Endoscopy 2002; 34(2): 111-118
DOI: 10.1055/s-2002-19853
State of the Art Review

© Georg Thieme Verlag Stuttgart · New York

Nonvariceal Upper Gastrointestinal Bleeding

C.  Rollhauser 1 , D.  E.  Fleischer 2
  • 1Hospital Privado, Catholic University School of Medicine, Córdoba, Córdoba, Argentina
  • 2Mayo Clinic Scottsdale, Scottsdale, Arizona, USA
Further Information

Publication History

Publication Date:
14 August 2002 (online)

Nonvariceal upper gastrointestinal bleeding (NVUGIB) remains an important cause of morbidity and mortality. The etiological role and the relative risk of nonsteroidal anti-inflammatory drugs (NSAIDs) in association with other clinical factors are the focus of several papers published in the last year. Data from studies that evaluate the interaction of NSAIDs with Helicobacter pylori suggest that there is a clear role for eradication in aspirin-related bleeding. Although the benefit of H. pylori eradication in nonaspirin NSAID-related bleeding is being debated, they should both be eliminated given their relative contribution to the causation of peptic ulcer hemorrhage. The search for reliable and accurate tools to predict outcomes after NVUGIB continues. Recent important contributions in this area of research are the use of a clinical prediction guide to identify patients who are likely to require endoscopic intervention, and the use of Doppler ultrasound examination of the ulcer base to predict rebleeding. The role of antisecretory therapy in the setting of acute NVUGIB has been revisited in two meta-analyses and one randomized, placebo-controlled trial of omeprazole as an adjunct to endoscopic intervention. Until more definitive data are available, it appears that the effect of acid-decreasing medications is more important when endoscopic therapy is not provided than when effective endoscopic intervention is instituted. With regard to therapeutic endoscopy for upper gastrointestinal bleeding, the few randomized trials that have been published in full form in the last year focus on the use of mechanical methods of hemostasis for peptic ulcer bleeding and other etiologies such as Mallory-Weiss tears and Dieulafoy lesions.

