CLINICIANS CORNER THE RATIONAL

CLINICAL EXAMINATION
Does This Patient Have a Severe
Upper Gastrointestinal Bleed?
F. Douglas Srygley, MD
Charles J. Gerardo, MD
Tony Tran, MD
Deborah A. Fisher, MD, MHS
CLINICAL SCENARIO
Case 1
A62-year-oldmanpresents tothe emer-
gency department after an episode of
syncope following several weeks of fa-
tigue. He has a history of upper gastro-
intestinal bleeding (UGIB) due to pep-
tic ulcer disease. His blood pressure is
90/60 mmHg, pulse of 105/min, and a
black, foul-smelling stool is foundupon
rectal examination. Blood test results
showa hemoglobin level of 6.5 g/dL, a
creatinine level of 1.0 mg/dL, and a se-
rum urea nitrogen level of 55 mg/dL.
Would the results of a nasogastric la-
vage help determine between an up-
per endoscopy or a colonoscopy as the
test most likely to identify the bleed-
ing source?
Case 2
A45-year-old woman presents with 24
hours of diarrhea, nausea, and 2 epi-
sodes of vomiting coffee ground mate-
rial. She takes no prescription medica-
tions other than those for hypertension
and she takes no over-the-counter
medications. Physical examination re-
veals bloodpressure of 145/100mmHg,
pulse of 70/min, and rectal examina-
tion with liquid brown stool. Blood
test results reveal a hemoglobin level
of 13.7 g/dL, a creatinine level of 1.1
CME available online at
www.jamaarchivescme.com
and questions on p 1091.
Author Affiliations: Departments of Medicine (Drs
Srygley, Tran, and Fisher) and Surgery (Dr Gerardo),
Duke University Medical Center, Durham, North Caro-
lina; and Center for Health Services Research in Pri-
mary Care, Durham Veterans Affairs Medical Cen-
ter, Durham, North Carolina (Dr Fisher).
Corresponding Author: F. Douglas Srygley, MD,
Department of Medicine, Duke University Medical
Center, PO Box 3913, Durham, NC 27710 (srygl001
@mc.duke.edu).
The Rational Clinical Examination Section Editors: Da-
vid L. Simel, MD, MHS, DurhamVeterans Affairs Medi-
cal Center and Duke University Medical Center, Dur-
ham, NC; Drummond Rennie, MD, Deputy Editor.
Context Emergency physicians must determine both the location and the severity
of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic ap-
proaches.
Objectives To identify the historical features, symptoms, signs, bedside maneu-
vers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from
acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to
have severe bleeding that necessitates an urgent intervention.
Data Sources A structured search of MEDLINE (1966-September 2011) and refer-
ence lists from retrieved articles, review articles, and physical examination textbooks.
Study Selection High-quality studies were included of adult patients who were either
admitted with GIB or evaluated in emergency departments with bedside evaluations
and/or routine laboratory tests, and studies that did not include endoscopic findings
in prediction models. The initial search yielded 2628 citations, of which 8 were re-
tained that tested methods of identifying a UGIB and 18 that identified methods of
determining the severity of UGIB.
Data Extraction One author abstracted the data (prevalence, sensitivity, specific-
ity, and likelihood ratios [LRs]) and assessed methodological quality, with confirma-
tion by another author. Data were combined using random effects measures.
Data Synthesis The majority of patients (N=1776) had an acute UGIB (preva-
lence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that
a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-
5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage
with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitro-
gen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Con-
versely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38)
decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute
UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with
red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-
7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the like-
lihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (sum-
mary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires
urgent intervention.
Conclusions Melena, nasogastric lavage with blood or coffee grounds, or serumurea
nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots
in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which
does not require nasogastric lavage, is very efficient for identifying patients who do
not require urgent intervention.
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mg/dL, and a serumurea nitrogen level
of 12 mg/dL. A nasogastric lavage has
clear fluid. What is the probability that
this patient is having a severe UGIB?
WHY ARE THESE QUESTIONS
IMPORTANT?
In the United States, an estimated
390 000 hospitalizations annually oc-
cur with a principal diagnosis of gastro-
intestinal bleeding (GIB) and an addi-
tional 600 000 hospitalizations occur
witha secondarydiagnosis of GIB.
1
Some
patients will have severe bleedingandre-
quire urgent intervention to reduce the
potential for morbidity and mortality;
however, many patients with minor
bleeding can be managed effectively by
arranging an endoscopy in the outpa-
tient setting, which can spare the pa-
tient an urgent intervention and hospi-
talization.
2
Urgent interventions for the
patient withsevere bleeding include en-
doscopic therapy, blood transfusion, ra-
diological intervention, or surgery. Pa-
tients hospitalized with a UGIB have a
mortality of 4.5% to 8.2%,
3-5
and simi-
lar patients witha lower GIB(LGIB) have
a mortality of 3.0% to 8.8%.
4,6,7
Identification of a UGIB (proximal to
the ligament of Treitz) vs LGIB (distal
tothe ligament of Treitz) is critical toper-
forming an effective, efficient evalua-
tion and may be difficult even for an ex-
perienced clinician (FIGURE 1). In 1
study,
8
more than a third of patients
without hematemesis presenting with
anacute GIBunderwent diagnostic test-
ing of both the upper and lower gas-
trointestinal tract. Although all pa-
tients with GIB require assessment of
hemodynamics and blood cell count,
the remaining evaluations and poten-
tial interventions for a UGIB and LGIB
differ considerably. For example, evalu-
ation of a likely LGIB will include colo-
noscopy, flexible sigmoidoscopy, tagged
red blood cell scan, or an angiogram.
Conversely, if a patient has a likely
UGIB, the first diagnostic study is typi-
cally an upper endoscopy. Addition-
ally, certain medical therapies such as
proton pump inhibitors and octreo-
tide would only be appropriate for a
UGIB. Once the location of the GIB is
determined to be fromanupper source,
management will reflect the likeli-
hood of severe bleeding. We con-
ducted a systematic review to deter-
mine the accuracy of historical features,
symptoms, signs, and combinations of
findings that might help assess pa-
tients with GIB.
VISUAL EVIDENCE OF GIB
Melena
Although patients will recognize he-
matemesis or hematochezia, they may
not appreciate andtherefore may not re-
port the passage of black, tarrystools that
characterize melena. However, not all
darkstools aremelenic. Iron- or bismuth-
containingmedications canproducedark
stools that mimic the appearance of true
melena.
