Upper GI Bleeding (non variceal) ASGE,ESGE, and WSES Guidelines
American Society of Gastrointestinal Endoscopy,
European Society of Gastrointestinal Endoscopy,
and, World Society of Emergency Surgery.
This document summarizes recent developments with SGLT2 inhibitors. It discusses their use in non-diabetic heart failure and kidney disease, where trials have shown benefits. Potential additional uses discussed include NAFLD, obesity, sleep apnea, and PCOS, though evidence is limited. Risks are discussed for using SGLT2 inhibitors in type 1 diabetes or with very low carb diets. In conclusion, SGLT2 inhibitors have cardio-renal-metabolic effects but significant challenges remain in establishing their role for various non-standard conditions.
The document discusses the proposal to change the name of non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD). It notes that NAFLD's name does not accurately capture the metabolic nature of the disease. The name change was proposed by an international panel of experts and aims to reduce stigmatization and increase consideration of the disease. If adopted, MAFLD would be used instead of NAFLD to describe fatty liver disease associated with metabolic dysfunction. The document supports the name change as a way to properly frame the growing epidemic of this liver disease.
- Recorded videos of the lecture:
English Language version of this lecture is available at: https://youtu.be/-Ynxvhbcl7U
Arabic Language version of this lecture is available at: https://youtu.be/QpK_toctVlw
- Visit our website for more lectures: www.NephroTube.com
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Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadNephroTube - Dr.Gawad
- English version of this lecture is available at:
https://youtu.be/zrFm0hAZk2A
- Arabic version of this lecture is available at:
https://youtu.be/M_BV8WJVbx0
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a rare systemic necrotizing vasculitis characterized by granulomatous inflammation involving the respiratory tract and necrotizing glomerulonephritis. It is associated with the presence of antineutrophil cytoplasmic antibodies (ANCA). Treatment involves inducing remission with high-dose corticosteroids combined with cyclophosphamide or rituximab to prevent organ damage and relapses. With effective treatment, remission rates are high but relapses remain common, requiring long-term management and monitoring.
Presentation performed for highlighting VERIFY: Galvus-met trials superiority in managing newly diagnosed DMT2 patients with preserving B cell function, evidence.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
This document summarizes recent developments with SGLT2 inhibitors. It discusses their use in non-diabetic heart failure and kidney disease, where trials have shown benefits. Potential additional uses discussed include NAFLD, obesity, sleep apnea, and PCOS, though evidence is limited. Risks are discussed for using SGLT2 inhibitors in type 1 diabetes or with very low carb diets. In conclusion, SGLT2 inhibitors have cardio-renal-metabolic effects but significant challenges remain in establishing their role for various non-standard conditions.
The document discusses the proposal to change the name of non-alcoholic fatty liver disease (NAFLD) to metabolic associated fatty liver disease (MAFLD). It notes that NAFLD's name does not accurately capture the metabolic nature of the disease. The name change was proposed by an international panel of experts and aims to reduce stigmatization and increase consideration of the disease. If adopted, MAFLD would be used instead of NAFLD to describe fatty liver disease associated with metabolic dysfunction. The document supports the name change as a way to properly frame the growing epidemic of this liver disease.
- Recorded videos of the lecture:
English Language version of this lecture is available at: https://youtu.be/-Ynxvhbcl7U
Arabic Language version of this lecture is available at: https://youtu.be/QpK_toctVlw
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadNephroTube - Dr.Gawad
- English version of this lecture is available at:
https://youtu.be/zrFm0hAZk2A
- Arabic version of this lecture is available at:
https://youtu.be/M_BV8WJVbx0
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a rare systemic necrotizing vasculitis characterized by granulomatous inflammation involving the respiratory tract and necrotizing glomerulonephritis. It is associated with the presence of antineutrophil cytoplasmic antibodies (ANCA). Treatment involves inducing remission with high-dose corticosteroids combined with cyclophosphamide or rituximab to prevent organ damage and relapses. With effective treatment, remission rates are high but relapses remain common, requiring long-term management and monitoring.
Presentation performed for highlighting VERIFY: Galvus-met trials superiority in managing newly diagnosed DMT2 patients with preserving B cell function, evidence.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
1. Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic liver disease characterized by inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts, leading to multifocal bile duct strictures.
2. PSC is diagnosed based on cholangiography showing characteristic bile duct changes along with elevated cholestatic liver enzymes and exclusion of secondary causes.
3. There is no established medical treatment for PSC, but ursodeoxycholic acid and immunosuppressants have been used to limited benefit. Endoscopic retrograde cholangiography can help relieve symptoms from dominant strictures.
This document discusses management strategies for nonalcoholic fatty liver disease (NAFLD). It begins by outlining lifestyle changes like weight loss through diet and exercise as the foundation for treatment. Weight loss of at least 3-5% is associated with histological improvement. The document then reviews current pharmacologic options, noting that pioglitazone and vitamin E are the only FDA-approved therapies. Surgical management through bariatric surgery can also improve clinical parameters and resolve fibrosis. Emerging investigational therapies discussed include elafibranor, obeticholic acid, and cenicriviroc, though pioglitazone remains the most effective option based on clinical trials to date.
Evidence based management of Non Alcoholic fatty liver diseaseJayastu Senapati
Non-Alcoholic Fatty Liver Disease (NAFLD) is a growing problem, with a prevalence of 9-32% in India. The document discusses the epidemiology, diagnosis, and treatment of NAFLD. For diagnosis, it recommends using diagnostic indices along with imaging and liver tests, with biopsy as a last resort. Treatment involves lifestyle changes like exercise and diet modification as the most important non-pharmacological approach. Pharmacological options and investigational therapies are also discussed.
This document summarizes key aspects of primary biliary cholangitis (PBC), formerly known as primary biliary cirrhosis. It discusses the epidemiology, risk factors, natural history, presentation, diagnosis and management of PBC. If left untreated, PBC progresses through several clinical phases over many years, eventually leading to liver failure and death in some patients. Prognosis is generally better in asymptomatic patients than in those with symptoms.
Dyslipidemia, or abnormal lipid levels in the blood, increases the risk of atherosclerosis and cardiovascular disease. The document discusses the definition and causes of dyslipidemia as well as screening recommendations. It also summarizes the roles of different lipids like LDL, HDL, and triglycerides in atherosclerosis. The treatment approaches for different lipid abnormalities are outlined, including lifestyle modifications and medications like statins, fibrates, bile acid sequestrants, nicotinic acid, and ezetimibe.
This is about the management approach to a patient presenting with acute upper gastrointestinal bleeding. A brief account on epidemiology and pathophysiology is included. This is mainly based on NICE guideline & journal of hepatology.
The document summarizes clinical trials evaluating SGLT2 inhibitors:
1) The EMPA-REG trial found that empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure, and all-cause mortality compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
2) The CANVAS trial found that canagliflozin reduced the risk of major adverse cardiovascular events and hospitalization for heart failure compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
3) The DECLARE-TIMI 58 trial found that dapagliflozin did not increase the risk of major adverse cardiovascular events compared to placebo in patients with type 2 diabetes
Upper GI bleeding can occur anywhere in the GI tract proximal to the ligament of Treitz. The majority of cases are non-variceal upper GI bleeding, with peptic ulcers being the most common cause. Initial management involves resuscitation, monitoring, lab tests, and fluid replacement. Patients are then risk stratified as low, intermediate, or high risk to guide further treatment and length of hospital stay. Endoscopic intervention is preferred for moderate to severe bleeding to achieve hemostasis through methods like injection, cauterization, or clips. Ongoing treatment depends on the underlying cause but generally involves acid suppression and management of comorbidities.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
This document summarizes the key details of the DAPA-CKD clinical trial which assessed the effects of the SGLT2 inhibitor dapagliflozin in patients with chronic kidney disease (CKD). The trial randomized over 4,000 patients with CKD stages 2-4 and elevated urinary albumin levels to receive either dapagliflozin 10mg daily or placebo. The primary outcome was a composite of sustained decline in kidney function, need for kidney replacement therapy, or death from renal or cardiovascular causes. Secondary outcomes included safety events. The trial found that dapagliflozin reduced the primary composite outcome compared to placebo in patients with CKD with and without diabetes.
Although type 1 diabetes continues to remain the most common form of childhood diabetes in most of the
countries including India, the prevalence of type 2 diabetes is increasing worldwide. This increase is attributed to the modern sedentary lifestyle causing a phenotype of insulin resistance in genetically predisposed individuals. The differentiation between type 1 and type 2 diabetes can be done in most of the cases but may be difficult in obese adolescents with relatively acute presentation. The demonstration of various antibodies is helpful in such circumstances. The earlier age of onset puts patients at risk of earlier age of complications. The management is very challenging as lifestyle modification by the patient and the family is the mainstay of the management. Emphasis should be done on primary prevention with a focus on
healthier lifestyles among children.
