Use of the Blatchford score may allow early discharge of 16% to 25% of all patients presenting with UGIB [103, 105, CYT387 cell line 106]. The use of a nasogastric tube remains controversial [98]; in theory, the presence of bright red blood via nasogastric aspirate suggests active UGIB and should prompt urgent to esophagogastroduodenoscopy (EGD). The absence of blood on nasogastric aspirate, however, does not exclude the presence of a culprit UGIB source [81].

In a study by Aljebreen et al., 15% of patients with UGIB and clear or bilious nasogastric aspirate were ultimately found to have an underlying high risk lesion during EGD [100]. Pharmacologic therapy prior to endoscopy Early administration of intravenous PPIs in patients who present with signs of UGIB is reasonable. A Cochrane meta-analysis of

six randomised controlled trials (n = 2223) noted a see more reduction in high-risk stigmata of bleeding (37,2% vs. 46,5%,) with early use of PPIs and a lower proportion of patients undergoing endoscopic therapy (8,6% vs. 11,7%). The reduction in endoscopic treatment leads to early discharge in some patients with clean-based ulcers and low-risk stigmata and is cost saving. However, the use of proton-pump inhibitors should not replace urgent endoscopy in patients with active bleeding [94, 107]. A prokinetic drug given before endoscopy helps to empty stomach contents and improves viewing at endoscopy. These drugs are rarely used by endoscopists. Only five randomised trials and their pooled analysis have been published: three with the use of erythromycin and two with metoclopramide. The use of these drugs reduces the need for a second endoscopic examination for diagnosis STI571 but no

significant difference in other clinical outcomes was recorded [94, 108]. At present, insufficient evidence exists to support the use of tranexamic acid in acute PUB [94]. Endoscopic treatment Endoscopy in patients with PUB is effective and is associated with a reduction in blood transfusion requirements and length of intensive care unit/total hospital stay [98, 109]. The optimal timing for endoscopy in PUB remains under debate [81]. In appropriate settings, endoscopy can be used to assess the need for inpatient admission. Several studies have demonstrated Niclosamide that hemodynamically stable patients who are evaluated for UGIB with upper endoscopy and subsequently found to have low-risk stigmata for recurrent bleeding can be safely discharged and followed as outpatients [110, 111]. Patients with unstable haemodynamics and active haematemesis should be offered urgent endoscopy with a view to haemostasis. Patients who are stable after initial resuscitation generally undergo endoscopy the next morning. Evidence for the use of early endoscopy (generally defined by endoscopy within 24 h) came from cohort studies and their meta-analysis and results in significantly reduction of the hospital stay and improvement of the outcome [86, 94, 112].