Bleeding from the upper gastrointestinal (GI) tract is a common medical emergency, with an incidence of between 50-150 cases per 100,000 per year.1 A recent audit by the British Society of Gastroenterology showed the mortality rate from upper GI bleeds has fallen from 14%2 in 1993 to 10% in 2007.3 However, despite the use of proton pump inhibitors (ppis), admission rates for peptic ulcer haemorrhage have increased in older age groups,4 probably related to increased use of antiplatelet agents such as aspirin and clopidogrel and anticoagulants in acute coronary syndromes, stroke and atrial fibrillation. The rising age of the population may also have offset further reductions in mortality and morbidity that may have otherwise come about through improved supportive and endoscopic care.
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1. Palmer KR. Non-variceal upper gastrointestinal haemorrhage: guidelines Gut 2002; 51(suppl IV): iv1–iv6.
2. Rockall TA, Logan RFA, Devlin HB, Northfield TC. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. BMJ 1995; 311: 222–226.
3. UK comparative audit of upper gastrointestinal bleeding and the use of blood. December 2007.
4. Higham J, Kang J-Y, Majeed A. Recent trends in admissions and mortality due to peptic ulcer in England: increasing frequency of haemorrhage among older subjects. Gut 2002; 50: 460–464.
5. Mendall MA and Northfield TC. Transmission of Helicobacter pylori infection. Gut 1995; 37: 1–3.
6. Ng FH, Wong SY, Chang CM, Chen WH, et al. High incidence of clopidogrel-associated gastrointestinal bleeding in patients with previous peptic ulcer disease. Aliment Pharmacol Ther 2003; 18(4): 443–9.
7. Resuscitation Guidelines 2010 at http://www.resus.org.uk/pages/ guide.htm.
8. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support Course Manual. Chicago, Ill: American College of Surgeons; 1997.
9. Gutierrez G, Reines HD, Wulf-Gutierrez ME. Clinical review: haemorrhagic shock. Critical Care 2004; 8: 373–381.
10. Bickell W, Wall M, Jr., Pepe P, Russell Martin R, Ginger V, Allen M, and Mattox K. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331: 1105–1109.
11. Levacher S, Blaise M, Pourriat J-L, Letoumelin P, Lapandry C and Pateron D. Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patient. Lancet 1995; 346(8979): 865–868.
12. Hou M-C, Lin H-C, Liu T-T, Kuo Be I-T, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: A randomized trial. Hepatology 2004; 39(3): 746–753.
13. Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment following acute gastrointestinal haemorrhage. Gut 1996; 38: 316–21.
14. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 356; 3: 1318–1321.
15. Romagnuolo J, Barkan AN, Enns R, et al. Simple clinical predictors may obviate urgent endoscopy in selected patients with nonvariceal upper gastrointestinal tract bleeding. Arch Intern Med 2007; 167(3): 265–270.
16. Sanders DS, Carter MJ, Goodchap RJ, et al. Prospective validation of the Rockall risk scoring system for upper GI hemorrhage in subgroups of patients with varices and peptic ulcers. Am J Gastroenterol 97: 630–635.
17. Park DK, Um SH, Lee JW, Lee JB, et al. Clinical significance of variceal hemorrhage in recent years in patients with liver cirrhosis and esophageal varices. J Gastro Hep 2004; 19: 1042–1051.
18. Jalan R, Hayes PC. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2000; 46(Suppl 3): iii1–iii15.
19. Burroughs AK, Triantos CK, O'Beirne J et al. Predictors of early rebleeding and mortality after acute variceal hemorrhage in patients with cirrhosis. Nature Reviews Gastroenterology and Hepatology 2009; 6: 72–73.
20. Marmo R, Rotondano G, Piscopo R , Bianco MA, D'Angella R and Cipolletta L. Dual Therapy Versus Monotherapy in the Endoscopic Treatment of High-Risk Bleeding Ulcers: A Meta-Analysis of Controlled Trials. Am J Gastroenterol 102: 279–289.
21. Lau JYW, Sung JJY, Lee KKC Yung M-y, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Eng J Med 2000; 343: 310–316.
22. Leontiadis GI, Sreedharan A, Dorward S et al. Systematic review of the clinical effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding. Health Technol Assess 2007; 11: 51.
23. Lau JY, Leung WK, Wu JCY, Chan FKL, et al, and Sung JJY. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med 2007; 356: 1631–164.
24. Ioannou GN, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002147. DOI: 10.1002/14651858. CD002147.
25. Garcia-Tsao G and Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010; 362: 823–832.
26. Chey WD, Wong BCY, Practice Parameters Committee of the American College of Gastroenterology. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol 2007; 102: 1808–25.
27. Chiu PWY, Lam CYW, Lee SW, et al. Effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomised trial Gut 2003; 52: 1403–1407.
28. Lau JYW, Sung JJY, Lam Y-H, Chan ACW, et al. Endoscopic retreatment compared with surgery in patients with recurrent bleeding after initial endoscopic control of bleeding ulcers. N Eng J Med 1999; 340: 751–756.
29. Kate V, Ananthakrishnan N and Badrinath S. Effect of Helicobacter pylori eradication on the ulcer recurrence rate after simple closure of perforated duodenal ulcer: retrospective and prospective randomized controlled studies. Br J Surg 2001; 88: 10541058.
30. Burris JM, Lin PH, Johnston WF, et al. Emergent embolization of the gastroduodenal artery in the treatment of upper gastrointestinal bleeding. The experience from a surgeon-initiated interventional program. Am J Surgery 2009; 198(1): 59–63.