Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding

  1. Alan Barkun, MD, MSc;
  2. Marc Bardou, MD, PhD;
  3. John K. Marshall, MD, MSc; and
  4. for the Nonvariceal Upper GI Bleeding Consensus Conference Group*
  1. From McGill University, Montreal, Quebec, Canada; Faculté de Médecine, Dijon Cedex, France; and McMaster University, Hamilton, Ontario, Canada.

    Abstract

    Background: The management of patients with acute nonvariceal upper gastrointestinal bleeding has evolved substantially over the past 10 years amid a paucity of published consensus guidelines.

    Purpose: To provide evidence-based management recommendations that address clinically relevant issues.

    Review and Consensus Processes: A multidisciplinary consensus group of 25 voting participants representing 11 national societies used a 7-step approach to develop recommendation statements according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. The quality of the evidence, the strength of the recommendation, and the level of consensus were graded according to recognized classifications.

    Main Findings: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. The placement of endoscopic clips for endoscopic hemostasis appears promising. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding should be tested for Helicobacter pylori infection and receive eradication therapy if infection is present.

    Future Directions: The efficacy of newer endoscopic therapeutic technologies, the optimal regimen of proton-pump inhibition, and the roles of other pharmacologic agents require further research.

    *For a list of the voting participants in the Nonvariceal Upper GI Bleeding Consensus Conference Group, see the Appendix.

    Article and Author Information

    • Acknowledgments: The authors thank Pauline Lavigne for the preparation of the manuscript. They also acknowledge the contributions of Dalila Benhaberou-Brun, Mary Muccino, Debbie Ross, and Shelley Natovitch, as well as Paul Sinclair and Sandra Daniels, in assisting in the organization of the Consensus Conference. The Canadian Association of Gastroenterology thanks the sponsors of the Banff Consensus Conference: Abbott Laboratories Ltd., Altana Canada Inc., AstraZeneca Canada, and Janssen-Ortho Inc. It also thanks the conference's supporters: Carsen Group Inc. and Pentax Precision Instrument Corp.

    • Grant Support: In part by “arms-length” grants to the Canadian Association of Gastroenterology from Abbott Laboratories Ltd., Altana Pharma Canada Inc., AstraZeneca Canada, Carsen Group Inc. (distributors for Olympus in Canada), Janssen-Ortho Inc., and Pentax Precision Instrument Corp.; a peer-reviewed grant from the Canadian Institutes for Health Research; and an institutional award from the McGill University Health Centre Research Institute. The RUGBE initiative referred to in the consensus document was a collaborative effort supported by the Canadian Association of Gastroenterology and an unrestricted grant from Altana Pharma Canada (formerly Byk Canada Inc.).

    • Potential Financial Conflicts of Interest:Consultancies: A. Barkun (Altana Pharma Canada Inc.); Honoraria: A. Barkun (Altana Pharma Canada Inc.); Grants received: A. Barkun (Altana Pharma Canada Inc.).

    • Requests for Single Reprints: Alan Barkun, MD, MSc, Division of Gastroenterology, Montreal General Hospital Site, McGill University Health Centre, 1650 Cedar Avenue, Room D7.148, Montreal, Quebec H3G 1A4, Canada.

    • This consensus conference was endorsed and organized by the Canadian Association of Gastroenterology and was held in Banff, Alberta, Canada, on 8–9 June 2002.

    • Current Author Addresses: Dr. Barkun: Division of Gastroenterology, Montreal General Hospital Site, McGill University Health Centre, 1650 Cedar Avenue, Room D7.148, Montreal, Quebec H3G 1A4, Canada.

    • Dr. Bardou: Faculté de Médecine de Dijon, 7, boulevard Jeanne d'Arc, BP 87900, 21079 Dijon Cedex, France.

    • Dr. Marshall: Division of Gastroenterology, Room 4W8, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.

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    1. Ann Intern Med November 18, 2003 vol. 139 no. 10 843-857
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