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Canadian Journal of Gastroenterology
Volume 18, Issue 10, Pages 605-609
Special Article

A Canadian Clinical Practice Algorithm for the Management of Patients with Non-Variceal Upper Gastrointestinal Bleeding

Alan Barkun,1 Carlo A Fallone,1 Naoki Chiba,2 Marty Fishman,3 Nigel Flook,4 Janet Martin,5 Alaa Rostom,6 Anthony Taylor,7 and for the Nonvariceal Upper GI Bleeding Consensus Conference Group

1Department of Medicine, Division of Gastroenterology, McGill University, Montreal, Quebec, Canada
2Division of Gastroenterology, McMaster University, Hamilton, Ontario, Canada
3Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
4Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
5Department of Physiology & Pharmacology, University of Western Ontario, London, Ontario, Canada
6Division of Gastroenterology, University of Ottawa, Ottawa, Ontario, Canada
7Department of Emergency Medicine, Calgary Health Region, University of Calgary, Calgary, Alberta, Canada

Received 15 March 2004; Accepted 13 July 2004

Copyright © 2004 Canadian Association of Gastroenterology. This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (, which permits reuse, distribution, and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes.


AIM: To use current evidence-based recommendations to provide a user-friendly clinical algorithm for the management of upper gastrointestinal bleeding, adapted to the Canadian environment.

METHODS: A multidisciplinary consensus group of 25 participants representing 11 national societies used a seven-step approach to develop recommendations according to accepted standards. Sources of data included narrative and systematic reviews as well as published and new meta-analyses. A small writing subgroup subsequently created the algorithm.

RESULTS: Recommendations emphasize appropriate initial resuscitation of the patient and a multidisciplinary approach to clinical risk stratification that determines the need for early endoscopy. Early endoscopy allows safe and prompt discharge of selected patients classified as low risk. Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions. Although monotherapy with injection or thermal coagulation is effective, the combination is superior to either treatment alone. High-dose intravenous proton-pump inhibition is recommended in patients who have undergone successful endoscopic therapy. Routine second-look endoscopy is not recommended. Patients with upper gastrointestinal bleeding secondary to ulcer disease should be tested and treated for Helicobacter pylori infection.

CONCLUSIONS: This algorithm should facilitate appropriate risk stratification, use of endoscopic therapy and the appropriate utilization of proton-pump inhibition to optimize the care of patients with upper gastrointestinal bleeding. The algorithm should be customized to the resources of individual medical centres. Its application should be studied with appropriate outcomes recorded and validation performed.