9
Melena suggests a proximal
bleeding source in which there is more
time for enzymatic breakdown to trans-
form blood to melena and produce the
characteristic pungent odor that an ex-
perienced practitioner can often iden-
tify immediately. In clinical experi-
ments, placing as little as 50mLof blood
in the stomach can cause melena.
10
Al-
thoughgastric acid may play a role inits
formation, blood inserted into the small
bowel or cecumcan still create melenic
stool. Melena appears todependprimar-
ily on the length of time between instal-
lation of the blood and the patient hav-
ing a bowel movement.
11,12
For example,
1 L of blood placed in the stomach can
result in bright red blood per rectum
within 4 hours, which implies that red
blood or clots per rectum are due to
either a very rapid blood loss or a distal
source of bleeding.
10,13
Figure 1. Anatomical Landmarks and Location of Gastrointestinal Bleeding
Ligament of Treitz
Celiac trunk of aorta
Endoscope
(distal extent)
Duodenojejunal junction
Inferior vena cava
DI A P HRA GM
Endoscope
Bleeding sources proximal to the duodenojejunal junction, as approximated by the ligament of Treitz, are con-
sidered upper gastrointestinal bleeds.
SEVERE UPPER GASTROINTESTINAL BLEEDING
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Gastric Contents
Nasogastriclavageprovidesamethodfor
samplingcontentsfromthestomach. Al-
thoughtheroutineuseof nasogastricla-
vage in patients with suspected GIB re-
mains controversial,
14,15
it is frequently
usedinthe UnitedStates andCanada. A
studyperformedinLos Angeles revealed
that 60%(n=632)of patientsunderwent
nasogastric lavage for UGIB,
16
and 28%
(n=1869)of patientsunderwent thepro-
cedureinastudyfromCanada.
17
Arecent
survey of gastroenterologists opinions
about the role of nasogastric lavage for
UGIBshowedtheywere uncertainof its
appropriateness (quantified with the
RAND appropriateness scale) and also
showedextremevariation (quantified
withadisagreement index)intheir opin-
ionsabout itsrole.
18
Someclinicianscon-
sider the presence of varices a relative
contraindicationfor the use of nasogas-
tric lavage. However, there are no pub-
lished trials to suggest that nasogastric
lavageworsensbleeding
19
inpatientswith
or without varices.
Once a nasogastric tube has been
properly inserted (FIGURE 2), a mini-
mum of 100 to 200 mL of room tem-
perature water or normal saline is in-
serted via the tube into the stomachand
then aspirated to evaluate the color of
return. Bright red blood indicates fresh
blood. Aspirate that looks like wet cof-
fee grounds indicates blood that has
been partially degraded.
13,15,20
Many cli-
nicians infer that yellow-green tinge in-
dicates bile from contents beyond the
pylorus, but visual determinationof bile
may not be accurate.
21
METHODS
Search Strategy and Study
Selection
We searched MEDLINE (1966-
September 2011) for articles on the re-
liability and diagnostic accuracy for
components of the clinical examina-
tion and routine investigations for dis-
tinguishing acute UGIB fromLGIB and
for determining the severity of a UGIB.
Our strategy was intentionally broad to
minimize the chance of overlooking a
relevant article. We definedacute by the
setting (defined as patients having pre-
sented to an emergency department for
assessment of GIB, patients being ad-
mitted to the hospital for GIB, or both).
We defined a severe UGIB as one with
either high-riskendoscopic stigmata be-
cause interventionis recommended
22
or
if an intervention was performed, in-
cluding endoscopic therapy, blood
transfusion, radiological intervention,
or surgery. Previous studies have used
similar definitions as any of the above
outcomes would necessitate an imme-
diate intervention by the clinician.
2,23
The search was conducted using a
similar strategy developed for the Ra-
tional Clinical Examination series
(eMethods, http://www.jama.com). We
included studies that evaluated the di-
agnostic accuracy or reliability of some
element of the history, physical exami-
nation, bedside maneuvers (nasogas-
tric lavage), or routine investigations
(defined as complete blood cell count,
electrolytes, creatinine level, serumurea
nitrogen level, prothrombin time, par-
tial thromboplastin time, bilirubin,
transaminases, alkaline phosphatase)
for determining either the presence of
a UGIB in a patient presenting with a
Figure 2. Key Steps in Nasogastric (NG) Tube Insertion
Insert the NG tube along the base
of the nares parallel to the ground.
A
Continue to advance the NG tube through
the oropharynx.
B
Confirm proper position of the NG tube. C
Esophagus
Trachea
Floor of the
nasopharynx
Trachea
f the
arynx
Epiglottis Epiglottis
NG tube
NG tube
To ease insertion past the trachea,
advance the tube while the patient
swallows sips of water from a straw,
which closes the epiglottis.
Prior to insertion of the NG tube, inspect the nares to confirm the absence of any obstruction. If the nares are symmetrical, insert the tube in the side with the larger
passageway. Most experts suggest applying topical lidocaine in the nares for patient comfort during insertion. A, With the patient seated and head level, insert the first
10 cm of a lubricated NG tube along the floor of the nasopharynx (parallel to the ground). B, Advance the tube through the oropharynx past the epiglottis and trachea
into the esophagus and stomach. C, Confirmproper location of the NGtube by aspiration for stomach contents, auscultation over the stomach after pushing air through
the tube with a syringe, or by an abdominal radiograph.
SEVERE UPPER GASTROINTESTINAL BLEEDING
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clinically apparent GIB or for deter-
mining the need for an urgent evalua-
tionof a patient presenting witha UGIB.
To convert creatinine level to micro-
moles per liter, multiply by 88.4; and
serum urea nitrogen level to milli-
moles per liter, multiply by 0.357.
Statistical Analysis
For eachstudy, we calculatedthe preva-
lence, sensitivity, specificity, likeli-
hood ratios (LRs), and 95% CIs from
22 tables (for studies with a 0 cell
value, 0.5 was added to each cell to cal-
culate the LR CI). When possible, we
reanalyzed the reported results fromin-
dividual studies that allowed us to es-
timate the stratum-specific LR (serial
LR) for increasing levels of abnormal-
ity fromscoring systems. Findings that
were evaluated in only 2 studies are
summarizedwithranges andthose find-
ings in only 3 studies were summa-
rized with univariate random effects
measures (Comprehensive Meta-
analysis, version 2.2.057; Biostat). We
attempted to use bivariate random ef-
fects for findings reported in 4 or more
studies, but when results did not con-
verge on a solution we used univariate
measures.