Cardiovascular disease is a major risk for those with diabetes.
1) Studies like the Framingham Heart Study and UKPDS found diabetes to be a significant risk factor for cardiovascular mortality and events like heart attacks.
2) Having diabetes poses similar risks as having a heart attack, with endothelial dysfunction, dyslipidemia, and other factors increasing cardiovascular risks.
3) Lifestyle changes like diet, exercise, weight loss and optimal control of blood pressure, cholesterol and blood sugars can help prevent premature cardiovascular events for those with diabetes.
The document summarizes emerging concepts around SGLT2 inhibitors and renal outcomes. It discusses the mechanism of action of SGLT2 inhibitors including reducing glucose reabsorption and increasing sodium delivery to the macula densa. A key trial on the SGLT2 inhibitor dapagliflozin showed it reduced the composite of sustained ≥50% eGFR decline, end-stage kidney disease, or renal or cardiovascular death by 39% compared to placebo in patients with chronic kidney disease. Updated guidelines now recommend SGLT2 inhibitors to reduce renal and cardiovascular risk in patients with chronic kidney disease based on these renal protection benefits shown in clinical trials.
This document summarizes information about GLP-1 receptor agonists for treating diabetes. It reviews the pharmacology and mechanism of action of GLP-1 receptor agonists, comparing the advantages and disadvantages of the class. Specific products are discussed, including dosing and side effects. Head-to-head clinical trials comparing different GLP-1 receptor agonists are summarized. Safety issues like the black box warning for thyroid cancer risk are also addressed. The document provides an overview of GLP-1 receptor agonists for non-insulin treatment of diabetes.
Dyslipidemia
Disorder of Lipid & Lipoprotein Metabolism
A common form of Dyslipidemia is characterized
by three lipid abnormalities:
Elevated triglycerides,
Elevated LDL and
Reduced HDL cholesterol.
Important Modifiable Risk Factor for CAD
This document provides information about Fibrocalculous Pancreatic Diabetes (FCPD). It discusses the historical background and definitions of FCPD. FCPD is characterized by severe diabetes associated with chronic pancreatitis and pancreatic stones. It predominantly affects poor populations in tropical developing countries. The document outlines the diagnostic criteria and clinical presentation of FCPD. Imaging findings like pancreatic calcifications on X-ray and changes on ultrasound or ERCP support the diagnosis. The document also discusses the worldwide distribution of FCPD, genetic studies conducted, various theories about its etiopathogenesis, and principles of management including treatment of diabetes with diet and insulin.
Diabetes greatly increases the risk of cardiovascular disease. The document discusses several studies showing higher rates of heart disease and stroke in people with diabetes. It recommends aspirin and statin therapy to lower cardiovascular risk based on a patient's individual risk factors. Lifestyle interventions like diet and exercise are also emphasized as a way to both prevent and manage diabetes and related health risks.
- Recorded videos of this lecture:
English Language version of this lecture is available at: https://youtu.be/YT5IlPs6F0I
Arabic Language version of this lecture is available at: https://youtu.be/HUZt4ahXlxo
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
1) The document discusses insulin therapy for type 2 diabetes, providing cases of patients not achieving optimal blood sugar control on oral medications alone.
2) It recommends starting basal insulin alone for some patients or adding meal insulin to basal insulin for others based on blood sugar patterns.
3) Patient education materials and algorithms for self-titrating insulin are provided to help patients adjust insulin doses based on home blood sugar monitoring.
This document discusses the management of gastrointestinal bleeding. It covers the clinical presentation and definitions of acute upper and lower GI bleeding. The core principles of GI bleeding management are outlined as assessing and stabilizing hemodynamic status, determining the source of bleeding, stopping active bleeding, treating any underlying abnormalities, and preventing recurrent bleeding. Specific causes, diagnostic evaluations, endoscopic and surgical treatments are described for various types of acute GI bleeding.
1. Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic liver disease characterized by inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts, leading to multifocal bile duct strictures.
2. PSC is diagnosed based on cholangiography showing characteristic bile duct changes along with elevated cholestatic liver enzymes and exclusion of secondary causes.
3. There is no established medical treatment for PSC, but ursodeoxycholic acid and immunosuppressants have been used to limited benefit. Endoscopic retrograde cholangiography can help relieve symptoms from dominant strictures.
This document discusses management strategies for nonalcoholic fatty liver disease (NAFLD). It begins by outlining lifestyle changes like weight loss through diet and exercise as the foundation for treatment. Weight loss of at least 3-5% is associated with histological improvement. The document then reviews current pharmacologic options, noting that pioglitazone and vitamin E are the only FDA-approved therapies. Surgical management through bariatric surgery can also improve clinical parameters and resolve fibrosis. Emerging investigational therapies discussed include elafibranor, obeticholic acid, and cenicriviroc, though pioglitazone remains the most effective option based on clinical trials to date.
Evidence based management of Non Alcoholic fatty liver diseaseJayastu Senapati
Non-Alcoholic Fatty Liver Disease (NAFLD) is a growing problem, with a prevalence of 9-32% in India. The document discusses the epidemiology, diagnosis, and treatment of NAFLD. For diagnosis, it recommends using diagnostic indices along with imaging and liver tests, with biopsy as a last resort. Treatment involves lifestyle changes like exercise and diet modification as the most important non-pharmacological approach. Pharmacological options and investigational therapies are also discussed.
This document summarizes key aspects of primary biliary cholangitis (PBC), formerly known as primary biliary cirrhosis. It discusses the epidemiology, risk factors, natural history, presentation, diagnosis and management of PBC. If left untreated, PBC progresses through several clinical phases over many years, eventually leading to liver failure and death in some patients. Prognosis is generally better in asymptomatic patients than in those with symptoms.
Dyslipidemia, or abnormal lipid levels in the blood, increases the risk of atherosclerosis and cardiovascular disease. The document discusses the definition and causes of dyslipidemia as well as screening recommendations. It also summarizes the roles of different lipids like LDL, HDL, and triglycerides in atherosclerosis. The treatment approaches for different lipid abnormalities are outlined, including lifestyle modifications and medications like statins, fibrates, bile acid sequestrants, nicotinic acid, and ezetimibe.
This is about the management approach to a patient presenting with acute upper gastrointestinal bleeding. A brief account on epidemiology and pathophysiology is included. This is mainly based on NICE guideline & journal of hepatology.
The document summarizes clinical trials evaluating SGLT2 inhibitors:
1) The EMPA-REG trial found that empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure, and all-cause mortality compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
2) The CANVAS trial found that canagliflozin reduced the risk of major adverse cardiovascular events and hospitalization for heart failure compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
3) The DECLARE-TIMI 58 trial found that dapagliflozin did not increase the risk of major adverse cardiovascular events compared to placebo in patients with type 2 diabetes
Upper GI bleeding can occur anywhere in the GI tract proximal to the ligament of Treitz. The majority of cases are non-variceal upper GI bleeding, with peptic ulcers being the most common cause. Initial management involves resuscitation, monitoring, lab tests, and fluid replacement. Patients are then risk stratified as low, intermediate, or high risk to guide further treatment and length of hospital stay. Endoscopic intervention is preferred for moderate to severe bleeding to achieve hemostasis through methods like injection, cauterization, or clips. Ongoing treatment depends on the underlying cause but generally involves acid suppression and management of comorbidities.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
This document summarizes the key details of the DAPA-CKD clinical trial which assessed the effects of the SGLT2 inhibitor dapagliflozin in patients with chronic kidney disease (CKD). The trial randomized over 4,000 patients with CKD stages 2-4 and elevated urinary albumin levels to receive either dapagliflozin 10mg daily or placebo. The primary outcome was a composite of sustained decline in kidney function, need for kidney replacement therapy, or death from renal or cardiovascular causes. Secondary outcomes included safety events. The trial found that dapagliflozin reduced the primary composite outcome compared to placebo in patients with CKD with and without diabetes.
Although type 1 diabetes continues to remain the most common form of childhood diabetes in most of the
countries including India, the prevalence of type 2 diabetes is increasing worldwide. This increase is attributed to the modern sedentary lifestyle causing a phenotype of insulin resistance in genetically predisposed individuals. The differentiation between type 1 and type 2 diabetes can be done in most of the cases but may be difficult in obese adolescents with relatively acute presentation. The demonstration of various antibodies is helpful in such circumstances. The earlier age of onset puts patients at risk of earlier age of complications. The management is very challenging as lifestyle modification by the patient and the family is the mainstay of the management. Emphasis should be done on primary prevention with a focus on
healthier lifestyles among children.
