A Canadian Clinical Practice Algorithm for the Management of Patients with Non-Variceal Upper Gastrointestinal Bleeding

Barkun, Alan N.; Fallone, Carlo A; Chiba, Naoki; Fishman, Marty; Flook, Nigel; Martin, Janet; Rostom, Alaa; Taylor, Anthony

doi:10.1155/2004/595470

Cited by 37 publications

(17 citation statements)

References 60 publications

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“…The causes of UGIB have been classified into variceal bleeding (esophageal and gastric varices) and non-variceal bleeding (peptic ulcer, erosive gastroduodenitis, reflux esophagitis, tumor, vascular ectasia, etc). Currently, emergency esophagogastrodu odenoscopy (EGD) is the standard investigation of choice for active UGIB since it provides both diagnosis and treatment of UGIB [2][3][4][5][6][7][8][9][10][11] . However, in the real life situation, emergency EGD is seldom available in most hospitals due to the difficulty of setting up emergency services in non-official time, an insufficiency of well-trained endoscopists and medical teams and lack of equipment.…”

Section: Introductionmentioning

confidence: 99%

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Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

Pongprasobchai¹,

Nimitvilai²,

Chasawat³

et al. 2009

WJG

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AIM:To identify clinical parameters, and develop an Upper Gastrointesinal Bleeding (UGIB) Etiology Score for predicting the types of UGIB and validate the score. METHODS:Patients with UGIB who underwent endoscopy within 72 h were enrolled. Clinical and basic laboratory parameters were prospectively collected. Predictive factors for the types of UGIB were identified by univariate and multivariate analyses and were used to generate the UGIB Etiology Score. The best cutoff of the score was defined from the receiver operating curve and prospectively validated in another set of patients with UGIB. RESULTS:Among 261 patients with UGIB, 47 (18%) had variceal and 214 (82%) had non-variceal bleeding. Univariate analysis identified 27 distinct parameters significantly associated with the types of UGIB. Logistic regression analysis identified only 3 independent factors for predicting variceal bleeding; previous diagnosis of cirrhosis or signs of chronic liver disease (OR 22.4, 95% CI 8.3-60.4, P < 0.001), red vomitus (OR 4.6, 95% CI 1.8-11.9, P = 0.02), and red nasogastric (NG) aspirate (OR 3.3, 95% CI 1.3-8.3, P = 0.011).The UGIB Etiology Score was calculated from (3.1 × previous diagnosis of cirrhosis or signs of chronic liver disease) + (1.5 × red vomitus) + (1.2 × red NG aspirate), when 1 and 0 are used for the presence and absence of each factor, respectively. Using a cutoff ≥ 3.1, the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) in predicting variceal bleeding were 85%, 81%, 82%, 50%, and 96%, respectively. The score was prospectively validated in another set of 195 UGIB cases (46 variceal and 149 non-variceal bleeding). The PPV and NPV of a score ≥ 3.1 for variceal bleeding were 79% and 97%, respectively. CONCLUSION:The UGIB Etiology Score, composed of 3 parameters, using a cutoff ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy.

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Section: Introductionmentioning

confidence: 99%

“…Some practice guidelines on non-variceal bleeding [5,6] , variceal bleeding [12,13] including Thai guidelines in 2004 [14] recommend giving empirical treatments to patients with UGIB while waiting for EGD. If variceal bleeding is suspected, empirical treatment with vasoactive agents (e.g.…”

Section: Introductionmentioning

confidence: 99%

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

Pongprasobchai¹,

Nimitvilai²,

Chasawat³

et al. 2009

WJG

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“…At the time of randomization, lead investigators at both control and experimental sites received the guidelines 1 and the corresponding algorithm 8 on the care of patients with nonvariceal upper gastrointestinal bleeding, adapted to Canadian practice. The experimental group also received a multifaceted intervention; its specific components were determined following a national analysis of needs and barriers.…”

Section: Study Interventionsmentioning

confidence: 99%

“…11 During months 4-5, a 2-hour collaborative care workshop was held, with the aim of producing an institution-specific management algorithm using a published template. 8 …”

Section: Study Interventionsmentioning

confidence: 99%

Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial

Barkun

Bhat

Armstrong

et al. 2013

CMAJ

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Background:International guidelines for the management of nonvariceal upper gastrointestinal bleeding have not been widely adopted in clinical practice. We sought to determine whether a national, multifaceted intervention could improve adherence to guidelines, especially for patients at high risk of nonvariceal upper gastrointestinal bleeding. Methods:In this randomized trial, we stratified hospitals by region and size and allocated sites to either the control or experimental group. Health care workers in the experimental group were given published guidelines, generic algorithms, stratification scoring systems and written reminders and attended multidisciplinary guideline education groups and case-based workshops. These interventions were implemented over a 12-month period after randomization, with performance feedback and benchmarking. The primary outcome of adherence rates to key guidelines in endoscopic and pharmacologic management, determined by chart review, was adjusted according to site characteristics and possible within-site dependencies. We also report the rates of adherence to other recommendations.Results: Forty-three sites were randomized to the experimental (n = 21) or control (n = 22) groups. In our primary analysis, we compared patients before (experimental group: n = 402 patients; control group: n = 424 patients) and after (experimental group: n = 361 patients; control group: n = 389 patients) intervention. Patient-level analysis revealed no significant difference in adherence rates to the guidelines after the intervention (experimental group: 9.8%; control group: 4.8%; p = 0.99) after adjustment for the rate of adherence before the intervention (experimental group: 13.2%; control group: 7.1%). The adherence rates to other guidelines were similar and decreased over time, varying between 5% and 93%.Interpretation: This national knowledge translation-based trial suggests poor adherence to guidelines on nonvariceal upper gastrointestinal bleeding. Adherence was not improved by an educational intervention, which highlights both the complexity and poor predictability of attempting to alter the behaviour of health care providers (Trial registration: ClinicalTrials .gov, no.

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“…2,3 Previous studies have suggested that a lower hemoglobin threshold for red cell transfusion can be safe and effective, but those studies did not include patients with gastrointestinal bleeding. 4,5 Current Canadian guidelines for management of nonvariceal upper gastrointestinal bleeding fail to address a hemoglobin threshold for red cell transfusion, 6 whereas British guidelines for the same suggest red cell transfusion whenever hemoglobin concentration falls below 100 g/L. 7 There have been no studies that directly assess whether a restrictive threshold for red cell transfusion in patients with acute upper gastrointestinal bleeding is more effective than a liberal transfusion strategy.…”

mentioning

confidence: 99%

Transfusion strategy for acute upper gastrointestinal bleeding

Handel

Lang

2015

CJEM

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A Canadian Clinical Practice Algorithm for the Management of Patients with Non-Variceal Upper Gastrointestinal Bleeding

Cited by 37 publications

References 60 publications

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

Upper gastrointestinal bleeding etiology score for predicting variceal and non-variceal bleeding

Effectiveness of disseminating consensus management recommendations for ulcer bleeding: a cluster randomized trial

Transfusion strategy for acute upper gastrointestinal bleeding

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