References

  • 1 Czernichow P, Hochain P, Nousbaum J B. et al . Epidemiology and course of acute upper gastro-intestinal haemorrhage in four French geographical areas.  Eur J Gastroenterol Hepatol. 2000;  12 175-181
  • 2 Rockall T A, Logan R F, Devlin H B, Northfield T C. Risk assessment after acute upper gastrointestinal haemorrhage.  Gut. 1996;  38 316-321
  • 3 Rockall T A, Logan R F, Devlin H B, Northfield T C. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage.  Lancet. 1996;  347 1138-1140
  • 4 Fiaccadori E, Maggiore U, Clima B. et al . Incidence, risk factors, and prognosis of gastrointestinal hemorrhage complicating acute renal failure.  Kidney Int. 2001;  59 1510-1519
  • 5 Andersen I B, Jorgensen T, Bonnevie O. et al . Smoking and alcohol intake as risk factors for bleeding and perforated peptic ulcers: a population-based cohort study.  Epidemiology. 2000;  11 434-439
  • 6 Laine L. Approaches to nonsteroidal anti-inflammatory drug use in the high-risk patient.  Gastroenterology. 2001;  120 594-606
  • 7 Godil A, DeGuzman L, Schilling R C. et al . Recent nonsteroidal anti-inflammatory drug use increases the risk of early recurrence of bleeding in patients presenting with bleeding ulcer.  Gastrointest Endosc. 2000;  51 146-151
  • 8 Kaplan R C, Heckbert S R, Koepsell T D. et al . Risk factors for hospitalized gastrointestinal bleeding among older persons. Cardiovascular Health Study Investigators.  J Am Geriatr Soc. 2001;  49 126-133
  • 9 Hernandez-Diaz S, Garcia-Rodriguez L A. Epidemiologic assessment of the safety of conventional nonsteroidal anti-inflammatory drugs.  Am J Med. 2001;  110 (Suppl 1) 20-27
  • 10 Griffin M R, Scheiman J M. Prospects for changing the burden of nonsteroidal anti-inflammatory drug toxicity.  Am J Med. 2001;  110 33S-37S
  • 11 de Abajo F J, Garci Rodriguez L A. Risk of upper gastrointestinal bleeding and perforation associated with low-dose aspirin as plain and enteric-coated formulations.  BMC Clin Pharmacol. 2001;  1 1
  • 12 Sorensen H T, Mellemkjaer L, Blot W J. et al . Risk of upper gastrointestinal bleeding associated with use of low-dose aspirin.  Am J Gastroenterol. 2000;  95 2218-2224
  • 13 Hawkey C J. Risk of ulcer bleeding in patients infected with Helicobacter pylori taking non-steroidal anti-inflammatory drugs.  Gut. 2000;  46 310-311
  • 14 Fendrick A M, Scheiman J M. Helicobacter pylori and NSAID gastropathy: an ambiguous association.  Curr Rheumatol Rep. 2001;  3 107-111
  • 15 Chan F K, Chung S C, Suen B Y. et al . Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen.  N Engl J Med. 2001;  344 967-973
  • 16 Altman D G. Confidence intervals for the number needed to treat.  Br Med J. 1998;  317 1309-1312
  • 17 Capurso G, Annibale B, Osborn J. et al . Occurrence and relapse of bleeding from duodenal ulcer: respective roles of acid secretion and Helicobacter pylori infection.  Aliment Pharmacol Ther. 2001;  15 821-829
  • 18 Pellicano R, Peyre S, Leone N. et al . The effect of the eradication of Helicobacter pylori infection on hemorrhage because of duodenal ulcer.  J Clin Gastroenterol. 2001;  32 222-224
  • 19 Lanas A, Bajador E, Serrano P. et al . Nitrovasodilators, low-dose aspirin, other nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding.  N Engl J Med. 2000;  343 834-839
  • 20 Chan H L, Wu J C, Chan F K. et al . Is non-Helicobacter pylori, non-NSAID peptic ulcer a common cause of upper gastrointestinal bleeding? A prospective study of 977 patients.  Gastrointest Endosc. 2001;  53 438-442
  • 21 Colin R, Czernichow P, Baty V. et al . Low sensitivity of invasive tests for the detection of Helicobacter pylori infection in patients with bleeding ulcer.  Gastroenterol Clin Biol. 2000;  24 31-35
  • 22 Wong R C, Chak A, Kobayashi K. et al . Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?.  Gastrointest Endosc. 2000;  52 315-321
  • 23 Gostout C J. Do we need more technology to reduce recurrence of bleeding from ulcers?.  Gastrointest Endosc. 2000;  52 438-440
  • 24 Kohler B, Maier M, Benz C, Riemann J F. Acute ulcer bleeding: a prospective randomized trial to compare Doppler and Forrest classifications in endoscopic diagnosis and therapy.  Dig Dis Sci. 1997;  42 1370-1374
  • 25 Blatchford O, Davidson L A, Murray W. et al . Acute upper gastrointestinal hemorrhage in west of Scotland: case ascertainment study.  Br Med J. 1997;  315 510-514