24,25
Heterogeneity for find-
ings reported in 3 or more studies was
assessed with a derSimonian-Laird pro-
cedure using Comprehensive Meta-
analysis.
26
RESULTS
Search Results
A total of 2628 citations were identi-
fied in our literature search. Of these,
2516were excludedafter reviewof their
abstracts andtitles. The remaining stud-
ies (n=112) were reviewed in detail,
with 25 studies meeting inclusion cri-
teria (eMethods, eFigure, eTable 1, and
eTable 2).
Prevalence of UGIB Hemorrhage
A summary prevalence of 8 stud-
ies
8,27-33
in our review that differenti-
ated UGIB from LGIB found that 63%
(95% CI, 51%-73%) of patients pre-
senting with gastrointestinal hemor-
rhage have an upper gastrointestinal
source. A summary prevalence from 8
prospective studies of severity of UGIB
includedinour reviewshowedthat 36%
(95% CI, 29%-44%) of patients who
present with a UGIB require immedi-
ate intervention (blood transfusion, ur-
gent endoscopic therapy, radiological
intervention, or surgery).
Accuracy of Findings That
Distinguish UGIB From LGIB
The factors of the history, physical ex-
amination, and basic laboratory test re-
sults with positive LR of 2.0 or more
or negative LR of 0.5 or less that dis-
criminate UGIB from LGIB are shown
in TABLE 1 (eTable 3 includes com-
plete data for other findings with less
useful LR and eTable 4 includes re-
sults of individual studies presented as
summary measures).
8,27-33
Historical Factors. Patients with a
UGIB are much more likely to have had
a prior history of UGIB (LR, 6.2; 95%
CI, 2.8-14.0). Conversely, a prior his-
tory of an LGIB makes an upper source
less likely (LR, 0.17; 95% CI, 0.09-
0.35). Patients with UGIB are more
likely to be younger than 50 years (LR,
3.5; 95% CI, 2.0-6.1). Although war-
farin use was twice as likely in pa-
tients with a UGIB rather than an LGIB
(LR, 2.3; 95%CI, 1.1-5.0), all other his-
torical features with an LRof more than
2 had a CI that included 1. The use of
nonsteroidal anti-inflammatory drugs,
aspirin, and alcohol had LRs approach-
ing 1 and could not differentiate be-
tween UGIB and LGIB (eTable 3).
Symptoms. Ahistory of passing black
stool (LR range, 5.1-5.9) or tarry stool
Table 1. Clinical Factors of the Bleeding Location for the Evaluation of UGIB From the History
and Clinical Examination With Positive LR of 2.0 or Negative LR of 0.5
Clinical Factors
Sensitivity, %
(95% CI)
Specificity, %
(95% CI)
Positive LR
(95% CI)
Negative LR
(95% CI)
Demographic and
historical features
Prior history of
UGIB
8
22 (18-25) 96 (94-98) 6.2 (2.8-14.0) 0.81 (0.74-0.89)
Age 50 y
8
27 (22-31) 92 (89-95) 3.5 (2.0-6.1) 0.80 (0.71-0.89)
Cirrhosis
8
5 (3-6) 99 (97-99.4) 3.1 (0.78-12.0) 0.97 (0.93-1.00)
Warfarin use
8
12 (8-15) 95 (93-97) 2.3 (1.1-5.0) 0.93 (0.87-1.00)
Iron use
8
6 (3-8) 98 (96-99) 2.2 (0.7-6.6) 0.97 (0.93-1.00)
History of LGIB
8
6 (3-11) 64 (62-67) 0.17 (0.09-0.35) 1.5 (1.3-1.6)
Symptoms
Black stool history
(melena)
8,27, a
77-95 81-87 5.1-5.9 0.06-0.27
Epigastric pain
8
17 (12-21) 93 (90-95) 2.3 (1.2-4.4) 0.90 (0.82-0.98)
Signs
Melenic stool on
examination
27
49 (45-50) 98 (91-99.6) 25 (4-174) 0.52 (0.42-0.64)
Nasogastric lavage
with blood or
coffee grounds
28
44 (39-48) 95 (90-98) 9.6 (4.0-23.0) 0.58 (0.49-0.70)
Clots in stool
8
15 (14-15) 99.2 (96.0-99.9) 0.05 (0.01-0.38) 1.2 (1.1-1.2)
Laboratory findings
Serum urea nitrogen:
creatinine ratio
30
8,29-33, b
51 (26 to 75) 93 (87 to 99) 7.5 (2.8-12.0) 0.53 (0.28-0.78)
Hematocrit, %
8, c
20 NA NA 2.6 (1.4-4.6)
21-29 NA NA 1.9 (1.4-2.5)
30-39 NA NA 0.46 (0.32-0.65)
40 NA NA 0.26 (0.10-0.67)
Abbreviations: LGIB, lower gastrointestinal bleeding; LR, likelihood ratio; NA, not applicable; UGIB, upper gastrointestinal
bleeding.
a
Summary estimate provided as a range because the finding was evaluated in only 2 studies.
b
Summary estimates calculated with bivariate random effects. For serum urea nitrogen:creatinine ratio of more than 30,
the positive LR test for homogeneity, I
2
=17%; P=.31; and the negative LR test for homogeneity, I
2
=94%; P.001.
c
Serial LR (95% CI) is a multilevel LR that can be used to give LR for each different threshold as opposed to choosing a
single cutoff and then giving a dichotomous LR.
SEVERE UPPER GASTROINTESTINAL BLEEDING
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makes a UGIB much more likely. Epi-
gastric discomfort also favors a UGIB
(LR, 2.3; 95% CI, 1.2-4.4).
Signs. The physicians examination
finding of melena (either observed as
a passed stool or stool obtained via rec-
tal examination) was the most useful
finding for identifying a UGIB (LR, 25;
95% CI, 4-174). In patients without a
history of hematemesis, nasogastric la-
vage with clear evidence of blood in the
aspirate (blood or coffee grounds
grossly present) suggests a UGIB with
an LR of 9.6 (95% CI, 4.0-23.0).
The presence of clots in the stool
makes a UGIB much less likely (LR,
0.05; 95% CI, 0.01-0.38). Nasogas-
tric lavage without evidence of blood
in the aspirate (no blood or coffee
grounds grossly present) makes a
UGIB less likely (LR, 0.58; 95% CI,
0.49-0.70).
