Gastroenterology and Hepatology


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Mortality ranges 10 -14%

Stratify patients with UGIB into high and low risk:

Predictors of rebleed and mortality are:


Endoscopic predictors:


Rockall scoring:







< 60

60     – 80





PR > 100

SBP < 100


Co Morbid




CLD/ CKD / Cancer






Bleeding evidence



Clots / Spurter



Score that is < 3: low risk while > 8: high risk


What to do:

Initiate fluids and large bore brannula

Prognosticate and stratify

NGT in some patients, not all (bile stained/ coffee ground/ fresh blood aspirate)

Blood transfusion if Hb < 8

Correct coagulopathy but shouldn’t delay endoscopy. No recommended level. <1.8? <2.5?

Consider promotility in some patients (IV Erythromycin 250mg 30 min before scope)

Consider pre endoscopic PPI (80mg stat and 8mg/hour infusion)


Pharmacologic therapy:

H2 antagonist and Octreotide not recommended in NVUGIB

IV stat then infusion PPI (80mg stat and 8mg/hr infusion for 72 hours) if high risk stigmata or endoscopic therapy performed

Discharge with oral PPI for appropriate duration


Endoscopic management:

OGDS within 24 hours is recommended except high risk subgroup (fresh blood NGT or vomitus, haemodynamic instability, Hb < 8, TWBC > 12) then < 12 hours OGDS is beneficial

Endoscopic therapy not needed in clean base or non protruberant pigmented spot

Endoscopic therapy is needed in high risk stigmata

Clots warrant irrigation (70% has high risk stigmata)

Adherent clots is controversial (Removal vs high dose PPI no significant difference) (consider low risk vs high risk, if high risk preinject adrenaline and cold guillotining snare removal of clots)

Adrenaline injection alone is insufficient, need combination therapy

Routine second look not recommended, only recommended if evidence of rebleed or high risk rebleed

No single thermal coaptive therapy is superior to another


In Hospital management:

Low risk patients can be start oral intake in < 24 hours

At least 72 hours in hospital stay in those requiring endoscopic therapy (because highest risk of rebleed is within 72 hours. Also high risk lesions take 72 hours to downgrade to low risk lesion)

Surgical consult if fail 2 endoscopic therapy

Should be tested for H Pylori, if negative in acute setting, repeat later


Post Discharge:

Consider NSAID + PPI or COX 2 or COX 2 + PPI after stratification

ASA should be started as soon as possible if clearly indicated (2 fold increase in rebleed but 7 fold reduction in mortality at 2 months)

Clopidogrel alone has higher rick or rebleeding than ASA + PPI



edited 19th July 2010