  • 26 Blatchford O, Murray W R, Blatchford M. A risk score to predict need for treatment for upper-gastrointestinal haemorrhage.  Lancet. 2000;  356 1318-1321
  • 27 Quirk D M, Barry M J, Aserkoff B, Podolsky D. Physicians' specialty and variations in the cost of treating patients with acute upper gastrointestinal bleeding.  Gastroenterology. 1997;  113 1443-1448
  • 28 Sandel M H, Kolkman J J, Kuipers E J. et al . Nonvariceal upper gastrointestinal bleeding: differences in outcome for patients admitted to internal medicine and gastroenterological services.  Am J Gastroenterol. 2000;  95 2357-2362
  • 29 Podila P V, Ben-Menachem T, Batra S K. et al . Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway.  Am J Gastroenterol. 2001;  96 208-219
  • 30 Lau J Y, Sung J J, Lee K K. et al . Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.  N Engl J Med. 2000;  343 310-316
  • 31 Chung S SC, Lau J Y, Sung J J. et al . Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers.  Br Med J. 1997;  314 1307-1311
  • 32 Selby N M, Kubba A K, Hawkey C J. Acid suppression in peptic ulcer haemorrhage: a ”meta-analysis.”  Aliment Pharmacol Ther. 2000;  14 1119-1126
  • 33 Gisbert J P, Gonzalez L, Calvet X. et al . Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer.  Aliment Pharmacol Ther. 2001;  15 917-926
  • 34 Vreeburg E M, Levi M, Rauws E A. et al . Enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the beneficial effect of acid suppression.  Aliment Pharmacol Ther. 2001;  15 639-646
  • 35 Gutierrez A, Sanchez-Paya J, Marco P, Perez-Mateo M. Prognostic value of fibrinolytic tests for hospital outcome in patients with acute upper gastrointestinal hemorrhage.  J Clin Gastroenterol. 2001;  32 315-318
  • 36 Veyradier A, Balian A, Wolf M. et al . Abnormal von Willebrand factor in bleeding angiodysplasias of the digestive tract.  Gastroenterology. 2001;  120 346-353
  • 37 Chak A, Cooper G S, Lloyd L E. et al . Effectiveness of endoscopy in patients admitted to the intensive care unit with upper gastrointestinal hemorrhage.  Gastrointest Endosc. 2001;  53 6-13
  • 38 Cipolletta L, Bianco M A, Marmo R. et al . Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial.  Gastrointest Endosc. 2001;  53 147-151
  • 39 Lee J G, Leung J W. Recurrent ulcer bleeding: is the hemoclip an answer?.  Gastrointest Endosc. 2001;  53 256-258
  • 40 Lee K J, Kim J H, Hahm K B. et al . Randomized trial of N-butyl-2-cyanoacrylate compared with injection of hypertonic saline-epinephrine in the endoscopic treatment of bleeding peptic ulcers.  Endoscopy. 2000;  32 505-511
  • 41 Cheah W K, So J, Chong S M, Goh P. Duodenal ulcer perforation following cyanoacrylate injection.  Endoscopy. 2000;  32 S23
  • 42 Chung I K, Kim E J, Lee M S. et al . Bleeding Dieulafoy's lesions and the choice of endoscopic method: comparing the hemostatic efficacy of mechanical and injection methods.  Gastrointest Endosc. 2000;  52 721-724
  • 43 Buffoli F, Graffeo M, Nicosia F. et al . Peptic ulcer bleeding: comparison of two hemostatic procedures.  Am J Gastroenterol. 2001;  96 89-94
  • 44 Chung S C. Peptic ulcer bleeding.  Am J Gastroenterol. 2001;  96 1-3
  • 45 Nishiaki M, Tada M, Yanai H. et al . Endoscopic hemostasis for bleeding peptic ulcer using a hemostatic clip or pure ethanol injection.  Hepatogastroenterology. 2000;  47 1042-1044
  • 46 Peng Y C, Tung C F, Chow W K. et al . Efficacy of endoscopic isotonic saline-epinephrine injection for the management of active Mallory-Weiss tears.  J Clin Gastroenterol. 2001;  32 119-122
  • 47 Yamaguchi Y, Yamato T, Katsumi N. et al . Endoscopic hemoclipping for upper gastrointestinal bleeding due to Mallory-Weiss syndrome.  Gastrointest Endosc. 2001;  53 427-430
  • 48 Chung Y F, Wong W K, Soo K C. Diagnostic failures in endoscopy for acute upper gastrointestinal haemorrhage.  Br J Surg. 2000;  87 614-617
  • 49 Schmulewitz N, Baillie J. Dieulafoy lesions: a review of 6 years of experience at a tertiary referral center.  Am J Gastroenterol. 2001;  96 1688-1694
  • 50 Kramer S C, Gorich J, Rilinger N. et al . Embolization for gastrointestinal hemorrhages.  Eur Radiol. 2000;  10 802-805

Carlos Rollhauser, M.D.

Gastroenterology Division · Hospital Privado

686 Naciones Unidas · Córdoba, Córdoba 5016 · Argentina

Fax: + 54-351-468-8804

Email: rollhaus@powernet.net.ar