Laboratory Findings. An increased
serumurea nitrogen:creatinine ratiosug-
gests a UGIB. Although several differ-
ent thresholds have beenevaluated, com-
biningall results inwhichthe serumurea
nitrogen:creatinine ratiois more than30
results inahomogeneous diagnosticodds
ratio (I
2
=17%, P=.31), with a summary
LRof 7.5(95%CI, 2.8-12.0). Serumurea
nitrogen:creatinine ratios of 30or less de-
crease the odds of a UGIB with a sum-
mary LRof 0.53 (95%CI, 0.28-0.78), al-
though there is heterogeneity in the
results (I
2
=94%, P.001).
Increasing severity of anemia in-
creases the likelihood of UGIB. Pa-
tients with severe anemia (hematocrit
20%) are more likely to have a UGIB
(LR, 2.6; 95% CI, 1.4-4.6), but those
with no anemia are less likely to have
a UGIB (hematocrit 40%; LR, 0.26;
95% CI, 0.10-0.67).
Accuracy of Factors to Identify
Need for Urgent Evaluation of UGIB
In patients presenting with symptoms
of UGIB, the factors obtained fromthe
history, physical examination, and ba-
sic laboratory test results predictive of
a severe UGIB with a positive LR of 2.0
or more or a negative LR of 0.5 or less
are shown in TABLE 2 (eTable 5 in-
cludes complete data for other find-
ings with less useful LR and eTable 6
includes results of individual studies
presented as summary measures) and
TABLE 3. Single-study clinical predic-
tion rules are shown in eTable 7.
Historical Factors, Symptoms, and
Signs. Onceapatient is identifiedas hav-
ing a UGIB, patients with history of cir-
rhosisormalignancy(LR, 3.7; 95%CI, 1.6-
8.8), syncope(LR, 3.0; 95%CI, 1.7-5.4),
or those using analgesics (LR, 2.6; 95%
CI, 1.3-5.2)aremorelikelytohavesevere
bleeding. Theimportanceof analgesicuse
requires confirmationbecausetheuseof
nonsteroidalanti-inflammatorydrugs(LR,
1.8; 95%CI, 1.2-2.6) was less important
foridentifyingpatientswithseverebleed-
ing (eTable 5).
The clinical use of the nasogastric la-
vage depends on the color of the re-
turned fluid. The highest likelihood of
a severe UGIB is with an aspirate of red
blood (summary LR, 3.1; 95% CI, 1.2-
14.0). A similar result was found in
studies that considered either red blood
or coffee grounds as positive for UGIB
(summary LR, 2.0; 95%CI, 1.0-4.0). A
nasogastric lavage without bright red
blood (summary LR, 0.32; 95% CI,
0.17-0.57) makes severe bleeding less
likely. As opposed to visible blood, the
presence of occult blood is not diag-
nostic of UGIB needing urgent inter-
vention, andthe absence of occult blood
has a broad CI and thus its use is un-
certain (eTable 5).
Hemodynamic signs associated with
volumeloss, suchas tachycardia(LR, 4.9;
95% CI, 3.2-7.6), shock (summary LR,
2.8; 95% CI, 1.1-7.2), and hypotension
Table 2. Clinical Factors of Severity of Bleeding From the History and Clinical Examination
Used to Determine the Need for Urgent Evaluation of UGIB With Positive LR of 2.0 or
Negative LR of 0.5
a
Clinical Factors
Sensitivity,
% (95% CI)
Specificity,
% (95% CI)
Positive LR
(95% CI)
Negative LR
(95% CI)
Demographic and
historical features
History of malignancy
or cirrhosis
34
22 (14-28) 94 (92-96) 3.7 (1.6-8.8) 0.83 (0.72-0.97)
Cirrhosis
35
15 (12-18) 95 (94-97) 3.2 (2.1-4.9) 0.89 (0.85-0.94)
Syncope
35
8 (6-10) 98 (97-98) 3.0 (1.7-5.4) 0.95 (0.91-0.98)
Analgesic use
36
13 (8-19) 95 (94-96) 2.6 (1.3-5.2) 0.92 (0.84-0.99)
Coffee ground
vomiting
35
7 (4-10) 83 (82-84) 0.41 (0.26-0.64) 1.1 (1.1-1.2)
Hematochezia
35
2 (1-4) 92 (91-93) 0.22 (0.09-0.53) 1.1 (1.0-1.1)
Signs
Pulse rate
100/min
34
71 (60-79) 86 (82-89) 4.9 (3.2-7.6) 0.34 (0.22-0.53)
Nasogastric lavage, red
blood
16,17,21,34, b
77 (57-90) 76 (32-95) 3.1 (1.2-14.0) 0.32 (0.17-0.57)
Shock
17,34, c,d
78 (56-90) 71 (46-88) 2.8 (1.1-7.2) 0.32 (0.10-0.96)
Nasogastric lavage, red
blood or coffee
grounds
17,21,28, c
81 (67-89) 55 (19-87) 2.0 (1.0-4.0) 0.40 (0.20-0.81)
Hypotension
34,36, e
55-59 53-89 1.2-4.8 0.51-0.78
Laboratory findings
Hemoglobin level
8 g/dL
34, e
65-68 86-89 4.5-6.2 0.36-0.41
Serum urea nitrogen level
90 mg/dL
34
63 (52-72) 83 (79-86) 3.6 (2.4-5.5) 0.45 (0.31-0.65)
White blood cell count
12 x10
9
/L
34
61 (50-71) 82 (78-86) 3.4 (2.2-5.1) 0.48 (0.34-0.68)
Abbreviations: LR, likelihood ratio; UGIB, upper gastrointestinal bleeding.
SI conversion: To convert serum urea nitrogen level to mmol/L, multiply by 0.357.
a
Summary ranges and LR are presented for factors evaluated in multiple studies.
b
Heterogeneity for bivariate random effects (positive LR, I
2
=90%; P.001; negative LR, I
2
=81%; P.001).
c
Heterogeneity for univariate random effects (shock: positive LR, I
2
=96%; P.001; negative LR, I
2
=91%; P.001; red
blood or coffee grounds: positive LR, I
2
=95%; P.001; negative LR, I
2
=67%; P=.047).
d
Systolic blood pressure of less than 100 mm Hg or pulse of more than 100/min or orthostatic decrease in systolic blood
pressure by more than 10% or orthostatic increase in pulse of more than 10% between sitting and supine position.
e
Range given because finding evaluated in only 2 studies.