Cardiovascular disease is a major risk for those with diabetes.
1) Studies like the Framingham Heart Study and UKPDS found diabetes to be a significant risk factor for cardiovascular mortality and events like heart attacks.
2) Having diabetes poses similar risks as having a heart attack, with endothelial dysfunction, dyslipidemia, and other factors increasing cardiovascular risks.
3) Lifestyle changes like diet, exercise, weight loss and optimal control of blood pressure, cholesterol and blood sugars can help prevent premature cardiovascular events for those with diabetes.
The document summarizes emerging concepts around SGLT2 inhibitors and renal outcomes. It discusses the mechanism of action of SGLT2 inhibitors including reducing glucose reabsorption and increasing sodium delivery to the macula densa. A key trial on the SGLT2 inhibitor dapagliflozin showed it reduced the composite of sustained ≥50% eGFR decline, end-stage kidney disease, or renal or cardiovascular death by 39% compared to placebo in patients with chronic kidney disease. Updated guidelines now recommend SGLT2 inhibitors to reduce renal and cardiovascular risk in patients with chronic kidney disease based on these renal protection benefits shown in clinical trials.
This document summarizes information about GLP-1 receptor agonists for treating diabetes. It reviews the pharmacology and mechanism of action of GLP-1 receptor agonists, comparing the advantages and disadvantages of the class. Specific products are discussed, including dosing and side effects. Head-to-head clinical trials comparing different GLP-1 receptor agonists are summarized. Safety issues like the black box warning for thyroid cancer risk are also addressed. The document provides an overview of GLP-1 receptor agonists for non-insulin treatment of diabetes.
Dyslipidemia
Disorder of Lipid & Lipoprotein Metabolism
A common form of Dyslipidemia is characterized
by three lipid abnormalities:
Elevated triglycerides,
Elevated LDL and
Reduced HDL cholesterol.
Important Modifiable Risk Factor for CAD
This document provides information about Fibrocalculous Pancreatic Diabetes (FCPD). It discusses the historical background and definitions of FCPD. FCPD is characterized by severe diabetes associated with chronic pancreatitis and pancreatic stones. It predominantly affects poor populations in tropical developing countries. The document outlines the diagnostic criteria and clinical presentation of FCPD. Imaging findings like pancreatic calcifications on X-ray and changes on ultrasound or ERCP support the diagnosis. The document also discusses the worldwide distribution of FCPD, genetic studies conducted, various theories about its etiopathogenesis, and principles of management including treatment of diabetes with diet and insulin.
Diabetes greatly increases the risk of cardiovascular disease. The document discusses several studies showing higher rates of heart disease and stroke in people with diabetes. It recommends aspirin and statin therapy to lower cardiovascular risk based on a patient's individual risk factors. Lifestyle interventions like diet and exercise are also emphasized as a way to both prevent and manage diabetes and related health risks.
- Recorded videos of this lecture:
English Language version of this lecture is available at: https://youtu.be/YT5IlPs6F0I
Arabic Language version of this lecture is available at: https://youtu.be/HUZt4ahXlxo
- Visit our website for more lectures: www.NephroTube.com
- Subscribe to our YouTube channel: www.youtube.com/NephroTube
- Join our facebook group: www.facebook.com/groups/NephroTube
- Like our facebook page: www.facebook.com/NephroTube
- Follow us on twitter: www.twitter.com/NephroTube
1) The document discusses insulin therapy for type 2 diabetes, providing cases of patients not achieving optimal blood sugar control on oral medications alone.
2) It recommends starting basal insulin alone for some patients or adding meal insulin to basal insulin for others based on blood sugar patterns.
3) Patient education materials and algorithms for self-titrating insulin are provided to help patients adjust insulin doses based on home blood sugar monitoring.
This document discusses the management of gastrointestinal bleeding. It covers the clinical presentation and definitions of acute upper and lower GI bleeding. The core principles of GI bleeding management are outlined as assessing and stabilizing hemodynamic status, determining the source of bleeding, stopping active bleeding, treating any underlying abnormalities, and preventing recurrent bleeding. Specific causes, diagnostic evaluations, endoscopic and surgical treatments are described for various types of acute GI bleeding.
This document provides guidelines for the management of acute pancreatitis (AP). It summarizes key recommendations regarding the diagnosis, etiology, risk stratification, and management of AP. The diagnosis of AP is usually established by abdominal pain and elevated serum amylase and/or lipase levels. Contrast-enhanced CT or MRI is only recommended if the diagnosis is unclear or the patient fails to improve. Patients should be stratified based on the presence of organ failure or systemic inflammatory response syndrome and those with organ failure admitted to intensive care. Aggressive intravenous hydration within the first 24 hours and assessment of fluid status is important. Guidelines are also provided for managing gallstone pancreatitis, infectious complications, and interventions.
Villanueva upperg ibleedtransfusionrestrictivenejm2012pimpollopitt
This randomized controlled trial compared the efficacy and safety of a restrictive red blood cell transfusion strategy (transfusion threshold of 7 g/dL hemoglobin) versus a liberal strategy (threshold of 9 g/dL) in patients with acute upper gastrointestinal bleeding. A total of 921 patients were enrolled and randomly assigned to the restrictive (n=461) or liberal (n=460) strategy groups. The primary outcome was mortality within 6 weeks. The restrictive strategy resulted in significantly lower mortality (5% vs 9%) and further bleeding episodes (10% vs 16%) compared to the liberal strategy. The restrictive strategy also improved outcomes for patients with cirrhosis and mild or moderate liver disease.
The document summarizes information about upper gastrointestinal bleeding (UGIB), including:
1. Peptic ulcers are the most common cause of UGIB, accounting for around 50% of cases. Endoscopic therapy can help reduce bleeding, hospital stay, and mortality for actively bleeding ulcers.
2. Mallory-Weiss tears account for 2-10% of UGIB cases and typically present with vomiting preceding hematemesis. Endoscopic therapy is indicated for actively bleeding tears.
3. Esophageal varices, which cause 2-40% of UGIB, have poorer outcomes. Urgent endoscopy within 12 hours is recommended along with combination medical and endoscopic therapy.
This document provides an overview of gastrointestinal bleeding, including:
- Clinical presentation and definitions of upper and lower GI bleeding
- Core principles of assessment, stabilization, determining bleeding source, stopping active bleeding, and treatment/prevention
- Risk stratification scoring systems like Blatchford and Rockall scores
- Differential diagnosis and management of acute upper GI bleeding from sources like peptic ulcers, varices, and Mallory-Weiss tears
- Endoscopic findings, therapies, and outcomes for peptic ulcer bleeding
- Management of variceal bleeding with band ligation or TIPS procedures
- Guidelines for antibiotic prophylaxis and management of ulcer bleeding from professional organizations
The document discusses the management of upper gastrointestinal bleeding (UGIB) in the emergency room. It recommends initial resuscitation including IV access and fluid resuscitation. Patients should be risk stratified using scoring systems like Rockall or Blatchford to determine need for endoscopy. Early endoscopy within 24 hours is recommended to identify risk level and manage high risk lesions. Post-endoscopy, high-dose PPIs should be given and H. pylori testing and treatment initiated if positive to prevent rebleeding.
Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NV...Waleed Mahrous
This document provides guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) for the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). It recommends immediate assessment of patients' hemodynamic status and volume replacement if unstable. It also recommends early upper endoscopy within 24 hours of presentation to determine the source of bleeding and apply endoscopic hemostasis as needed. The guidelines provide recommendations on risk stratification, medication management, endoscopic diagnosis and treatment options for various bleeding lesions.
This document discusses the management of variceal bleeding, specifically focusing on esophageal and gastric varices. It provides an overview of endoscopic and medical therapies for controlling acute esophageal variceal bleeding such as endoscopic band ligation, sclerotherapy, and pharmacologic therapies like octreotide. For gastric varices, it describes different classification systems and challenges in managing bleeding, noting endoscopic therapies like sclerotherapy, ligation, and glue injection can control acute bleeding but have high rebleeding risks. It emphasizes a multidisciplinary approach is often needed for gastric variceal management.
