Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018

There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

Abstract

Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the ’gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement.

Related collections

Most cited references 112

Record: found
Abstract: found
Article: not found

Transfusion strategies for acute upper gastrointestinal bleeding.

Càndid Villanueva, Alan Colomo, Alba Bosch … (2013)

The hemoglobin threshold for transfusion of red cells in patients with acute gastrointestinal bleeding is controversial. We compared the efficacy and safety of a restrictive transfusion strategy with those of a liberal transfusion strategy. We enrolled 921 patients with severe acute upper gastrointestinal bleeding and randomly assigned 461 of them to a restrictive strategy (transfusion when the hemoglobin level fell below 7 g per deciliter) and 460 to a liberal strategy (transfusion when the hemoglobin fell below 9 g per deciliter). Randomization was stratified according to the presence or absence of liver cirrhosis. A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence interval [CI], 0.33 to 0.92; P=0.02). Further bleeding occurred in 10% of the patients in the restrictive-strategy group as compared with 16% of the patients in the liberal-strategy group (P=0.01), and adverse events occurred in 40% as compared with 48% (P=0.02). The probability of survival was slightly higher with the restrictive strategy than with the liberal strategy in the subgroup of patients who had bleeding associated with a peptic ulcer (hazard ratio, 0.70; 95% CI, 0.26 to 1.25) and was significantly higher in the subgroup of patients with cirrhosis and Child-Pugh class A or B disease (hazard ratio, 0.30; 95% CI, 0.11 to 0.85), but not in those with cirrhosis and Child-Pugh class C disease (hazard ratio, 1.04; 95% CI, 0.45 to 2.37). Within the first 5 days, the portal-pressure gradient increased significantly in patients assigned to the liberal strategy (P=0.03) but not in those assigned to the restrictive strategy. As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.).

0 comments Cited 346 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.

Jerrold Levy, Charles V Pollack, Paul Reilly … (2017)

Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran.

0 comments Cited 222 times – based on 0 reviews      Review now

Bookmark

Record: found
Abstract: found
Article: not found

Clopidogrel with or without omeprazole in coronary artery disease.

Deepak Bhatt, Byron L Cryer, Charles Contant … (2010)

Gastrointestinal complications are an important problem of antithrombotic therapy. Proton-pump inhibitors (PPIs) are believed to decrease the risk of such complications, though no randomized trial has proved this in patients receiving dual antiplatelet therapy. Recently, concerns have been raised about the potential for PPIs to blunt the efficacy of clopidogrel. We randomly assigned patients with an indication for dual antiplatelet therapy to receive clopidogrel in combination with either omeprazole or placebo, in addition to aspirin. The primary gastrointestinal end point was a composite of overt or occult bleeding, symptomatic gastroduodenal ulcers or erosions, obstruction, or perforation. The primary cardiovascular end point was a composite of death from cardiovascular causes, nonfatal myocardial infarction, revascularization, or stroke. The trial was terminated prematurely when the sponsor lost financing. We planned to enroll about 5000 patients; a total of 3873 were randomly assigned and 3761 were included in analyses. In all, 51 patients had a gastrointestinal event; the event rate was 1.1% with omeprazole and 2.9% with placebo at 180 days (hazard ratio with omeprazole, 0.34, 95% confidence interval [CI], 0.18 to 0.63; P<0.001). The rate of overt upper gastrointestinal bleeding was also reduced with omeprazole as compared with placebo (hazard ratio, 0.13; 95% CI, 0.03 to 0.56; P = 0.001). A total of 109 patients had a cardiovascular event, with event rates of 4.9% with omeprazole and 5.7% with placebo (hazard ratio with omeprazole, 0.99; 95% CI, 0.68 to 1.44; P = 0.96); high-risk subgroups did not show significant heterogeneity. The two groups did not differ significantly in the rate of serious adverse events, though the risk of diarrhea was increased with omeprazole. Among patients receiving aspirin and clopidogrel, prophylactic use of a PPI reduced the rate of upper gastrointestinal bleeding. There was no apparent cardiovascular interaction between clopidogrel and omeprazole, but our results do not rule out a clinically meaningful difference in cardiovascular events due to use of a PPI. (Funded by Cogentus Pharmaceuticals; ClinicalTrials.gov number, NCT00557921.).

0 comments Cited 201 times – based on 0 reviews      Review now

Bookmark

All references

Author and article information

Journal

Journal ID (nlm-ta): Gut

Journal ID (iso-abbrev): Gut

Journal ID (hwp): gutjnl

Journal ID (publisher-id): gut

Title: Gut

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Print): 0017-5749

ISSN (Electronic): 1468-3288

Publication date (Print): October 2018

Publication date (Electronic): 24 April 2018

Volume: 67

Issue: 10

Pages: 1757-1768

Affiliations

[1 ] departmentInstitute of Digestive Disease , The Chinese University of Hong Kong , Hong Kong

[2 ] departmentDepartment of Gastroenterology and Hepatology , University of Malaya , Kuala Lumpur, Malaysia

[3 ] departmentYong Loo Lin School of Medicine , National University of Singapore , Singapore

[4 ] University of Ulsan College of Medicine , Ulsan, South Korea

[5 ] UST Hospital, University of Santo Tomas , Manila, Philippines

[6 ] departmentDivision of Gastroenterology and Hepatology , Nihon University School of Medicine , Tokyo, Japan

[7 ] departmentAsian Institute of Gastroenterology , Asian Healthcare Foundation , Hyderabad, India

[8 ] departmentDepartment of Medicine , Lyell McEwin Hospital, University of Adelaide , Adelaide, South Australia, Australia

[9 ] departmentDepartment of Medicine , Jichi Medical School , Shimotsuke, Japan

[10 ] departmentState Key Laboratory of Cancer Biology , Xijing Hospital of Digestive Diseases , Xi’an, China

[11 ] China Medical University , Taichung, Taiwan

[12 ] University of Utah College of Health , Salt Lake City, Utah, USA

[13 ] University of California , Los Angeles, California, USA

[14 ] departmentDepartment of Gastroenterology and Hepatology , Erasmus University Medical Center , Rotterdam, The Netherlands

[15 ] departmentDepartment of Gastroenterology , University Hospital , Zaragoza, Spain

Author notes

[Correspondence to ] Professor Joseph JY Sung, Institute of Digestive Disease, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China; jjysung@ 123456cuhk.edu.hk

Author information

Francis K L Chan http://orcid.org/0000-0001-7388-2436

Article

Publisher ID: gutjnl-2018-316276

DOI: 10.1136/gutjnl-2018-316276

PMC ID: 6145289

PubMed ID: 29691276

SO-VID: efdf5e4f-0854-4693-a3c2-25657e5afe0a

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/