SEVERE UPPER GASTROINTESTINAL BLEEDING
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(LR range, 1.2-4.8), may be helpful for
identifying patients with severe UGIB,
but havebroadCIs. Theabsenceof tachy-
cardia (LR, 0.34; 95%CI, 0.22-0.53) was
the most useful sign for decreasing the
likelihood of severe UGIB.
Laboratory Findings. Ahemoglobin
level of less than 8 g/dL (LRrange, 4.5-
6.2), aserumureanitrogenlevel of more
than90mg/dL(LR, 3.6; 95%CI, 2.4-5.5),
or a white bloodcell count of more than
1210
9
/L(LR, 3.4; 95%CI, 2.2-5.1) in-
crease the likelihoodof severe UGIB. A
hemoglobinlevel of 8g/dLor higher (LR
range, 0.36-0.41), a serum urea nitro-
gen level of 90 mg/dL or less (LR, 0.45;
95%CI, 0.31-0.65), and a white blood
cell count of 1210
9
/Lor less (LR, 0.48;
95%CI, 0.34-0.68) decrease the likeli-
hood of severe UGIB.
Clinical Prediction Models. Com-
binations of findings have been evalu-
ated to better guide clinical decision
making (TABLE 4) (eTable 8, eTable 9,
eTable 10, and eTable 11 include de-
tailed descriptions of the algorithms).
The Blatchford score
23
(Table 4) has the
most extensive validation and the best
accuracy for identifying patients who
present with UGIB who do not need ur-
gent intervention (Table 3). A Blatch-
ford score of 0 occurs in up to 22% of
patients withUGIB
2,23
and identifies pa-
tients with a low likelihood of severe
bleeding (summary LR, 0.02; 95% CI,
0-0.05). Blatchford scores at a thresh-
old of 2 or less perform similarly, al-
though the CI is broader (summary LR,
0.08; 95% CI, 0.01-0.41). The compo-
nents of the full Rockall score that can
be obtained before endoscopy pro-
duce the preendoscopic Rockall score.
Apreendoscopic Rockall score of more
than 0 does not increase the likeli-
hood of severe bleeding (summary LR,
1.20; 95% CI, 0.97-1.30), but a score
equal to 0 decreases the likelihood of
severe bleeding (summary LR, 0.41;
95% CI, 0.12-0.70) (Table 3).
COMMENT
Our reviewandmeta-analysis have limi-
tations inherent in the particular study
questions. The reference standard for a
study that seeks to establish a definitive
location of a GIB is problematic. Often,
a patient may have either no definitive
source or multiple possible sources of a
GIB. For example, a recent studyof LGIB
foundthat inpatients whoreceivedstan-
dard care, only 22% had a definitive
source of bleeding and only 76% had
either a definitive or a presumptive
source of bleeding.
44
Thus, all studies
identifyingfactors associatedwithsource
of bleeding may be limited by ascertain-
ment bias. Other limitations are due to
the paucity of published investigations
for certain predictive factors. For ex-
ample, few data exist regarding the as-
sociation of hematemesis and GIB loca-
tionbecause presumablyall patients with
hematemesis have a UGIB. In accor-
dance with the format and focus of the
Rational Clinical Examinationseries, our
reviewwas designedtosystematicallyex-
amine the clinical factors that may as-
sist onlyinthe diagnosis of GIB. Our goal
was toidentifyboththe locationof bleed-
ing (ie, upper vs lower intestinal tract)
and in those patients with UGIB the se-
verity of bleeding as defined by those
likely to require anintervention. The re-
viewdoes not, however, discuss the role
anddata for specific interventions totreat
patients with UGIB.
Heterogeneity in results may come
from differences in study populations
(eg, severity of comorbid illnesses), lo-
cal practice patterns (eg, admissionrates
for patients with UGIB), prevalence of
different etiologies of UGIB, and even
changing practice patterns over time.
Both the diagnostic process and likely
even underlying pathophysiology (in
the proton pump inhibitor era) have
changed dramatically in the last 25
years, leading to differences in results
that may manifest as wide CIs for sum-
mary LRs. Heterogeneity may also arise
Table 3. Well-Validated Clinical Prediction Rules Used to Determine the Need for Urgent
Evaluation of UGIB
Clinical Score Threshold
Sensitivity, %
(95% CI)
Specificity,
%
(95% CI)
Positive LR
(95% CI)
Negative LR
(95% CI)
Blatchford
score
37-39
2
a
98 (92-99) 27 (11-53) 1.4 (1.1-1.8) 0.08 (0.01-0.41)
Blatchford
score
2,23,35,37-41
0
b
99.6 (99.0-100.0) 15 (5-25) 1.2 (1.0-1.3) 0.02 (0-0.05)
Preendoscopic
Rockall
score
2,38,40-42
0
c
91 (88-95) 21 (9-34) 1.20 (0.97-1.30) 0.41 (0.12-0.70)
Modified
Blatchford
score
43
1 95 (93-96) 12 (11-13) 1.1 (1.0-1.1) 0.45 (0.31-0.66)
Abbreviations: LR, likelihood ratio; UGIB, upper gastrointestinal bleeding.
a
Heterogeneity for univariate random effects (positive LR, I
2
=86%; P.001; negative LR, I
2
=45%; P=.16).
b
Because sensitivity was 99%to 100%in every study, sensitivity was treated as a fixed effect. Heterogeneity (positive LR,
I
2
=97%; P.001; negative LR, I
2
=0%; P=.59).
c
Heterogeneity (positive LR, I
2
=92%; P.001; negative LR, I
2
=70%; P.001).
Table 4. The Blatchford Score
23
Variable Score
Serum urea nitrogen, mg/dL
18.2 0
18.2-22.4 2
22.4-28.0 3
28.0-70.0 4
70.0 6
Hemoglobin for men, g/dL
13.0 0
12.0-13.0 1
10.0-12.0 3
10.0 6
Hemoglobin for women, g/dL
12.0 0
10.0-12.0 1
10.0 6
Systolic blood pressure, mm Hg
109 0
100-109 1
90-99 2
90 3
Pulse rate 100/min 1
Presentation with melena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 2
SI conversion: To convert serum urea nitrogen to mmol/L,
multiply by 0.357.
