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. 2002 Jan;78(915):4–14. doi: 10.1136/pmj.78.915.4

Management of gastrointestinal haemorrhage

S Ghosh 1, D Watts 1, M Kinnear 1
PMCID: PMC1742226  PMID: 11796865

Abstract

A variety of endoscopic haemostatic techniques have enabled major advances in the management of not only bleeding peptic ulcers and bleeding varices, but also in a variety of bleeding lesions in the small intestine and in the colon. Indeed, the development and widespread implementation of endoscopic haemostasis has been one of the most important developments in clinical gastroenterology in the past two decades. An increasingly ageing cohort of patients with multiple co-morbidity are being treated and therefore improving the outcome of gastrointestinal bleeding continues to pose major challenges.

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Selected References

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  1. Askin M. P., Lewis B. S. Push enteroscopic cauterization: long-term follow-up of 83 patients with bleeding small intestinal angiodysplasia. Gastrointest Endosc. 1996 Jun;43(6):580–583. doi: 10.1016/s0016-5107(96)70195-5. [DOI] [PubMed] [Google Scholar]
  2. Berner J. S., Mauer K., Lewis B. S. Push and sonde enteroscopy for the diagnosis of obscure gastrointestinal bleeding. Am J Gastroenterol. 1994 Dec;89(12):2139–2142. [PubMed] [Google Scholar]
  3. Bhatti N., Amoateng-Adjepong Y., Qamar A., Manthous C. A. Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes. Chest. 1998 Oct;114(4):1137–1142. doi: 10.1378/chest.114.4.1137. [DOI] [PubMed] [Google Scholar]
  4. Blair S. D., Janvrin S. B., McCollum C. N., Greenhalgh R. M. Effect of early blood transfusion on gastrointestinal haemorrhage. Br J Surg. 1986 Oct;73(10):783–785. doi: 10.1002/bjs.1800731007. [DOI] [PubMed] [Google Scholar]
  5. Bombardier C., Laine L., Reicin A., Shapiro D., Burgos-Vargas R., Davis B., Day R., Ferraz M. B., Hawkey C. J., Hochberg M. C. Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group. N Engl J Med. 2000 Nov 23;343(21):1520-8, 2 p following 1528. doi: 10.1056/NEJM200011233432103. [DOI] [PubMed] [Google Scholar]
  6. Browder W., Cerise E. J., Litwin M. S. Impact of emergency angiography in massive lower gastrointestinal bleeding. Ann Surg. 1986 Nov;204(5):530–536. doi: 10.1097/00000658-198611000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Buffoli F., Graffeo M., Nicosia F., Gentile C., Cesari P., Rolfi F., Paterlini A. Peptic ulcer bleeding: comparison of two hemostatic procedures. Am J Gastroenterol. 2001 Jan;96(1):89–94. doi: 10.1111/j.1572-0241.2001.03456.x. [DOI] [PubMed] [Google Scholar]
  8. Cappell M. S. A study of the syndrome of simultaneous acute upper gastrointestinal bleeding and myocardial infarction in 36 patients. Am J Gastroenterol. 1995 Sep;90(9):1444–1449. [PubMed] [Google Scholar]
  9. Chak A., Cooper G. S., Lloyd L. E., Kolz C. S., Barnhart B. A., Wong R. C. Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage. Gastrointest Endosc. 2001 Jan;53(1):6–13. doi: 10.1067/mge.2001.108965. [DOI] [PubMed] [Google Scholar]
  10. Chan F. K., Chung S. C., Suen B. Y., Lee Y. T., Leung W. K., Leung V. K., Wu J. C., Lau J. Y., Hui Y., Lai M. S. Preventing recurrent upper gastrointestinal bleeding in patients with Helicobacter pylori infection who are taking low-dose aspirin or naproxen. N Engl J Med. 2001 Mar 29;344(13):967–973. doi: 10.1056/NEJM200103293441304. [DOI] [PubMed] [Google Scholar]
  11. Chong J., Tagle M., Barkin J. S., Reiner D. K. Small bowel push-type fiberoptic enteroscopy for patients with occult gastrointestinal bleeding or suspected small bowel pathology. Am J Gastroenterol. 1994 Dec;89(12):2143–2146. [PubMed] [Google Scholar]