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver
places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones
and hernia are more common in patients with cirrhosis http://www.jcehapatology.com
Surgery is often needed in patients with concurrent liver disease. The multiple physiological roles of the liver
places these patients at an increased risk of morbidity and mortality. Diseases necessitating surgery like gallstones
and hernia are more common in patients with cirrhosis http://www.jcehapatology.com
This document provides an overview of gastrointestinal bleeding, including:
- Clinical presentation and definitions of upper and lower GI bleeding
- Core principles of assessment, stabilization, determining bleeding source, stopping active bleeding, and treatment/prevention
- Risk stratification based on vital signs and estimated blood loss
- Differential diagnosis and management of acute upper GI bleeding including endoscopic findings, therapies, and outcomes
- Risk factors, scoring systems, and definitions used in gastrointestinal bleeding management
Sickle cell anemia management guidelines provide recommendations for screening, preventing complications, and treating acute issues and chronic conditions in patients with sickle cell disease (SCD). Key points include: screening children annually with transcranial Doppler ultrasound to prevent stroke; administering pneumococcal and meningococcal vaccines; using hydroxyurea or transfusions as disease-modifying therapies; and treating acute complications like vaso-occlusive crises, acute chest syndrome, fever, and splenic sequestration with hydration, antibiotics, analgesics, and transfusions. The guidelines aim to help community providers properly care for patients with SCD.
This document summarizes the presentation, evaluation, and management of acute upper gastrointestinal bleeding (UGIB). It discusses risk stratification tools like the Blatchford and Rockall scores used to predict patient risk and need for intervention. It recommends early endoscopy within 24 hours for high risk patients to determine the source of bleeding and administer endoscopic therapy if needed. For high risk patients with lesions like active bleeding, endoscopic therapy with methods like injection and thermal therapy is recommended to decrease rebleeding risk. Proton pump inhibitors are recommended as adjunct medical therapy for 72 hours to promote clot stability and healing. Surgery is now reserved for uncontrolled bleeding after failed endoscopic therapy while angiography may be considered if endoscopy fails
The document provides guidelines for the management of acute pancreatitis (AP). It summarizes that AP is one of the most common gastrointestinal diseases, leading to significant burden. The incidence of AP has been increasing. Recent studies have identified two phases of AP - early (within 1 week) characterized by systemic inflammatory response and late (>1 week) characterized by local complications. Key recommendations include establishing the diagnosis of AP using clinical criteria including abdominal pain and elevated serum amylase/lipase. Imaging such as CT should be reserved for unclear or non-improving cases. Early management focuses on hemodynamic support and aggressive hydration to decrease morbidity and mortality. Guidelines are provided for evaluating etiology, risk stratification, nutritional support, antibiotic use
The document provides guidelines for the management of acute pancreatitis (AP). It summarizes that AP diagnosis is typically established by abdominal pain and elevated serum amylase and/or lipase levels. Contrast-enhanced CT or MRI is only recommended if diagnosis is unclear or patient fails to improve to evaluate for complications. It outlines recommendations for early medical management including aggressive hydration and nutrition, as well as management of complications like pancreatic necrosis with antibiotics, endoscopic or radiologic drainage, or surgery.
The document provides guidelines for the management of acute pancreatitis (AP). It summarizes that AP is one of the most common gastrointestinal diseases, leading to significant burden. The incidence of AP has been increasing. Recent studies have identified two phases of AP - early (within 1 week) characterized by systemic inflammatory response and late (>1 week) characterized by local complications. Key recommendations include establishing the diagnosis of AP using clinical criteria including abdominal pain and elevated serum amylase/lipase. Imaging such as CT should be reserved for unclear or non-improving cases. Early management focuses on hemodynamic support and aggressive hydration to decrease morbidity and mortality. Guidelines are provided for evaluating etiology, risk stratification, nutritional support, antibiotic use
This document summarizes guidelines for the management of upper gastrointestinal bleeding (UGIB). It discusses initial patient assessment and risk stratification, the role of endoscopy within 24 hours, endoscopic findings that predict risk of rebleeding, endoscopic therapies, post-endoscopy management including PPI infusion, and strategies to prevent recurrent bleeding related to causes like H. pylori and NSAID use. Endoscopy is important to determine the source of bleeding and apply therapies when needed to reduce risks of additional bleeding, surgery, and mortality. Post-endoscopy care involves PPI therapy and follow up based on risk level.
Similar to Upper GI Bleeding guidelines ppt.pptx (20)
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
How to Control Your Asthma Tips by gokuldas hospital.Gokuldas Hospital
Respiratory issues like asthma are the most sensitive issue that is affecting millions worldwide. It hampers the daily activities leaving the body tired and breathless.
The key to a good grip on asthma is proper knowledge and management strategies. Understanding the patient-specific symptoms and carving out an effective treatment likewise is the best way to keep asthma under control.
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
5-hydroxytryptamine or 5-HT or Serotonin is a neurotransmitter that serves a range of roles in the human body. It is sometimes referred to as the happy chemical since it promotes overall well-being and happiness.
It is mostly found in the brain, intestines, and blood platelets.
5-HT is utilised to transport messages between nerve cells, is known to be involved in smooth muscle contraction, and adds to overall well-being and pleasure, among other benefits. 5-HT regulates the body's sleep-wake cycles and internal clock by acting as a precursor to melatonin.
It is hypothesised to regulate hunger, emotions, motor, cognitive, and autonomic processes.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga
GASTROINTESTINAL INFECTIONS AND GASTRITIS
Osvaldo Bernardo Muchanga
Gastrointestinal Infections
GASTROINTESTINAL INFECTIONS result from the ingestion of pathogens that cause infections at the level of this tract, generally being transmitted by food, water and hands contaminated by microorganisms such as E. coli, Salmonella, Shigella, Vibrio cholerae, Campylobacter, Staphylococcus, Rotavirus among others that are generally contained in feces, thus configuring a FECAL-ORAL type of transmission.
Among the factors that lead to the occurrence of gastrointestinal infections are the hygienic and sanitary deficiencies that characterize our markets and other places where raw or cooked food is sold, poor environmental sanitation in communities, deficiencies in water treatment (or in the process of its plumbing), risky hygienic-sanitary habits (not washing hands after major and/or minor needs), among others.
These are generally consequences (signs and symptoms) resulting from gastrointestinal infections: diarrhea, vomiting, fever and malaise, among others.
The treatment consists of replacing lost liquids and electrolytes (drinking drinking water and other recommended liquids, including consumption of juicy fruits such as papayas, apples, pears, among others that contain water in their composition).
To prevent this, it is necessary to promote health education, improve the hygienic-sanitary conditions of markets and communities in general as a way of promoting, preserving and prolonging PUBLIC HEALTH.
Gastritis and Gastric Health
Gastric Health is one of the most relevant concerns in human health, with gastrointestinal infections being among the main illnesses that affect humans.
Among gastric problems, we have GASTRITIS AND GASTRIC ULCERS as the main public health problems. Gastritis and gastric ulcers normally result from inflammation and corrosion of the walls of the stomach (gastric mucosa) and are generally associated (caused) by the bacterium Helicobacter pylor, which, according to the literature, this bacterium settles on these walls (of the stomach) and starts to release urease that ends up altering the normal pH of the stomach (acid), which leads to inflammation and corrosion of the mucous membranes and consequent gastritis or ulcers, respectively.
In addition to bacterial infections, gastritis and gastric ulcers are associated with several factors, with emphasis on prolonged fasting, chemical substances including drugs, alcohol, foods with strong seasonings including chilli, which ends up causing inflammation of the stomach walls and/or corrosion. of the same, resulting in the appearance of wounds and consequent gastritis or ulcers, respectively.
Among patients with gastritis and/or ulcers, one of the dilemmas is associated with the foods to consume in order to minimize the sensation of pain and discomfort.
acne vulgaris -Mpharm (2nd semester) Cosmetics and cosmeceuticals
Upper GI Bleeding guidelines ppt.pptx
1. UPPER GI BLEEDING (NON VARICEAL) ASGE,ESGE,AND WSES
GUIDELINES
Dr Nasib Al Shibli
Senior Registrar GS,
Price Mutaib in Abdulaziz hospital Saudi Arabia
FACS, FRCSI, MRCSEng, ABHS(GS)
2. • ESSENTIALS OF DIAGNOSIS
• Symptoms: Coffee ground vomiting,
hematemesis, melena, hematochezia,
anemic symptoms
• Past medical history: Liver cirrhosis, use
of non-steroidal anti-inflammatory drugs
• Signs: Hypotension, tachycardia, pallor,
altered mental status, melena or blood
per rectum, decreased urine output
• Bloods: Anemia, raised urea, high urea
to creatinine ratio
• Endoscopy: Ulcers, varices, Mallory-
Weiss tear, erosive disease, neoplasms,
vascular ectasia, and vascular
malformations
• Epidemiology
• 48 to 160 cases per 100 000 adults per
year
• Mortality generally from 6% to 14%
Barkun et al. Ann Intern Med
2010;152:101-13.