SEVERE UPPER GASTROINTESTINAL BLEEDING
2012 American Medical Association. All rights reserved. JAMA, March 14, 2012Vol 307, No. 10 1077
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fromdifferences in case definitions for
bleeding source or severity. Despite
these potential differences, we chose to
combine studies whenever possible to
provide an overall assessment of the
usefulness of each clinical feature or
predictive rule, while also providing ac-
companying CIs to allowthe appropri-
ate interpretation of the complete data.
Nasogastric aspiration has advan-
tages as a diagnostic bedside maneuver
toevaluate GIBdue toits availability, low
cost, and very low risk of complica-
tions.
45
Additional benefits include re-
moval of excess fluid, blood, and clots,
which may improve visualization and
decrease the risk of aspiration if endos-
copy is performed.
46
Generally patients
with a positive result go on to upper en-
doscopy. However, patients with nega-
tive results may still require upper en-
doscopy instead of an examination for
LGIB because the negative LR is insuf-
ficient to rule out a UGIB. Therefore, its
role as a diagnostic test to differentiate
UGIB and LGIB should be ques-
tioned.
14,15
Furthermore, nasogastric in-
sertion is among the most uncomfort-
abl e bedsi de procedures i n the
emergency department andpatients rate
its discomfort comparable with frac-
ture reduction or abscess drainage.
47
Often the clinical challenge is not to
identifythe source of bleeding, but rather
toassess theseverityof asuspectedUGIB.
Althoughclinical situations suchas sus-
picion of variceal bleeding in a patient
with cirrhosis or of an aortoenteric fis-
tula require urgent evaluation,
48,49
most
situations are not as clear. Some gastro-
enterologists use the presence of bright
red blood on nasogastric lavage as a cri-
terionfor performing endoscopy within
6 to 12 hours, although there is no clear
evidence that rapid endoscopy pro-
vides clinical benefit in nonvariceal
bleeding
50,51
and consensus guidelines
only recommendthat endoscopy be per-
formed within24 hours inpatients with
UGIB.
52
Although a nasogastric lavage
with a bloody result has a significant LR
that canfurther helprule in a UGIBre-
quiring urgent endoscopy, seldom is a
clinicianencounteredwitha situationin
whichnasogastric lavage is usedto rule
in severe bleeding. Much more fre-
quently, the physician is attempting to
rule out a bleed requiring urgent in-
tervention. Unfortunately, a negative na-
sogastric lavage has an LRthat provides
little or no assistance in ruling out se-
vere bleeding and is unlikely to change
the clinical determinationfor urgent en-
doscopy.
SCENARIO RESOLUTION
Case 1
This older man has multiple factors in-
creasing the likelihood for an upper
source of blood loss with a history of
prior UGIB(LR, 6.2), melena (LRrange,
5.1-5.9), low hemoglobin level (LR,
2.6), and an increased serum urea ni-
trogen:creatinine ratio (LR, 7.5). With
a pretest probability of 63%for a UGIB,
these findings increase the probability
of a UGIB to at least 82%. Likewise, this
patient has several factors that in-
crease the likelihood of a severe UGIB
with signs of tachycardia (LR, 4.9), low
hemoglobin level (LR range, 4.5-6.2),
and a Blatchford score of more than 1
(LR, 1.4). Based only on these factors,
this patient shouldreceive anurgent up-
per endoscopy either in the emer-
gency department or as an inpatient,
and a diagnostic nasogastric lavage is
unnecessary to differentiate a UGIB
from an LGIB.
Case 2
This womanhas multiple factors that de-
crease the likelihood of a severe UGIB.
She has notachycardia (LR, 0.34), a nor-
mal hemoglobin level (range LR, 0.36-
0.41), a clear nasogastric lavage (LR,
0.40), and a Blatchford score of 0 (LR,
0.02). Based on a pretest probability of
30% for a severe UGIB among all pa-
tients with gastrointestinal hemor-
rhage, the best individual finding low-
ers the likelihoodof a severe hemorrhage
to 13% or less. However, the combina-
tionof findings fromthe Blatchfordscore
make a severe GIB unlikely (probabil-
ity 1%) in this patient.
BOTTOM LINE
Gastrointestinal hemorrhage is the com-
monpathway of myriaddifferent patho-
physiological processes. Inspection of
the stool is the most important factor
for identifying the bleeding source. Me-
lenic stool onphysical examination(LR,
25) provides compelling evidence for
a UGIB, although red blood and clots
are unlikely to come froma UGIB (LR,
0.05). Nasogastric lavage for blood or
coffee grounds (LR, 9.6), a history of a
prior UGIB (LR, 6.2), and a serumurea
nitrogen:creatinine ratio of more than
30 (LR, 7.5) are other findings that sug-
gest a UGIB.
Tachycardia (pulse rate of 100/
min; LR, 4.9), a history of cirrhosis or
malignancy (LR, 3.7), hemoglobinlevel
of less than 8 g/dL (LR range, 4.5-6.2),
or a nasogastric lavage with red blood
(LR, 3.1) increase the likelihood of se-
vere bleeding. All patients with a UGIB
should have a Blatchford score, which
does not require a nasogastric lavage,
to help assess the severity (Blatchford
score=0; LR, 0.02 for identifying pa-
tients requiring urgent evaluation).
When negative, prediction rules
combining symptoms, signs, and rou-
tine laboratory test results almost
definitively rule out severe UGIB,
thereby identifying at least some pa-
tients who can be safely evaluated as an
outpatient.
Author Contributions: Drs Srygley and Fisher had full
access to all of the data in the study and take respon-
sibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Srygley, Fisher.
Acquisition of data: Srygley, Gerardo, Tran, Fisher.
Analysis and interpretation of data: Srygley, Gerardo,
Fisher.
Drafting of the manuscript: Srygley.
Critical revision of the manuscript for important in-
tellectual content: Srygley, Gerardo, Tran, Fisher.
Statistical analysis: Srygley.
Administrative, technical, or material support: Gerardo,
Tran.
Study supervision: Gerardo, Fisher.
Conflict of Interest Disclosures: All authors have com-
pleted and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Dr Fisher reported
receiving consultancy money from Epigenomics Inc.
No other authors reported any financial disclosures.
Funding/Support: Dr Fisher is supported in part by a
Veterans Affairs Health Services Research and Devel-
opment Career Development Transition Award (RCD
03-174).
Role of the Sponsor: The Veterans Affairs had no role
in the design and conduct of the study, in the collec-
tion, analysis, and interpretation of the data, or in the
preparation, review, or approval of the manuscript.