  12. Chung C. S. Surgery and gastrointestinal bleeding. Gastrointest Endosc Clin N Am. 1997 Oct;7(4):687–701. [PubMed] [Google Scholar]
  13. Chung S. C. Preventing ulcer rebleeding: the role of second-look endoscopy. Can J Gastroenterol. 1999 Jun;13(5):409–411. doi: 10.1155/1999/747064. [DOI] [PubMed] [Google Scholar]
  14. Chung S. S., Lau J. Y., Sung J. J., Chan A. C., Lai C. W., Ng E. K., Chan F. K., Yung M. Y., Li A. K. Randomised comparison between adrenaline injection alone and adrenaline injection plus heat probe treatment for actively bleeding ulcers. BMJ. 1997 May 3;314(7090):1307–1311. doi: 10.1136/bmj.314.7090.1307. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Cipolletta L., Bianco M. A., Marmo R., Rotondano G., Piscopo R., Vingiani A. M., Meucci C. Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial. Gastrointest Endosc. 2001 Feb;53(2):147–151. doi: 10.1067/mge.2001.111386. [DOI] [PubMed] [Google Scholar]
  16. Cook D. J., Guyatt G. H., Salena B. J., Laine L. A. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992 Jan;102(1):139–148. doi: 10.1016/0016-5085(92)91793-4. [DOI] [PubMed] [Google Scholar]
  17. Cook D. J., Reeve B. K., Guyatt G. H., Heyland D. K., Griffith L. E., Buckingham L., Tryba M. Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. JAMA. 1996 Jan 24;275(4):308–314. [PubMed] [Google Scholar]
  18. Cooper G. S., Chak A., Way L. E., Hammar P. J., Harper D. L., Rosenthal G. E. Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999 Feb;49(2):145–152. doi: 10.1016/s0016-5107(99)70478-5. [DOI] [PubMed] [Google Scholar]
  19. Desa L. A., Ohri S. K., Hutton K. A., Lee H., Spencer J. Role of intraoperative enteroscopy in obscure gastrointestinal bleeding of small bowel origin. Br J Surg. 1991 Feb;78(2):192–195. doi: 10.1002/bjs.1800780219. [DOI] [PubMed] [Google Scholar]
  20. Emenike E., Srivastava S., Amoateng-Adjepong Y., al-Kharrat T., Zarich S., Manthous C. A. Myocardial infarction complicating gastrointestinal hemorrhage. Mayo Clin Proc. 1999 Mar;74(3):235–241. doi: 10.4065/74.3.235. [DOI] [PubMed] [Google Scholar]
  21. Ettorre G. C., Francioso G., Garribba A. P., Fracella M. R., Greco A., Farchi G. Helical CT angiography in gastrointestinal bleeding of obscure origin. AJR Am J Roentgenol. 1997 Mar;168(3):727–731. doi: 10.2214/ajr.168.3.9057524. [DOI] [PubMed] [Google Scholar]
  22. Forrest J. A., Finlayson N. D., Shearman D. J. Endoscopy in gastrointestinal bleeding. Lancet. 1974 Aug 17;2(7877):394–397. doi: 10.1016/s0140-6736(74)91770-x. [DOI] [PubMed] [Google Scholar]
  23. Foutch P. G., Sawyer R., Sanowski R. A. Push-enteroscopy for diagnosis of patients with gastrointestinal bleeding of obscure origin. Gastrointest Endosc. 1990 Jul-Aug;36(4):337–341. doi: 10.1016/s0016-5107(90)71060-7. [DOI] [PubMed] [Google Scholar]
  24. García Rodríguez L. A., Jick H. Risk of upper gastrointestinal bleeding and perforation associated with individual non-steroidal anti-inflammatory drugs. Lancet. 1994 Mar 26;343(8900):769–772. doi: 10.1016/s0140-6736(94)91843-0. [DOI] [PubMed] [Google Scholar]
  25. Gow P. J., Chapman R. W. Modern management of oesophageal varices. Postgrad Med J. 2001 Feb;77(904):75–81. doi: 10.1136/pmj.77.904.75. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Graham D. Y., Hepps K. S., Ramirez F. C., Lew G. M., Saeed Z. A. Treatment of Helicobacter pylori reduces the rate of rebleeding in peptic ulcer disease. Scand J Gastroenterol. 1993 Nov;28(11):939–942. doi: 10.3109/00365529309098288. [DOI] [PubMed] [Google Scholar]
  27. Hardwick R. H., Armstrong C. P. Synchronous upper and lower gastrointestinal endoscopy is an effective method of investigating iron-deficiency anaemia. Br J Surg. 1997 Dec;84(12):1725–1728. [PubMed] [Google Scholar]
