Q&A: Guideline updates for nonvariceal GI bleeding
Click Here to Manage Email Alerts
New endoscopic techniques and changes in the pharmacologic landscape prompted an update in guidelines for managing patients with nonvariceal upper GI bleeding.
A multidisciplinary group of experts from 11 countries updated the 2010 International Consensus clinical practice guidelines, including making recommendations for initiating fluid resuscitation, how to manage patients on anticoagulation or antiplatelet therapy, and hemoglobin threshold for blood transfusions in patients with nonvariceal upper GI bleeding.
Lead author of the guidelines, Alan N. Barkun, MD, CM, FRCP(C), FACP, FACG, AGAF, MSc, chairholder in gastroenterology and professor of medicine at McGill University in Montreal, discussed the recommendations with Healio Primary Care. – by Erin Michael
Q: What is the importance of updating the guidelines for managing nonvariceal upper GI bleeding?
A: There have been many new evolutions in the field since the last publication of these high-quality recommendations that adopt state-of-the art guidelines methodology.
Q: How will initiating fluid resuscitation in patients with acute nonvariceal upper GI bleeding improve patient outcomes?
A: Appropriate and timely resuscitation is thought to be key to improving outcomes in this therapeutic area, which is why it is a good practice statement in the consensus document. Important conceptual considerations that are not specifically addressed by consensus recommendations due to a paucity of direct, high-quality data directly addressing patients with acute upper GI bleeding, but that are discussed in the document, include a realization that use of colloids for resuscitation in other urgent care areas have not demonstrated increased survival rates, but are more expensive than crystalloids; it was thus concluded by the group that their routine use in clinical practice cannot be justified by current evidence. Furthermore, of note also is that a recent large trial in critically ill hospitalized patients also found a borderline reduction in acute kidney injury and trend to reduction in in-hospital mortality with balanced crystalloids (eg, Ringer’s lactate) vs. saline.
Q: What updates are being made for patients with acute GI bleeding who receive anticoagulation or antiplatelet therapy?
A: A number of recommendations address this important and expanding subgroup of patients. These include a recommendation that in patients on anticoagulants (vitamin K antagonists, direct oral anticoagulants), not to delay endoscopy (with or without endoscopic hemostatic therapy). Furthermore, although there is limited evidence, members suggest secondary prophylaxis in patients with previous ulcer bleeding receiving either cardiovascular prophylaxis with single or dual antiplatelet therapy or anticoagulant therapy.
Q: What is the importance of a higher hemoglobin threshold for blood transfusion in patients with nonvariceal GI bleeding who have CVD?
A: The data supporting a restrictive approach adopting a transfusional hemoglobin threshold of < 80 g/L in patients with acute upper GI bleeding without underlying CVD are quite widely recognized. However, the evidence for patients with acute upper GI bleeding but with underlying CVD are much fewer. Based on these limited data, the consensus group suggests that a higher hemoglobin threshold be considered in patients with CVD, compared to those without CVD. However, the group does not recommend a specific cut-off level, stating this would be dependent on other factors including the patient’s overall clinical status, the type and severity of underlying CVD, and the severity of bleeding. Of note, guidelines from the U.K. National Institute for Health and Care Excellence also recommend a higher transfusion level for patients with underlying CVD than those without, while the AABB (formerly known as the American Association of Blood Banks) recommends a hemoglobin threshold of 80 g/L for patients with underlying CVD as compared to 70 g/L in hemodynamically stable critically ill patients without CVD.
Q: How will the guidelines change endoscopy management in patients with acute upper GI bleeding?
A: In addition to previous recommendations from past guidelines on the topic (such as recommending the use of through-the-scope clips) by the same international group, updates to existing systematic reviews and published data on new and emerging endoscopic approaches (although not all, due to the timely availability of data) informed the following recommendations: For patients admitted with acute upper GI bleeding, the group suggests performing early endoscopy (within 24 hours of presentation). This particular guideline acknowledges the importance of adequate resuscitation in the face of a U-shaped mortality curve as a function of time following presentation in higher risk individuals. For patients with acutely bleeding ulcers with high-risk stigmata, the consensus group recommends endoscopic therapy with thermocoagulation or sclerosant injection. Using TC-325 (Hemospray, Cook Medical) as a temporizing therapy to stop bleeding when conventional endoscopic therapies are not available or fail is suggested. However, members suggest against choosing TC-325 as single therapeutic strategy vs. conventional endoscopic therapy in actively bleeding ulcers. The consensus group could not make a recommendation for or against using Doppler endoscopic probe (DEP) vs. no DEP to assess the need for further endoscopic therapy due to the quantity and certainty of evidence.
Q: What efforts are being made to ensure these updates are implemented in clinical practice?
A: Wide distribution of these guidelines in the scientific literature and in social media is being encouraged as components of a dissemination strategy, while some members of the group will assess more formal knowledge translation initiatives, similar to what followed the last iteration of the international guidelines on nonvariceal upper GI bleeding.
Reference:
Barkun AN, et al. Ann Intern Med. 2019;doi:10.7326/M19-1795.
Disclosures: Barkun reported grants and consulting fees from and advisory board membership at AtGen and Pendopharm, and advisory membership at Cook and Olympus outside the submitted work. Please see guidelines for all other authors’ relevant financial disclosures.