Online-Only Material: The eMethods, eFigure, and
eTables 1 through 11 are available at http://www
.jama.com.
Additional Contributions: Cara L. OBrien, MD(Duke
SEVERE UPPER GASTROINTESTINAL BLEEDING
1078 JAMA, March 14, 2012Vol 307, No. 10 2012 American Medical Association. All rights reserved.
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University), Daniel Nishijima, MD (UC Davis Medical
Center), and Russell Yang, MD, PhD (Southern Illi-
nois University School of Medicine), provided advice
onearlier versions of the manuscript. Drs OBrien, Nishi-
jima, and Yang received no compensation for their
contribution.
REFERENCES
1. Healthcare Cost and Utilization Project (HCUP).
HCUP Clinical Classifications Software (CCS) for
I CD-9-CM. ht t p: //www. hcup-us. ahr q. gov
/toolssoftware/ccs/ccs.jsp. Accessed December 11,
2011.
2. Stanley AJ, Ashley D, Dalton HR, et al. Outpatient
management of patients with low-risk upper-
gastrointestinal haemorrhage: multicentre validation
and prospective evaluation. Lancet. 2009;373(9657):
42-47.
3. Marmo R, Koch M, Cipolletta L, et al. Predictive
factors of mortality from nonvariceal upper gastroin-
testinal hemorrhage: a multicenter study. Am J
Gastroenterol. 2008;103(7):1639-1647.
4. Lanas A, Garca-Rodrguez LA, Polo-Toma s M, et al.
Time trends and impact of upper and lower gastro-
intestinal bleeding and perforation in clinical practice.
Am J Gastroenterol. 2009;104(7):1633-1641.
5. Blatchford O, Davidson LA, Murray WR, Blatchford
M, Pell J. Acute upper gastrointestinal haemorrhage
in west of Scotland: case ascertainment study. BMJ.
1997;315(7107):510-514.
6. Das A, Ben-Menachem T, Cooper GS, et al. Pre-
diction of outcome in acute lower-gastrointestinal
haemorrhage based on an artificial neural network:
internal and external validation of a predictive model.
Lancet. 2003;362(9392):1261-1266.
7. Schmulewitz N, Fisher DA, Rockey DC. Early colo-
noscopy for acute lower GI bleeding predicts shorter
hospital stay: a retrospective study of experience in a
single center. Gastrointest Endosc. 2003;58(6):
841-846.
8. Witting MD, Magder L, Heins AE, Mattu A, Granja
CA, Baumgarten M. ED predictors of upper gastro-
i ntesti nal tract bl eedi ng i n pati ents wi thout
hematemesis. Am J Emerg Med. 2006;24(3):280-
285.
9. LeBlond RF, DeGowin RL, Brown DD. Chapter 9:
the abdomen, perineum, anus, and rectosigmoid. In:
LeBlond RF, DeGowin RL, Brown DD, eds. DeGow-
ins Diagnostic Examination. 9th ed. New York, NY:
McGraw-Hill; 2009.
10. Schiff L, Stevens R, Shaprio N, Goodman S. Ob-
servations on the oral administration of citrated blood
in man. Am J Med Sci. 1942;203:409-412.
11. Hilsman JH. The color of feces following the in-
stillation of citrated blood at various levels of the small
intestine. J Med Assoc Ga. 1950;39(10):402-405.
12. Luke RG, Lees W, Rudick J. Appearances of the
stools after the introduction of blood into the caecum.
Gut. 1964;5:77-79.
13. Feldman M, Friedman LS, Brandt LJ, eds. Sleis-
inger andFordtrans Gastrointestinal andLiver Disease.
Philadelphia, PA: Saunders; 2009:211-242.
14. Pallin DJ, Saltzman JR. Is nasogastric tube lavage
in patients with acute upper GI bleeding indicated or
antiquated? Gastrointest Endosc. 2011;74(5):981-
984.
15. Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Na-
sogastric aspiration and lavage in emergency depart-
ment patients with hematochezia or melena without
hematemesis. Acad Emerg Med. 2010;17(2):126-
132.
16. Huang ES, Karsan S, Kanwal F, Singh I, Makhani
M, Spiegel BM. Impact of nasogastric lavage on out-
comes in acute GI bleeding. Gastrointest Endosc. 2011;
74(5):971-980.
17. Aljebreen AM, Fallone CA, Barkun AN. Nasogas-
tric aspirate predicts high-risk endoscopic lesions in pa-
tients with acute upper-GI bleeding. Gastrointest
Endosc. 2004;59(2):172-178.
18. Esrailian E, Gralnek IM, Jensen D, et al. Evaluat-
ing the process of care in nonvariceal upper gastro-
intestinal haemorrhage: a survey of expert vs. non-
expert gastroenterologists. Aliment Pharmacol Ther.
2008;28(10):1199-1208.
19. Thomsen TW, Shaffer RW, Setnik GS. Videos in
clinical medicine: nasogastric intubation. NEngl J Med.
2006;354(17):e16.
20. Best C. Nasogastric tube insertion in adults who
require enteral feeding. Nurs Stand. 2007;21(40):
39-43.
21. Cuellar RE, Gavaler JS, Alexander JA, et al. Gas-
trointestinal tract hemorrhage: the value of a naso-
gastric aspirate. Arch Intern Med. 1990;150(7):
1381-1384.
22. Barkun AN, Bardou M, Kuipers EJ, et al; Interna-
tional Consensus Upper Gastrointestinal Bleeding Con-
ference Group. International consensus recommen-
dati ons on the management of pati ents wi th
nonvariceal upper gastrointestinal bleeding. Ann In-
tern Med. 2010;152(2):101-113.
23. Blatchford O, Murray WR, Blatchford M. A risk
score to predict need for treatment for upper-
gastrointestinal haemorrhage. Lancet. 2000;356
(9238):1318-1321.
24. Simel DL, Bossuyt PM. Differences between uni-
variate and bivariate models for summarizing diag-
nostic accuracy may not be large. J Clin Epidemiol.
2009;62(12):1292-1300.
25. Menke J. Bivariate random-effects meta-
analysis of sensitivity and specificity with SAS PROC
GLIMMIX. Methods Inf Med. 2010;49(1):54-62.
26. Borenstein M, Hedges L, Higgins J, Rothstein H.
Introduction to Meta-Analysis. Chichester, England:
John Wiley & Sons; 2009.