3. US KSA
Annual incidence:
100 per 100,000 adults
Peptic ulcer was the most common
cause
Annual incidence:
31 per 100,000
The most common cause esophageal
varices
duodenal ulcer
Longstreth GF. Am J Gastroenterol 1995; 90:206
Ahmed ME et al. J R Coll Physicians Lond 1997; 31 (1):62-4
Alam MK. Saudi J gastroenterol 2000;6:87-91
Al Karawi MA et al. Ann Saudi Med 1995;
4.
5. MANAGEMENT STEP
INITIAL ASSESSMENT. HAEMODYNAMIC STATUS
AND RESUSCITATION.
BLOOD TRANSFUSIONS. RISK ASSESSMENT AND
STRATIFACTION.
PREENDOSCOPIC
MEDICAL THERAPY.
POST ENDOSCOPY. ENDOSCOPIC THERAPY
6. Early intensive hemodynamic resuscitation of patients with acute UGIB has been shown to
significantly decrease mortality
The role of transfusion in clinically stable patients with mild GI bleeding remains
controversial, with uncertainty at which hemoglobin level transfusion should be initiated
Literature suggesting poor outcomes in patients managed with a liberal transfusion
The restrictive RBC transfusion had significantly improved survival and reduced rebleeding
Baradarian R et al. Am J Gastroenterol 2004; 99: 619 – 622
Marik PE, Corwin HL. Crit Care Med 2008; 36: 2667 – 2674
Restellini S, Kherad O, Jairath V et al. Aliment Pharmacol Ther 2013; 37: 316 – 322
Villanueva C, Colomo A, Bosch A et al. N Engl J Med 2013; 368: 11 – 21
7.
8.
9. Hearnshaw et al. Aliment Pharmacol Ther 2010;32:215-24.
RiskStratification
10.
11. RISK STRATIFICATION (CONT’D)
GBS (Glasgow-Blatchford score)
• Patients with Score of 2 or less can be safely
discharged for out patient management
• Scores of more than 6 are associated with the
need for transfusion of blood products and
urgent inpatient investigation
Mart Schiefer et al. European Journal of Gastroenterology &
Hepatology 2012,24:382–387
J Stevenson, K Bowling et al. Gut 2013;62:A21-A22
Rockall Score
Can predict rebleeding, surgery and
mortality
But cannot be used to identify safely
those suitable for outpatient
endoscopy
Chang-Yuan Wang et al. World J Gastroenterol 2013 Jun 14; 19(22):
3466-3472
12. RISK
STRATIFACTION
( CONTD)
GBS vs Rockall
• GBS is more sensitive in
identifying low risk
patients suitable for
out-patient management
• GBS is superior to
Rockall score in
predicting need for
transfusion and
intervention
• The GBS is as effective
as the Rockall score in
predicting mortalitiy
Stanley AJ. World J Gastroenterol 2012; 18(22): 2739-2744
J. Stanley et al. Aliment Pharmacol Ther 2011; 34: 470–475
GBS vs AIMS65
• The GBS has superior
sensitivity in identifying
patients who were not likely
to require interventions or
emergency endoscopy
• The GBS is superior for
predicting blood
transfusion
• The AIMS65 score is
superior to the GBS in
predicting inpatient
mortality
13. Pre-endoscopic therapy
Nasogastric aspirate is useful in predicting
high-risk lesions
(bloody NGT aspirate > high-risk lesions)
Aliebreen AM, Fallone CA, Barkun AN. Gastrointest
Endosc 2004; 59:
14. Pre-endoscopic therapy
PPI treatment initiated before endoscopy
reduce requirement for endoscopic therapy
Sreedharan A, Martin J, Leontiadis Gl et al. Cochrane Database Svst Rev 2010 (7):
CD005415Gl Leontiadis, A Sreedharan et al. Health Technology Assessment 2007; Vol. 11:
No. 51Lau JY, Leung WK, Wu JCY et al. N Eng Med 2007;356:1631-40
This Photo by Unknown Author is licensed under CC BY
15. Timing of endoscopy
Early endoscopy
Aids risk stratification
Reduces hospitalization,
Increase use of therapeutic endoscopy
No evidence exists that very early endoscopy (within a few hours of presentation) can
improve clinical outcomes
Most patients with acute UGIB can be effectively managed by endoscopy within 24 h
Tsoi KKF, Ma TKW, Sung JJY. Gastroenterol Hepatol 2009; 6: 463 -
16.
17. Admission to a ICU
For at least the first 24 hours
on the basis of risk or clinical
condition
Hemodynamic instability
Increasing age
Severe comorbidity
Active bleeding at endoscopy
Large ulcer size (>2 cm)
Barkun et al. Ann Intern
Med
18. Percutaneous or transcatheter arterial embolization
Technical success range from 52% to 98%
Recurrent bleeding in about 10% to 20%
Complications include
Bowel ischemia
Secondary duodenal stenosis
Gastric, hepatic, and splenic infarction
A second attempt at endoscopic therapy remains the preferred
strategy
Barkun et al. Ann Intern Med
21. INITIAL PATIENT EVALUATION
AND HEMODYNAMIC
RESUSCITATION
1 ESGE recommends immediate assessment of
hemodynamic status in patients who present
with acute upper gastrointestinal hemorrhage
(UGIH), with prompt intravascular volume
replacement initially using crystalloid fluids if
hemodynamic instability exists (strong
recommendation, moderate quality evidence).
2 ESGE recommends a restrictive red blood
cell transfusion strategy that aims for a target
hemoglobin between 7 g/dL and 9 g/dL. A
higher target hemoglobin should be
considered in patients with significant co-
morbidity (e. g., ischemic cardiovascular
disease) (strong recommendation, moderate
quality evidence).
22. RISK
STRATIFICATION
3 ESGE recommends the use of a validated risk
stratification tool to stratify patients into high
and low risk groups. Risk stratification can aid
clinical decision making regarding timing of
endoscopy and hospital discharge (strong
recommendation, moderate quality evidence).
4 ESGE recommends the use of the Glasgow-
Blatchford Score (GBS) for pre-endoscopy risk
stratification. Outpatients determined to be at
very low risk, based upon a GBS score of 0 – 1,
do not require early endoscopy nor hospital
admission. Discharged patients should be
informed of the risk of recurrent bleeding and be
advised to maintain contact with the discharging
hospital (strong recommendation, moderate
quality evidence).
23. PRE-ENDOSCOPY
MANAGEMENT
5 For patients taking vitamin K antagonists (VKAs), ESGE
recommends withholding the VKA and correcting coagulopathy while
taking into account the patient's cardiovascular risk in consultation
with a cardiologist. In patients with hemodynamic instability,
administration of vitamin K, supplemented with intravenous
prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP)
if PCC is unavailable, is recommended (strong recommendation, low
quality evidence).
6 If the clinical situation allows, ESGE suggests an international
normalized ratio (INR) value < 2.5 before performing endoscopy with
or without endoscopic hemostasis (weak recommendation, moderate
quality evidence).
7 ESGE recommends temporarily withholding new direct oral
anticoagulants (DOACs) in patients with suspected acute NVUGIH in
coordination/consultation with the local hematologist/cardiologist
(strong recommendation, very low quality evidence).
8 For patients using antiplatelet agents, ESGE recommends the
management algorithm detailed (strong recommendation, moderate
quality evidence).
9 ESGE recommends initiating high dose intravenous proton pump
inhibitors (PPI), intravenous bolus followed by continuous infusion
24.
25. 10 ESGE does not recommend the use of tranexamic acid in patients with NVUGIH (strong
recommendation, low quality evidence).
11 ESGE does not recommend the use of somatostatin, or its analogue octreotide, in
patients with NVUGIH (strong recommendation, low quality evidence).
12 ESGE recommends intravenous erythromycin (single dose, 250mg given 30 – 120
minutes prior to upper GI endoscopy) in patients with clinically severe or ongoing active
UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves
endoscopic visualization, reduces the need for second-look endoscopy, decreases the
number of units of blood transfused, and reduces duration of hospital stay (strong
recommendation, high quality evidence). Metoclopramide??
13 ESGE does not recommend the routine use of nasogastric or orogastric
aspiration/lavage in patients presenting with acute UGIH (strong recommendation,
moderate quality evidence).
14 In an effort to protect the patient's airway from potential aspiration of gastric contents,
ESGE suggests endotracheal intubation prior to endoscopy in patients with ongoing active
hematemesis, encephalopathy, or agitation (weak recommendation, low quality evidence).
26. 15 ESGE recommends adopting the following definitions regarding the timing of
upper GI endoscopy in acute overt UGIH relative to patient presentation: very early <
12 hours, early ≤ 24 hours, and delayed > 24 hours (strong recommendation,
moderate quality evidence).
