New international guideline updates recommendations on managing patients with nonvariceal GI bleeding

An international multidisciplinary consensus group has updated its 2010 recommendations for the management of patients with nonvariceal upper gastrointestinal (GI) bleeding.

The expert group, led by researchers at McGill University in Canada, agreed that an update on the management of upper GI bleeding was warranted, citing new endoscopic techniques and more frequent use of anticoagulant and/or antiplatelet therapy. The new guideline also refines previous recommendations on resuscitation, risk scores, and pharmacologic management before and during endoscopy. It was published online on Oct. 22 by Annals of Internal Medicine.

The guideline process was overseen by the Canadian Association of Gastroenterology clinical affairs committee, and recommendations were based on evidence in the literature through April 2018 and consensus discussion. Recommendations in the new guideline include the following:

• For patients with acute upper GI bleeding and hemodynamic instability, resuscitation should be initiated.
• Use a Glasgow Blatchford score of 1 or less to identify patients who are at very low risk for rebleeding or death and thus may not require hospitalization.
• Give blood transfusions at a hemoglobin threshold of 80 g/L for patients without cardiovascular (CV) disease and at a higher hemoglobin threshold for those with CV disease.
• Perform endoscopy within 24 hours of presentation in patients admitted with acute upper GI bleeding. Do not delay endoscopy, with or without endoscopic hemostatic therapy, in patients receiving anticoagulants.
• Use proton-pump inhibitor (PPI) therapy versus no PPI therapy in patients with previous ulcer bleeding requiring continued CV prophylaxis with single- or dual-antiplatelet therapy or anticoagulant therapy.
• Use high-dose PPI therapy for three days in patients with ulcer bleeding at high risk for rebleeding after endoscopy. Continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion.

While the guideline identifies unanswered questions that should prompt future research, it is “a step forward,” particularly regarding new endoscopic therapies and the management of nonvariceal upper GI bleeding in patients receiving antiplatelet or anticoagulant drugs, an accompanying editorial said. “The recommendations for managing patients receiving antiplatelets or anticoagulants and for the appropriate use of new therapeutic endoscopic techniques should be particularly helpful to clinicians,” the editorialist wrote.