The incidence of rebleeding in patients with UGIB shows a wide range from 5% to more than 20%, depending on the aetiology of the bleeding and the timing of endoscopic therapy. There is CB-5083 solubility dmso strong evidence that the risk of rebleeding is highest in the initial period of admission, and a 24-h time frame for endoscopic therapy is internationally

recommended as the see more optimal window of opportunity. Naturally, rebleeding must be prevented whenever possible [86, 89]. PUB is the most common cause of acute UGIB, accounting for 31%-67% of all cases, followed by erosive disease, varices, oesophagitis, malignancies and Mallory-Weiss tears (Table 3) [81, 83, 90]. Table 3 Causes of upper gastrointestinal bleeding   % Peptic ulcer 31–67 Erosive 7–31 Variceal bleeding 4–20 Oesophagitis 3–12 Mallory-Weiss 4–8 Malignancies 2–8 Other 2–8 In the subgroup of patients with PUB, bleeding from duodenal ulcers is slightly more

frequent than from gastric ulcers [91]. Emergency surgery for PUB has continued to decrease; in the UK, the rate of surgery dropped from 8% to 2% between 1993 and 2006. In the same period in the USA, admissions to hospital for peptic ulcer bleeding fell by 28,2%, the use of endoscopic treatment SB525334 cost increased by 58,9%, and the rate of emergency surgery for PUB decreased by 21,9% [92–94]. Initial assessment, resuscitation and risk-scores A primary goal of the initial assessment is to determine whether the patient requires urgent intervention (e.g., endoscopic, surgical, transfusion) or can undergo delayed endoscopy or even be discharged to outpatient management. Patients presenting with acute UGIB should be assessed promptly and resuscitated if needed. Volume should be replenished initially

G protein-coupled receptor kinase with crystalloid solutions. In patients with ongoing blood loss, symptomatic anaemia, or those at increased risk of impaired tissue oxygenation (e.g., patients with chronic heart conditions), blood should be transfused. In haemodynamically stable patients who are not bleeding actively, the threshold of transfusion needs to be defined. International guidelines recommend a policy of transfusion to a haemoglobin concentration of 7 g/dL [86]. Coagulopathy at presentation is a major adverse prognostic factor. From the UK National Audit, coagulopathy defined by an international normalised ratio (INR) above 1,5 was present in 16,4% of patients and was associated with a 15% mortality rate [95]. Coagulopathy is also a marker for other comorbidites, such as chronic liver disease. Bleeding in these patients is often more severe, and coagulopathy should be corrected in those with active bleeding. The target INR has not been defined and is established by the patient’s indication for anticoagulation. A study showed that mild to moderate anticoagulation (INR 1,3–2,7) at endoscopy did not increase the risk of recurrent bleeding compared with an INR of less than 1,3 [96].