16 Following hemodynamic resuscitation, ESGE recommends early ( ≤ 24 hours)
upper GI endoscopy. Very early ( < 12 hours) upper GI endoscopy may be considered
in patients with high risk clinical features, namely: hemodynamic instability
(tachycardia, hypotension) that persists despite ongoing attempts at volume
resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to
the interruption of anticoagulation (strong recommendation, moderate quality
evidence).
17 ESGE recommends the availability of both an on-call GI endoscopist proficient in
endoscopic hemostasis and on-call nursing staff with technical expertise in the use of
endoscopic devices to allow performance of endoscopy on a 24 /7 basis (strong
27. ENDOSCOPIC
THERAPY (PEPTIC
ULCER BLEEDING)
18 ESGE recommends that peptic ulcers with spurting or oozing
bleeding or with a nonbleeding visible vessel receive endoscopic
hemostasis because these lesions are at high risk for persistent
bleeding or rebleeding (strong recommendation, high quality
evidence).
19 ESGE recommends that peptic ulcers with an adherent clot be
considered for endoscopic clot removal. Once the clot is removed,
any identified underlying active bleeding or nonbleeding visible
vessel should receive endoscopic hemostasis (weak
recommendation, moderate quality evidence).
20 In patients with peptic ulcers having a flat pigmented spot or
clean base ESGE does not recommend endoscopic hemostasis as
these stigmata present a low risk of recurrent bleeding. In selected
clinical settings, these patients may be discharged to home on
standard PPI therapy, e. g., oral PPI once-daily (strong
recommendation, moderate quality evidence).
21 ESGE does not recommend the routine use of Doppler
ultrasound or magnification endoscopy in the evaluation of
endoscopic stigmata of peptic ulcer bleeding (strong
recommendation, low quality evidence).
22 For patients with actively bleeding ulcers ESGE recommends
combining epinephrine injection with a second hemostasis
28. INITIAL PATIENT EVALUATION
AND HEMODYNAMIC
RESUSCITATION
24 For patients with nonbleeding visible vessel
,ESGE recommends mechanical therapy,
thermal therapy, or injection of a sclerosing
agent as monotherapy or in combination with
epinephrine injection. ESGE recommends that
epinephrine injection therapy not be used as
endoscopic monotherapy (strong
recommendation, high quality evidence).
25 For patients with active NVUGIH bleeding
not controlled by standard endoscopic
hemostasis therapies, ESGE suggests the use
of a topical hemostatic spray as salvage
endoscopic therapy (weak recommendation,
low quality evidence).
29. ENDOSCOPIC THERAPY
(OTHER CAUSES OF
NVUGIH)
26 For patients with acid-related causes of NVUGIH different from
peptic ulcers (e. g., erosive esophagitis, gastritis, duodenitis), ESGE
recommends treatment with high dose PPI. Endoscopic hemostasis
is usually not required and selected patients may be discharged
early (strong recommendation, low quality evidence).
27 ESGE recommends that patients with a Mallory – Weiss lesion
that is actively bleeding receive endoscopic hemostasis. There is
currently inadequate evidence to recommend a specific endoscopic
hemostasis modality. Patients with a Mallory – Weiss lesion and no
active bleeding can receive high dose PPI therapy alone (strong
recommendation, moderate quality evidence).
28 ESGE recommends that a Dieulafoy lesion receive endoscopic
hemostasis using thermal, mechanical (hemoclip or band ligation),
or combination therapy (dilute epinephrine injection combined
with contact thermal or mechanical therapy) (strong
recommendation, moderate quality evidence). Transcatheter
angiographic embolization (TAE) or surgery should be considered
if endoscopic treatment fails or is not technically feasible (strong
recommendation, low quality evidence).
29 In patients bleeding from upper GI Angio ectasias, ESGE
recommends endoscopic hemostasis therapy. However, there is
currently inadequate evidence to recommend a specific endoscopic
hemostasis modality (strong recommendation, low quality
evidence).
30. ENDOSCOPY/ENDOSCOPIC
HEMOSTASIS
MANAGEMENT
31 ESGE recommends PPI therapy for patients who receive
endoscopic hemostasis and for patients with adherent clot not
receiving endoscopic hemostasis. PPI therapy should be high dose
and administered as an intravenous bolus followed by continuous
infusion (80mg then 8mg /hour) for 72 hours post endoscopy
(strong recommendation, high quality evidence).
32 ESGE suggests considering PPI therapy as intermittent
intravenous bolus dosing (at least twice-daily) for 72 hours post
endoscopy for patients who receive endoscopic hemostasis and for
patients with adherent clot not receiving endoscopic hemostasis. If
the patient’s condition permits, high dose oral PPI may also be an
option in those able to tolerate oral medications (weak
recommendation, moderate quality evidence).
33 In patients with clinical evidence of rebleeding following
successful initial endoscopic hemostasis, ESGE recommends repeat
upper endoscopy with hemostasis if indicated. In the case of failure
of this second attempt at hemostasis, transcatheter angiographic
embolization (TAE) or surgery should be considered (strong
recommendation, high quality evidence).
34 ESGE does not recommend routine second-look endoscopy as
part of the management of NVUGIH. However, second-look
endoscopy may be considered in selected patients at high risk for
rebleeding (strong recommendation, high quality evidence).
35 In patients with NVUGIH secondary to peptic ulcer, ESGE
recommends investigating for the presence of Helicobacter pylori
in the acute setting with initiation of appropriate antibiotic therapy
31. 36 ESGE recommends restarting anticoagulant therapy following
NVUGIH in patients with an indication for long-term anticoagulation.
The timing for resumption of anticoagulation should be assessed on a
patient-by-patient basis. Resuming warfarin between 7 and 15 days
following the bleeding event appears safe and effective in preventing
thromboembolic complications for most patients. Earlier resumption,
within the first 7 days, may be indicated for patients at high
thrombotic risk (strong recommendation, moderate quality evidence).
37 In patients receiving low dose aspirin for primary cardiovascular
prophylaxis who develop peptic ulcer bleeding, ESGE recommends
withholding aspirin, re-evaluating the risks/benefits of ongoing
aspirin use in consultation with a cardiologist, and resuming low dose
aspirin following ulcer healing or earlier if clinically indicated (strong
recommendation, low quality evidence).
38 In patients receiving low dose aspirin for secondary cardiovascular
prophylaxis who develop peptic ulcer bleeding, ESGE recommends
aspirin be resumed immediately following index endoscopy if the risk
of rebleeding is low In patients with high-risk peptic ulcer, early
reintroduction of aspirin by day 3 after index endoscopy is
recommended, provided that adequate hemostasis has been
established (strong recommendation, moderate quality evidence).
39 In patients receiving dual antiplatelet therapy (DAPT) who develop
peptic ulcer bleeding, ESGE recommends continuing low dose aspirin
therapy. Early cardiology consultation should be obtained regarding
the timing of resuming the second antiplatelet agent (strong
recommendation, low quality evidence).
40 In patients requiring dual antiplatelet therapy (DAPT) and who
32. BLEEDING PEPTIC ULCER
CLINICAL PRACTICE
GUIDELINES (2020)
bleeding peptic ulcer clinical practice guidelines were
released in January 2020 by the World Society of
Emergency Surgery WSES.
The recommended biochemical and imaging/procedural investigations in
the diagnosis of suspected bleeding peptic ulcer are as follows:
Blood-typing; hemoglobin, hematocrit, and electrolyte values; and
coagulation assessment
Performing endoscopy as soon as possible, particularly in high-risk patients
(Management decisions can be guided based on the damage noted from
recent hemorrhage during endoscopy, as this can help predict further
bleeding risk.)
The recommended parameters for evaluation at emergency department
referral and the criteria for defining an unstable patient are as follows:
Rapid, careful medical/surgical evaluation to prevent further bleeding and
reduce mortality
Upon emergency department referral, evaluation of signs, symptoms, and
laboratory findings to assess stability versus instability
Evaluation according to Rockall and Glasgow-Blatchford scoring systems to
assess disease severity and guide therapy
33. The recommended nonoperative and endoscopic
strategies in patients with bleeding peptic ulcer are as
follows:
Nonoperative management as first-line management
after endoscopy
Endoscopic treatment to achieve hemostasis and to
help prevent rebleeding, the need for surgery, and
mortality
Administration of pre-endoscopy erythromycin
Initiation of proton-pump inhibitor therapy as soon
as possible
Post successful endoscopic hemostasis, high-dose
proton-pump inhibitor therapy as a continuous
infusion for the first 72 hours
Proton-pump inhibitor therapy for 6-8 weeks
following endoscopic treatment
(Long-term proton-pump inhibitor therapy is not
recommended except in patients with ongoing
NSAID use.)
