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Antibiotic prophylaxis for prevention of bacterial infections and death in cirrhotic patients with upper gastrointestinal bleeding

Patients with liver cirrhosis have an impaired immune response. Often, liver cirrhosis patients experience complications from portal hypertension, such as gastroesophageal varices. These varices can bleed, increasing the risk of infection and death in a short period of time, despite proper endoscopic management. Patients who develop bacterial infections during hospitalisation for gastroesophageal haemorrhage are at increased risk of dying. Twelve trials (1241 patients) assessing several antibiotic prophylaxis regimens versus no intervention or placebo were analysed, showing that antibiotic prophylaxis successfully reduced the incidence of bacterial infections. Antibiotic prophylaxis was also associated with a reduction in mortality, mortality from bacterial infections, rebleeding rate, and days of hospitalisation. The prophylactic treatment was not associated with important adverse effects. Five trials (650 patients) assessed one antibiotic regimen compared with another. All antibiotic regimens provided similar benefits and none seemed superior. Thus, to this point there is no evidence to recommend one specific antibiotic regimen over the other. All trials analysed were subject to bias; thus, results should be interpreted carefully.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Red blood cell transfusion for the management of severe upper gastrointestinal bleeding

Bleeding in the upper gastrointestinal tract is common, affecting up to 1 in 1000 adults per year. It leads to death in 10% to 30% of cases, depending on whether patients are admitted with bleeding or bleed whilst in hospital with something else. Patients present with vomiting of fresh or partially digested blood, or with the passage of digested blood from the bowel (melaena). They may also present with symptoms associated with low blood pressure (which can occur secondary to rapid haemorrhage), or with symptoms of anaemia. Red blood cells may be transfused to patients to improve the blood pressure, haemoglobin concentration, or both, before the cause of the bleeding is identified and treated, usually with upper gastrointestinal endoscopy. Patients may also receive a transfusion after endoscopy to correct the haemoglobin concentration once the haemorrhage has been controlled. It is possible that blood transfusion (which has some serious potential adverse effects) may not always improve the patients' condition and may even make the bleeding worse.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease

We reviewed antifibrinolytic amino acids for upper gastrointestinal bleeding in people with acute or chronic liver disease.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Acute Upper Gastrointestinal Bleeding: Management

The incidence of acute upper gastrointestinal haemorrhage in the United Kingdom ranges between 84–172 /100,000/year, equating to 50–70,000 hospital admissions per year. This is therefore a relatively common medical emergency; it is also one that more often affects socially deprived communities.

NICE Clinical Guidelines - National Clinical Guideline Centre (UK).

Version: June 2012
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Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding

Bleeding from lesions in the oesophagus, stomach or duodenum is a common medical emergency. Research has suggested that reducing the amount of acid in the stomach may help to control the bleeding, but it is unknown if early initiation of such treatment (that is, before endoscopic diagnosis) is beneficial for patients.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Vitamin K for upper gastrointestinal bleeding in people with acute or chronic liver diseases

We reviewed vitamin K for upper gastrointestinal bleeding in people with acute liver disease (that is, loss of normal liver functions which occurs in days or weeks; most often, people do not have a pre‐existing liver disease) or chronic liver disease (that is, progressive destruction of normal liver functions, usually associated with fibrotic regeneration of the liver tissue).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2015

Recombinant human activated factor VII for upper gastrointestinal bleeding in patients with liver diseases

People with liver disease have an increased risk of upper gastrointestinal bleeding. Upper gastrointestinal bleeding is a frequent cause of morbidity and mortality in this population group. Due to severe liver damage, these people acquire coagulopathy (a bleeding disorder). Therefore, one of the approaches used for treating upper gastrointestinal bleeding is recombinant human activated factor VII, which is identical in structure and activity to human factor VII. The review includes two randomised clinical trials with 493 participants. The risk of bias was low. Both trials compared recombinant human activated factor VII with placebo. The meta‐analysis showed that the recombinant human activated factor VII does not seem to reduce mortality in patients with liver disease and suffering from upper gastrointestinal bleeding, irrespective of the grade of liver damage. The current evidence is insufficient to support or reject recombinant human activated factor VII for these patients.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Tranexamic acid, an agent that promotes blood clotting, for serious or uncontrolled upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a common reason for emergency hospital admission. The prognosis is serious. Some patients may die as the result of uncontrolled bleeding.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Cirrhosis in Over 16s: Assessment and Management

The guideline covers the identification and assessment of suspected cirrhosis, monitoring to detect complications and management of complications such as ascites and hepatorenal syndrome and referral for tertiary care.

NICE Guideline - National Guideline Centre (UK).

