Diagnosis and therapy of non-variceal upper gastrointestinal bleeding

Table 1 Causes of upper gastrointestinal bleeding

Peptic ulcer
Oesophagitis
Drug-induced mucosal damage (NSAID)	Ulcer
	Erosion
Traumatic or postoperative lesions	Mallory-Weiss lesion
	Arterio-intestinal fistula
Malignant tumor
Sequelae of portal hypertension	Oesophageal varices
	Varices of the gastric fundus
	Portal hypertensive gastropathy
Vascular anomalies	Dieulafoy lesion
	Gastric antral vascular ectasia (GAVE syndrome)
	Angiodysplasia
	Rendu-Osler-Weber syndrome (hereditary hemorrhagic telangiectasia)
Bleeding from the hepato-pancreatico-biliary system
Bleeding from a duodenal diverticulum

NSAID: Non-steroidal anti-inflammatory drugs.

Table 2 Glasgow-Blatchford Score[10]

Admission risk marker	Score component value
Blood urea (mmol/L)
6.5-8.0	2
8.0-10.0	3
10.0-25	4
> 25	6
Haemoglobin (g/dL) for men
12.0-12.9	1
10.0-11.9	3
< 10.0	6
Haemoglobin (g/dL) for women
10.0-11.9	1
< 10.0	6
Systolic blood pressure (mmHg)
100-109	1
90-99	2
< 90	3
Other markers
Pulse ≥ 100 (per minute)	1
Presentation with melaena	1
Presentation with syncope	2
Liver disease	2
Cardiac failure	2

The Blatchford score has to be used before endoscopy. The score component values are added up for each component. A score of 0 is the cut-off with any patient scoring > 0 at risk of requiring an intervention.

Table 3 Clinical (pre endoscopy) and full (post endoscopy) Rockall score[11]

Variable	Score 0	Score 1	Score 2	Score 3
Age	< 60	60-79	≥ 80
Shock	No shock	Pulse ≥ 100	Systolic blood pressure < 100
		Systolic blood pressure ≥ 100
Co-morbidity	Non major		Chronic heart failure, ischemic heart disease, major comorbidity	Renal failure, liver failure, metastatic cancer
Diagnosis	Mallory-Weiss lesion	All other diagnoses	GI malignancy
Evidence of bleeding	None		Blood, adherent clot, visible or spurting vessel

The first three rows make up the clinical score. After endoscopy the scores from the last two rows are added to create the full score. Scores are additive. A score of 0 for the clinical and scores from 0-2 for the full score are the clinical cut-offs to indicate patients at low risk of re-bleeding or death. GI: Gastrointestinal.

Table 4 Forrest classification[12] and the risk of re-bleeding within 24 h after exclusively medical therapy

	Re-bleeding risk (%)
Acute bleeding
Forrest I a (spurting bleeding)	90
Forrest I b (oozing bleeding)	50
Signs of recent bleeding
Forrest II a (visible vessel)	25-30
Forrest II b (adherent clot)	10-20
Forrest II c (flat pigmented haematin on ulcer base)	7-10
Lesions without active bleeding
Forrest III (lesions without signs of recent bleeding or fibrin-covered clean ulcer base)	3-5