Indications for surgical treatment and the appropriate
approach for surgery in patients with bleeding peptic
ulcer are as follows:
Surgical hemostasis, or, if equipment and qualified
personnel are available, angiographic embolization,
after failure of repeated endoscopy
Refractory bleeding peptic ulcer: Surgical
intervention with open surgery
34. WSES Guidelines contd:
Indications for antimicrobial therapy and for Helicobacter
pylori testing in patients with bleeding peptic ulcer are as
follows:
Empirical antimicrobial therapy not recommended
H pylori testing in all patients
If positive for H pylori, eradication therapy recommended
First-line eradication therapy: Standard triple therapy (ie,
amoxicillin, clarithromycin, proton-pump inhibitor)
First-line therapy if high clarithromycin resistance detected:
Ten-day sequential therapy with four drugs (ie, amoxicillin,
clarithromycin, metronidazole, proton-pump inhibitor)
Second-line therapy if first-line failed: Ten-day levofloxacin-
amoxicillin triple therapy
Start standard triple therapy after 72-96 hours of intravenous
proton-pump inhibitor, for 14-day duration
35. Medication Summary
Rebleeding in patients with upper gastrointestinal (GI)
hemorrhage (UGIB) is associated with increased morbidity
and mortality; therefore, prevention of rebleeding is the
major goal of therapy.
Proton pump inhibitors (PPIs)
There are two approved intravenous (IV) PPIs in use in the
United States, pantoprazole (Protonix IV formulation) and
esomeprazole magnesium (Nexium IV formulation).
These agents suppress gastric acid secretion by specifically
inhibiting the H+/K+/ATPase enzyme system at the
secretory surface of gastric parietal cells.
Use of the IV preparation has been studied only for short-
term therapy (ie, 7-10 d) and may be a useful adjunct via
stabilization of the clot by increasing intragastric pH. High-
dose IV treatment is the norm; however, high-dose oral
therapy may be able to maintain the intragastric pH at
about 6 as well.
In severe acute upper GI bleeding (UGIB), IV proton pump
inhibition should be initiated once the patient's
hemodynamic status has been addressed and appropriate
resuscitation measures have been implemented.
The use of H2-receptor antagonists has not been shown to
be effective in altering the course of UGIB. A meta-analysis
concluded that there was a possible minor benefit with
intravenous H2 antagonists in bleeding gastric ulcers but
no benefit in duodenal ulcers.
36. Aspirin, NSAIDs, and anti-thrombotics
Aspirin and nonsteroidal anti-inflammatory agents (NSAIDs) are
very common causes of ulcer bleeding. Antiplatelet drugs are
often associated with an increased severity of UGIB and may
pose unique challenges in management.
Discontinue NSAIDs when feasible in patients with bleeding
from gastric or duodenal ulcers. Selective cyclooxygenase
(COX)-2 inhibitors could be substituted, with a reduction in the
risk of recurrent ulcer bleeding. Continued concomitant use of
PPIs also reduces the risk of recurrent ulcer bleeding.
Take into account concerns for an associated risk of increased
cardiovascular and/or cerebrovascular side effects in patients
taking selective COX-2 inhibitors and the potential side effects
associated with long-term PPI use when managing relative risk
reduction
As noted earlier, al-Assi et al demonstrated that the
combination of H pylori infection and NSAID use may increase
the risk of ulcer hemorrhage; however, the treatment of H
pylori in patients who are taking NSAIDs remains controversial.
In general, aspirin and antithrombotic agents should be
withheld until the bleeding is controlled, particularly if serious
or life-threatening bleeding is apparent. In patients with
significant risk factors or known cardiovascular indications for
antithrombotic use, however, these agents should be started
back as soon as possible. A study by Sung et al showed that in
patients who had their aspirin held after treatment for a
bleeding peptic ulcer, there was a clear increase in 30-day
mortality, whereas those who continued taking their aspirin
had no increased risk of postprocedure bleeding.
Iron supplementation
Iron supplementation therapy is commonly used for anemia
following UGIB. Oral iron and parenteral iron are both effective
when compared with placebo.
GI tolerance, cost, and availability should be considered when
determining the best regimen for supplementation, if utilized.
37. H pylori eradication:
Eradication of H pylori can reduce the risk of rebleeding.
The treatment regimens approved by FDA have 70%-90% H
pylori eradication rates. The common regimens of “triple
therapy” with a PPI, clarithromycin, and amoxicillin, or
bismuth “quadruple therapy” consisting of a PPI, bismuth,
tetracycline, and a nitroimidazole for 10-14 days remain as
options for first-line therapy.
Clarithromycin resistance should be taken into
consideration, as should previous macrolide exposure and
penicillin allergy when considering a H pylori eradication
regimen.
The 2017 American College of Gastroenterology (ACG)
clinical guideline endorses additional regimens as potential
first-line H pylori eradication therapy as follows :
Sequential therapy: A PPI and amoxicillin for 5-7 days,
followed by a PPI, clarithromycin, and a nitroimidazole
for 5-7 days
Hybrid therapy: A PPI and amoxicillin for 7 days,
followed by a PPI, amoxicillin, clarithromycin, and a
nitroimidazole for 7 days
Fluoroquinolone sequential therapy: A PPI and
amoxicillin for 5-7 days, followed by a PPI,
fluoroquinolone, and nitroimidazole for 5-7 days
38. Bleeding peptic ulcer: WSES guidelines
Diagnosis
In patients with suspected bleeding peptic
ulcer, which biochemical and imaging
investigations should be requested?
In patients with suspected bleeding peptic
ulcer, we recommend blood-typing,
determinations of hemoglobin, hematocrit
and electrolytes, and coagulation
assessment (strong recommendation based
on very low-quality evidences, 1D).
In patients with suspected bleeding peptic
ulcer, what is the diagnostic role of
endoscopy?
In patients with suspected bleeding peptic,
ulcer, we recommend performing
endoscopy as soon as possible, especially
in high-risk patients (Strong
recommendation based on low-quality
39. In patients with bleeding peptic ulcer, are the
endoscopic findings useful to determine the risk for
rebleeding and how do they affect the clinical
management?
We suggest guiding management decisions according
to stigmata of recent hemorrhage during endoscopy
because they can predict the risk of further bleeding
(strong recommendation based on low-quality
evidences, 1C)
Resuscitation
In patients with bleeding peptic ulcer, which
parameters should be evaluated at ED referral and
which criteria should be adopted to define an
unstable patient?
We recommend a rapid and careful surgical/medical
evaluation of bleeding peptic ulcer disease patients
to prevent further bleeding and to reduce mortality
(strong recommendation based on very low-quality
evidences, 1D)
We recommend evaluating several elements
(symptoms, signs, and laboratory findings) to assess
the stability/instability of patients with bleeding
40. In patients with bleeding peptic ulcer, which are the appropriate
targets for resuscitation (hemoglobin level, blood pressure/heart rate,
lactates level, others)?
We recommend several resuscitation targets, similar to those of
damage control resuscitation in the bleeding trauma patient (weak
recommendation based on low-quality evidences, 1C).
In patients with bleeding peptic ulcer, we recommend to maintain an
Hb level of at least > 7g/dl during the resuscitation phase (strong
recommendation based on moderate-quality evidences, 1B).
Resuscitation must proceed simultaneously with endoscopic and
surgical procedures .
A rapid ABC (airway, breathing, and circulation) evaluation should be
done immediately. Appropriate targets for resuscitation in bleeding
peptic ulcer patients can be considered the same used in bleeding
trauma patients (systolic blood pressure of 90–100mmHg until major
bleeding has been stopped; normalization of lactate and base deficit;
hemoglobin 7–9g/dl; correction/prevention of coagulopathy); for this
reason, we refer to the abovementioned guideline Regarding
hemoglobin level, a randomized controlled trial comparing the efficacy
and safety of a restrictive transfusion strategy (transfusion with an Hb
> 7g/dl) with those of a liberal transfusion strategy (transfusion with
an Hb > 9g/dl) in severe acute gastrointestinal bleeding has been
performed .The restrictive strategy, compared with the liberal strategy,
41. Non-operative management—
endoscopic treatment
In patients with bleeding peptic ulcer,
which are the indications for non-
operative management?
In patients with bleeding peptic ulcer,
we recommend non-operative
management as the first line of
management after endoscopy (strong
recommendation based on low-quality
evidences, 1C).
Non-operative management of
bleeding peptic ulcer incorporates
principles of ABCDE :
Airway control
Breathing—ventilation and
oxygenation
Circulation—fluid resuscitation and
control of bleeding
Drugs—pharmacotherapy with PPIs,
prokinetics, etc.
