessments.3–5 High risk lesions such as actively bleeding ulcers, non-bleeding visible vessels (NBVV) and adherent clots (Table III) require effective aggressive intervention to reduce re-bleeding which is associated with a 5–16 fold increase in mortality.6,7 The re-bleeding rate of ulcers with a clean base or red or blue spots are low and endoscopic intervention is usually not recommended.8–10 In fact, early endoscopy-based triage may permit safe and early discharge of “low risk” patients with no increased rate of re-bleeding or mortality.11 Table III Forrest classification of peptic ulcers in UGIB Endoscopic SRH, particularly NBVV and flat pigmented spots, can be difficult to differentiate.12 Doppler assessment is unlikely to be widely available for some time because of technical and resource limitations, but may be effective at differentiating between patent vasculature and pigmented spots.13 In this study there was agreement between the endoscopic Forrest classification and Doppler assessment in only 58% of cases, suggesting that Doppler was more sensitive at detecting high-risk lesions. Re-bleeding, requirement for surgery and mortality rate were all significantly lower in the Doppler-assessed endoscopically treated group. Resuscitation and management of medical co-morbidities, often in intensive care or high dependency, remains the mainstay of the initial management of patients prior to endoscopy. The presence of blood-stained nasogastric aspirate can be used to predict the presence of high risk lesions and nasogastric tube insertion should be considered for some patients.14 The role of endotracheal intubation remains controversial; the benefits are easier endoscopy and reduced risk of massive aspiration in patient with a reduced level of consciousness, but evidence of a reduction in acquired pneumonia or cardiopulmonary events is lacking.15,16