Tag Archives: Guidelines


Nonvariceal Upper Gl Bleeding – international guidelines

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding have been published. Here is a summary of the recommendations; a link to the full text document is at the bottom of this page.

  1. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality.
  2. Blood transfusions should be administered to a patient with a hemoglobin level of 70 g/L or less.
  3. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy.
  4. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.
  5. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.
  6. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy (the observed lesion downstaging attributable to PPI therapy before endoscopy may be even more beneficial in situations in which early endoscopy may be delayed or when available endoscopic expertise may be suboptimal).
  7. Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding.
  8. A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.
  9. The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.
  10. Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.
  11. Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection
  12. Routine second-look endoscopy is not recommended.
  13. An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy.
  14. Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.
  15. Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.
  16. Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.
  17. Patients with bleeding peptic ulcers should be tested for H. pylori and receive eradication therapy if it is present, with confirmation of eradication.
  18. Negative H. pylori diagnostic tests obtained in the acute setting should be repeated
  19. In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a cyclooxygenase-2 (COX-2) inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
  20. In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
  21. In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
  22. In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.

International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Ann Intern Med. 2010 Jan 19;152(2):101-13 (Full Text)

New Paediatric DKA guidelines

The International Society for Paediatric and Adolescent Diabetes (ISPAD) has published new comprehensive guidelines, including those for diabetic ketoacidosis.

Their summary:

• DKA is caused by either relative or absolute insulin deficiency.

• Children and adolescents with DKA should be managed in centers experienced in its treatment and where vital signs, neurological status and laboratory results can be monitored frequently

• Begin with fluid replacement before starting insulin therapy.

• Volume expansion (resuscitation) is required only if needed to restore peripheral circulation.

• Subsequent fluid administration (including oral fluids) should rehydrate evenly over 48 hours at a rate rarely in excess of 1.5 – 2 times the usual daily maintenance requirement.

• Begin with 0.1 U/kg/h. 1 – 2 hours AFTER starting fluid replacement therapy

• If the blood glucose concentration decreases too quickly or too low before DKA has resolved,
increase the amount of glucose administered. Do NOT decrease the insulin infusion

• Even with normal or high levels of serum potassium at presentation, there is always a total body deficit of potassium.

• Begin with 40 mmol potassium/L in the infusate or 20 mmol potassium/L in the patient receiving fluid at a rate >10 mL/kg/h.

• There is no evidence that bicarbonate is either necessary or safe in DKA.

• Have mannitol or hypertonic saline at the bedside and the dose to be given calculated beforehand.

• In case of profound neurological symptoms, mannitol should be given immediately.

• All cases of recurrent DKA are preventable.

Full guidelines available here
Other ISPAD guidelines available here