Version: July 2016
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Systematic reviews of the clinical effectiveness and cost-effectiveness of proton pump inhibitors in acute upper gastrointestinal bleeding

Upper gastrointestinal (UGI) haemorrhage is a major cause of morbidity, mortality and medical care costs, with peptic ulcer (PU) being the most frequent source of bleeding.

NIHR Health Technology Assessment programme: Executive Summaries - NIHR Journals Library.

Version: 2007

Erythromycin infusion prior to emergency endoscopy for acute upper gastrointestinal bleeding: a systematic review

Bibliographic details: Zhou J, He JD, Ouyang XB, Wang YP.  Erythromycin infusion prior to emergency endoscopy for acute upper gastrointestinal bleeding: a systematic review. World Chinese Journal of Digestology 2009; 17(31): 3273-3277

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

Suspected Cancer: Recognition and Referral

Cancer is an important condition, both in terms of the number of people affected and the impacts on those people and the people close to them. Around one third of a million new cancers are diagnosed annually in the UK, across over 200 different cancer types. Each of these cancer types has different presenting features, though there may be overlap. More than one third of the population will develop a cancer in their lifetime. Although there have been large advances in treatment and survival, with a half of cancer sufferers now living at least ten years after diagnosis, it remains the case that more than a quarter of all people alive now will die of cancer.

NICE Guideline - National Collaborating Centre for Cancer (UK).

Version: June 2015
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Continuous versus Intermittent Intravenous Pantoprazole for Acute Gastrointestinal Bleeding: A Review of the Clinical Effectiveness and Guidelines [Internet]

The gastrointestinal (GI) tract stretches from the mouth to the anus and gastrointestinal bleeding describes any bleeding that starts in the GI tract. Acute GI bleeding refers to the passage of a clinically significant amount of blood (i.e., the passage of more than a scant amount of blood) Acute bleeding in the upper part of the GI tract often presents with hematemesis (i.e., vomiting of blood or coffee-ground-like material) and/or melena (i.e., black, tarry stools). Patients with acute bleeding in the lower part of the GI tract often present with hematochezia (i.e., bright red blood in the stool). Acute GI bleeding represents a serious medical emergency that can result in death. For example, the mortality rate associated with acute lower GI bleeding is two to four percent.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: May 1, 2015
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Fasting for haemostasis in children with gastrointestinal bleeding

To determine the effects and safety of fasting for haemostasis in children with gastrointestinal bleeding.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Optimizing Health System Use of Medical Isotopes and Other Imaging Modalities [Internet]

The purpose of this project was to provide national guidance on the optimal use of 99mTc during a situation of reduced supply. To accomplish this, our objective at CADTH was:

Optimal Use Report - Canadian Agency for Drugs and Technologies in Health.

Version: 2012
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Pre-Endoscopic Intravenous Proton Pump Inhibitors for Emergency Department Patients with Upper Gastrointestinal Bleeds: A Review of Clinical Effectiveness, Cost-Effectiveness and Guidelines [Internet]

The purpose of this report is to review the clinical efficacy of pre-endoscopic intravenous proton pump inhibitors (PPI) for patients with upper gastrointestinal bleeding (UGIB) and to review the evidence-based guidelines regarding the use of proton pump inhibitors before endoscopy in patients with UGIB.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: February 5, 2016
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Antibiotics vs. acid suppression therapy (with or without long‐term maintenance acid suppression therapy) for the prevention of recurrent bleeding from peptic ulcer

Peptic ulcers are caused by acidic stomach juices damaging the lining of the stomach (gastric ulcer) or upper small intestine (duodenal ulcer). This causes pain, indigestion and sometimes bleeding. Bleeding in the gut can be life‐threatening. Several treatments aim to heal the ulcer and prevent future bleeding. These include acid‐suppressing drugs and antibiotics to treat Helicobacter pylori, a bacterium that causes most peptic ulcers. The review found that, for people who have had a bleeding peptic ulcer caused by Helicobacter pylori, treatment with antibiotics more effectively prevents gastrointestinal re‐bleeding than acid‐suppressing drugs. Antibiotics when Helicobacter pylori infection is present are also cheaper and more convenient than long‐term acid‐suppressing drugs.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Meta-analysis: erythromycin before endoscopy for acute upper gastrointestinal bleeding

BACKGROUND: Studies evaluating the effect of erythromycin on patients with acute upper gastrointestinal bleeding (UGIB) had been reported, but the results were inconclusive.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2011

Restrictive vs liberal transfusion for upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials

AIM: To compare the outcome of upper gastrointestinal bleeding (UGIB) between patients receiving restrictive and liberal transfusion.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2013

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