27. Zuckerman GR, Trellis DR, Sherman TM, Clouse
RE. An objective measure of stool color for differen-
tiating upper fromlower gastrointestinal bleeding. Dig
Dis Sci. 1995;40(8):1614-1621.
28. Witting MD, Magder L, Heins AE, Mattu A, Granja
CA, Baumgarten M. Usefulness and validity of diag-
nostic nasogastric aspiration in patients without
hematemesis. Ann Emerg Med. 2004;43(4):525-
532.
29. Mortensen PB, Nhr M, Mller-Petersen JF, Balslev
I. The diagnostic value of serum urea/creatinine ratio
in distinguishing between upper and lower gastroin-
testinal bleeding: a prospective study. Dan Med Bull.
1994;41(2):237-240.
30. Snook JA, Holdstock GE, Bamforth J. Value of a
simple biochemical ratio in distinguishing upper and
lower sites of gastrointestinal haemorrhage. Lancet.
1986;1(8489):1064-1065.
31. Chalasani N, Clark WS, Wilcox CM. Blood urea
nitrogen to creatinine concentration in gastrointesti-
nal bleeding: a reappraisal. AmJ Gastroenterol. 1997;
92(10):1796-1799.
32. Olsen LH, Andreassen KH. Stools containing al-
tered blood-plasma urea: creatinine ratio as a simple
test for the source of bleeding. Br J Surg. 1991;
78(1):71-73.
33. Richards RJ, Donica MB, Grayer D. Can the blood
urea nitrogen/creatinine ratio distinguish upper from
lower gastrointestinal bleeding? J Clin Gastroenterol.
1990;12(5):500-504.
34. Adamopoulos AB, Baibas NM, Efstathiou SP, et al.
Differentiation between patients with acute upper gas-
trointestinal bleeding who need early urgent upper gas-
trointestinal endoscopy and those who do not: a pro-
spective study. Eur J Gastroenterol Hepatol. 2003;
15(4):381-387.
35. Pang SH, Ching JY, Lau JY, Sung JJ, Graham DY,
Chan FK. Comparing the Blatchford and pre-
endoscopic Rockall score in predicting the need for en-
doscopic therapy inpatients withupper GI hemorrhage.
Gastrointest Endosc. 2010;71(7):1134-1140.
36. Sto ltzing H, Ohmann C, Krick M, Thon K. Diag-
nostic emergency endoscopy in upper gastrointesti-
nal bleeding: do we have any decision aids for pa-
tient selection? Hepatogastroenterology. 1991;
38(3):224-227.
37. Masaoka T, Suzuki H, Hori S, Aikawa N, Hibi T.
Blatchford scoring system is a useful scoring system
for detecting patients with upper gastrointestinal bleed-
ing who do not need endoscopic intervention. J Gas-
troenterol Hepatol. 2007;22(9):1404-1408.
38. Srirajaskanthan R, Conn R, Bulwer C, Irving P. The
Glasgow Blatchford scoring system enables accurate
risk stratification of patients with upper gastrointes-
tinal haemorrhage. Int J Clin Pract. 2010;64(7):
868-874.
39. Chandra S, Hess EP, Agarwal D, et al. External vali-
dation of the Glasgow-Blatchford Bleeding Score and
the Rockall Score in the US setting. Am J Emerg Med.
2011.
40. Chen IC, Hung MS, Chiu TF, Chen JC, Hsiao CT.
Risk scoring systems to predict need for clinical inter-
vention for patients with nonvariceal upper gastroin-
testinal tract bleeding. Am J Emerg Med. 2007;
25(7):774-779.
41. Farooq FT, Lee MH, Das A, Dixit R, Wong RC.
Clinical triage decision vs risk scores in predicting the
need for endotherapy in upper gastrointestinal
bleeding. Am J Emerg Med. 2010;30(1):129-134.
42. Das A, Ben-Menachem T, Farooq FT, et al. Arti-
ficial neural network as a predictive instrument in pa-
tients with acute nonvariceal upper gastrointestinal
hemorrhage. Gastroenterology. 2008;134(1):65-
74.
43. Romagnuolo J, Barkun AN, Enns R, Armstrong
D, Gregor J. Simple clinical predictors may obviate ur-
gent endoscopy in selected patients with nonvariceal
upper gastrointestinal tract bleeding. Arch Intern Med.
2007;167(3):265-270.
44. Green BT, Rockey DC, Portwood G, et al. Ur-
gent colonoscopy for evaluation and management of
acute lower gastrointestinal hemorrhage: a random-
ized controlled trial. Am J Gastroenterol. 2005;
100(11):2395-2402.
45. Pillai JB, Vegas A, Brister S. Thoracic complica-
tions of nasogastric tube: review of safe practice. In-
teract Cardiovasc Thorac Surg. 2005;4(5):429-
433.
46. Lee SD, Kearney DJ. Arandomized controlled trial
of gastric lavage prior to endoscopy for acute upper
gastrointestinal bleeding. J Clin Gastroenterol. 2004;
38(10):861-865.
47. Singer AJ, Richman PB, Kowalska A, Thode HC Jr.
Comparison of patient and practitioner assessments
of pain from commonly performed emergency de-
partment procedures. Ann Emerg Med. 1999;33
(6):652-658.
48. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Pre-
vention and management of gastroesophageal vari-
ces and variceal hemorrhage in cirrhosis. Hepatology.
2007;46(3):922-938.
49. Champion MC, Sullivan SN, Coles JC, Goldbach
M, Watson WC. Aortoenteric fistula: incidence, pre-
sentation recognition, and management. Ann Surg.
1982;195(3):314-317.
50. Targownik LE, Murthy S, Keyvani L, Leeson S. The
role of rapidendoscopy for high-risk patients withacute
nonvariceal upper gastrointestinal bleeding. Can J
Gastroenterol. 2007;21(7):425-429.
51. Spiegel BM. Endoscopy for acute upper GI tract
hemorrhage: sooner is better. Gastrointest Endosc.
2009;70(2):236-239.
52. Sung JJ, Chan FK, Chen M, et al. Asia-Pacific Work-
ing Group consensus on non-variceal upper gastro-
intestinal bleeding. Gut. 2011;60(9):1170-1177.
SEVERE UPPER GASTROINTESTINAL BLEEDING
2012 American Medical Association. All rights reserved. JAMA, March 14, 2012Vol 307, No. 10 1079
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