Endoscopy (diagnostic and
therapeutic) or embolization
(therapeutic)
In acutely bleeding ulcers, endoscopy
is a part of resuscitation.
42. In patients with bleeding peptic ulcer, which are the
indications for endoscopic treatment?
In patients with bleeding peptic ulcer, we recommend
endoscopic treatment to achieve hemostasis and reduce
re-bleeding, the need for surgery, and mortality (strong
recommendation based on low-quality evidences, 1C).
We suggest stratifying patients based on the Blatchford
score and adopting a risk-stratified management (weak
recommendation based on very low-quality evidences, 2D):
In the very low-risk group, we suggest outpatient
endoscopy (weak recommendation based on low-
quality evidences, 2C)
In the low-risk group, we recommend early inpatient
endoscopy (≤ 24h of admission) (strong
recommendation based on low-quality evidences, 1C).
In the high-risk group, we recommend urgent inpatient
endoscopy (≤ 12h of admission) (strong
recommendation based on low-quality evidences, 1C).
In patients with spurting ulcer (Forrest 1a), oozing ulcer
(Forrest 1b), and ulcer with non-bleeding visible vessel
(Forrest 2a), endoscopic hemostasis is recommended
(strong recommendation based on low-quality evidences,
1C)
In patients with bleeding peptic ulcer, we suggest dual
modality for endoscopic hemostasis (weak
recommendation based on moderate-quality evidences, 2B)
43. In patients with bleeding peptic ulcer, what is the appropriate pharmacological
regimen (erythromycin, PPI, terlipressin, others)?
In patients with bleeding peptic ulcer, we suggest administering pre-endoscopy
erythromycin (weak recommendation based on moderate-quality evidences, 2B).
In patients with bleeding peptic ulcer, we suggest starting PPI therapy as soon as
possible (weak recommendation based on moderate-quality evidences, 2B),
In patients with bleeding peptic ulcer, after successful endoscopic hemostasis, we
suggest administration of high-dose PPI as continuous infusion for the first 72h
(weak recommendation based on moderate-quality evidences, 2B).
In patients with bleeding peptic ulcer, we recommend PPI for 6–8weeks following
endoscopic treatment. Long-term PPI is not recommended unless the patient has
ongoing NSAID use (strong recommendation based on moderate-quality evidences,
1B)
In patients with recurrent bleeding from peptic ulcer, what is the role of non-
operative management?
In patients with recurrent bleeding from peptic ulcer, we recommend endoscopy as a
first-line treatment (strong recommendation based on low-quality evidences, 1C).
In patients with recurrent bleeding, we suggest transcatheter angioembolization as an
alternative option where resources are available (weak recommendation based on very
low-quality evidences, 2D).
44. Angiography, embolization
In patients with bleeding peptic ulcer, which are the indications for
angiography?
In patients with bleeding peptic ulcer, we suggest considering angiography
for diagnostic purposes as a second-line investigation after a negative
endoscopy (weak recommendation based on low-quality evidences, 2C).
No recommendation can be made regarding the role of provocation
angiography.
Angiography may assist both the diagnosis and the treatment of hemorrhage
associated with peptic ulcer disease. However, endoscopy remains the first-
line investigation of choice for an undifferentiated upper gastrointestinal
hemorrhage Similarly, endoscopy is the first-line diagnostic modality for
patients with suspected upper gastrointestinal hemorrhage from ulcer
disease
In patients with bleeding peptic ulcer, which are the indications for
angioembolization?
In hemodinamically stable bleeding peptic ulcer patients, where endoscopic
hemostasis fails twice or is not possible/feasible, we suggest angiography
with angioembolization where technical skills and equipment are available
(weak recommendation based on very low-quality evidences, 2D)
45. Should embolization be considered for unstable patients with bleeding peptic ulcer?
We suggest against a routinely use of angioembolization unstable patients. Angioembolization in
unstable patients could be s considered only in selected cases and in selected facilities (weak
recommendation based on very low-quality evidences, 2D).
In patients with recurrent bleeding peptic ulcer, which are the indications for
angioembolization?
In patients with rebleeding peptic ulcer, we suggest angioembolization as a feasible option (weak
recommendation based on low-quality evidences, 2C).
In patients with bleeding peptic ulcer who underwent angioembolization, which are the
most appropriate embolization techniques and materials?
Varied techniques and materials exist for the use in the embolization of bleeding duodenal ulcer
disease. A tailored approach, guided by the multidisciplinary team, incorporating patient, pathology,
and environmental factors is suggested (weak recommendation based on low-quality evidences, 2C).
In patients with bleeding peptic ulcer and non-evident bleeding during angiography, is
there a role for prophylactic embolization?
No recommendation can be made on the role of prophylactic embolization.
46. Surgery
In patients with bleeding peptic ulcer, which are the indications for surgical treatment and which is the appropriate
timing for surgery?
In patients with bleeding peptic ulcer, we suggest surgical hemostasis (or angiographic embolization if immediately
available and with appropriate skills) after failure of repeated endoscopy. In patients with hypotension and/or
hemodynamic instability and/or ulcer larger than 2 cm at first endoscopy, we suggest surgical intervention without
repeated endoscopy (strong recommendation based on very low-quality evidences, 1D).
In patients with bleeding peptic ulcer, what is the most appropriate surgical approach (open vs laparoscopy) and
what are the most appropriate surgical procedures?
In patients with refractory bleeding peptic ulcer, we suggest surgical intervention with open surgery (weak
recommendation based on very low-quality evidences, 2D).
In patients operated for bleeding peptic ulcer, we suggest intra-operative endoscopy to facilitate the localization of the
bleeding site (weak recommendation based on very low-quality evidences, 2D).
We suggest choosing the surgical procedure according to the location and extension of the ulcer and the characteristics of
the bleeding vessel (weak recommendation based on low-quality evidences, 2C)
An immediate or delayed biopsy is recommended (weak recommendation based on low-quality evidences, 2C)
A refractory bleeding peptic ulcer is defined as an ulcer still bleeding after repeated endoscopy/angioembolization. Open surgery is
recommended when endoscopic treatments have failed and there is evidence of ongoing bleeding, plus or minus hemodynamic
instability. The choice of the appropriate surgical procedure for bleeding peptic ulcer should be made on the basis of the location and
extension of the ulcer and the characteristics of the bleeding vessel. Surgical approach involves ulcer oversew or resection. Bleeding
gastric ulcers should be resected or at least biopsied for the possibility of neoplasms. Conversely, most duodenal ulcers requiring surgery
for persistent bleeding are usually large and posterior lesions, and the bleeding is often from the gastro-duodenal artery.
47. Antimicrobial therapy
In patients with bleeding peptic ulcer, which are the indications for
antimicrobial therapy and for Helicobacter pylori testing?
In patients with bleeding peptic ulcer, empirical antimicrobial therapy
is not recommended (strong recommendation based on low-quality
evidences, 1C)
We recommend performing Helicobacter pylori testing in all patients
with bleeding peptic ulcer (strong recommendation based on low-
quality evidences, 1C).
In patients with bleeding peptic ulcer and positive tests for HP
infection, which are the therapeutic options?
In H. pylori-positive, eradication therapy is recommended to avoid
recurrent bleeding (strong recommendation based on low-quality
evidences, 1C)
In patients with HP positive tests, standard triple therapy (amoxicillin,
clarithromycin, and PPI) regimen is recommended as first-line
therapy if low clarithromycin resistance is present (strong
recommendation based on moderate-quality evidences, 1B)
10days of sequential therapy with four drugs (amoxicillin,
clarythromicin, metronidazole, and PPI) is recommended in selected
cases, if compliance to the scheduled regimen can be maintained,
and if clarithromycin high resistance is detected (strong
recommendation based on low-quality evidences, 1C).
In patients with HP positive tests, a 10-day levofloxacin-amoxicillin
triple therapy is recommended as second-line therapy if first-line
therapy failed (strong recommendation based on moderate-quality
evidences, 1B).
We recommend to start standard triple therapy (STT) after 72–96h of
intravenous administration of PPI and to administer it for 14days
(strong recommendation based on low-quality evidences, 1C)
48. Conclusions:
Resuscitation should be initiated prior to any
diagnostic procedure .
Gastrointestinal endoscopy allows visualization of
the stigmata, accurate assessment of the level of
risk and treatment of the underlying lesion .
Intravenous PPI therapy after endoscopy is crucial to
decrease the recurrence of bleeding .
Helicobacter pylori testing should be performed in
the acute setting .
49. Institutions
1 Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel
2 Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel
3 Gedyt Endoscopy Center, Buenos Aires, Argentina
4 Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC University
Medical Center, Rotterdam, The Netherlands
5 University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, Spain
6 Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
7 Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del Greco, Italy
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