ACG issues clinical guidelines on upper GI, ulcer bleeding
The American College of Gastroenterology published clinical guidelines regarding the management of patients with overt upper gastrointestinal bleeding.
“GI bleeding is the most common GI reason for hospitalization in the U.S. and thus the most common emergency dealt with by gastroenterologists,” Loren A. Laine, MD, FACG, past AGA president, Yale School of Medicine, told Healio. “Establishing up to date, evidence-based guidelines should be very useful in the day-to-day practice of gastroenterologists.”
In a systematic review, Laine and colleagues addressed predefined clinical questions like risk stratification, red blood cell transfusion and pre-endoscopic medical therapy to develop 16 recommendations using the GRADE approach for upper GI bleeding and ulcer bleeding.
Healio presents the following key recommendation from the ACG’s clinical guidelines.
Low-risk patients in the ED may be discharged with outpatient follow-up
Experts suggested very low-risk patients in the ED with upper GI bleeding, defined as a risk assessment score of less than 1% risk for transfusion, hemostatic intervention or death, may be safely discharged with outpatient follow-up.
Without the risk for poor outcomes requiring in-hospital management, this recommendation allows for fewer hospitalizations resulting in a reduction of associated cost.
Restrictive policy of red blood cell transfusion recommended
A restrictive red blood cell transfusion threshold of 7 g/dL in stable patients hospitalized with upper GI bleeding reduced further bleeding and death, experts wrote.
The basis of this recommendation came from a systematic review indicating restrictive policies reduced the number of patients receiving transfusions by 43% without an impact on clinically significant outcomes; it remains unchanged from the 2012 ACG guidelines.
Infusion of erythromycin before endoscopy
Using a prokinetic agent in patients with upper GI bleeding prior to endoscopy will propel blood and clot distally from the upper GI tract leading to improvement in visualization at endoscopy as well as diagnostic yield.
Specifically, experts suggested findings supported an infusion of 250 mg of erythromycin 20 minutes to 90 minutes pre-endoscopy. This may reduce the length of hospitalization and need for repeat endoscopy.
More research needed regarding pre-endoscopic proton pump inhibitor therapy
Available study data did not reveal any benefits of pre-endoscopic PPI therapy for clinical outcomes in patients with upper GI bleeding. Given the unproven possibility that PPIs may benefit select patients for those whom endoscopic therapy in unavailable, experts neither recommend the use of pre-endoscopic PPIs nor recommend against the use of pre-endoscopic PPIs.