  28. Hawkey C. J., Karrasch J. A., Szczepañski L., Walker D. G., Barkun A., Swannell A. J., Yeomans N. D. Omeprazole compared with misoprostol for ulcers associated with nonsteroidal antiinflammatory drugs. Omeprazole versus Misoprostol for NSAID-induced Ulcer Management (OMNIUM) Study Group. N Engl J Med. 1998 Mar 12;338(11):727–734. doi: 10.1056/NEJM199803123381105. [DOI] [PubMed] [Google Scholar]
  29. Hay J. A., Lyubashevsky E., Elashoff J., Maldonado L., Weingarten S. R., Ellrodt A. G. Upper gastrointestinal hemorrhage clinical--guideline determining the optimal hospital length of stay. Am J Med. 1996 Mar;100(3):313–322. doi: 10.1016/s0002-9343(97)89490-9. [DOI] [PubMed] [Google Scholar]
  30. Hernández-Díaz S., Rodríguez L. A. Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s. Arch Intern Med. 2000 Jul 24;160(14):2093–2099. doi: 10.1001/archinte.160.14.2093. [DOI] [PubMed] [Google Scholar]
  31. Jensen D. M., Machicado G. A. Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge. Gastroenterology. 1988 Dec;95(6):1569–1574. doi: 10.1016/s0016-5085(88)80079-9. [DOI] [PubMed] [Google Scholar]
  32. Jensen D. M., Machicado G. A., Jutabha R., Kovacs T. O. Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med. 2000 Jan 13;342(2):78–82. doi: 10.1056/NEJM200001133420202. [DOI] [PubMed] [Google Scholar]
  33. Junquera F., Quiroga S., Saperas E., Pérez-Lafuente M., Videla S., Alvarez-Castells A., Miró J. R., Malagelada J. R. Accuracy of helical computed tomographic angiography for the diagnosis of colonic angiodysplasia. Gastroenterology. 2000 Aug;119(2):293–299. doi: 10.1053/gast.2000.9346. [DOI] [PubMed] [Google Scholar]
  34. Kepczyk T., Kadakia S. C. Prospective evaluation of gastrointestinal tract in patients with iron-deficiency anemia. Dig Dis Sci. 1995 Jun;40(6):1283–1289. doi: 10.1007/BF02065539. [DOI] [PubMed] [Google Scholar]
  35. Labenz J., Börsch G. Role of Helicobacter pylori eradication in the prevention of peptic ulcer bleeding relapse. Digestion. 1994;55(1):19–23. doi: 10.1159/000201117. [DOI] [PubMed] [Google Scholar]
  36. Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage. A prospective controlled trial. N Engl J Med. 1987 Jun 25;316(26):1613–1617. doi: 10.1056/NEJM198706253162601. [DOI] [PubMed] [Google Scholar]
  37. Lanas A., Bajador E., Serrano P., Fuentes J., Carreño S., Guardia J., Sanz M., Montoro M., Sáinz R. Nitrovasodilators, low-dose aspirin, other nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding. N Engl J Med. 2000 Sep 21;343(12):834–839. doi: 10.1056/NEJM200009213431202. [DOI] [PubMed] [Google Scholar]
  38. Langman M. J., Jensen D. M., Watson D. J., Harper S. E., Zhao P. L., Quan H., Bolognese J. A., Simon T. J. Adverse upper gastrointestinal effects of rofecoxib compared with NSAIDs. JAMA. 1999 Nov 24;282(20):1929–1933. doi: 10.1001/jama.282.20.1929. [DOI] [PubMed] [Google Scholar]
  39. Langman M. J., Weil J., Wainwright P., Lawson D. H., Rawlins M. D., Logan R. F., Murphy M., Vessey M. P., Colin-Jones D. G. Risks of bleeding peptic ulcer associated with individual non-steroidal anti-inflammatory drugs. Lancet. 1994 Apr 30;343(8905):1075–1078. doi: 10.1016/s0140-6736(94)90185-6. [DOI] [PubMed] [Google Scholar]
  40. Lau J. Y., Sung J. J., Chan A. C., Lai G. W., Lau J. T., Ng E. K., Chung S. C., Li A. K. Stigmata of hemorrhage in bleeding peptic ulcers: an interobserver agreement study among international experts. Gastrointest Endosc. 1997 Jul;46(1):33–36. doi: 10.1016/s0016-5107(97)70206-2. [DOI] [PubMed] [Google Scholar]
  41. Lau J. Y., Sung J. J., Lee K. K., Yung M. Y., Wong S. K., Wu J. C., Chan F. K., Ng E. K., You J. H., Lee C. W. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med. 2000 Aug 3;343(5):310–316. doi: 10.1056/NEJM200008033430501. [DOI] [PubMed] [Google Scholar]
  42. Lau W. Y., Wong S. Y., Yuen W. K., Wong K. K. Intraoperative enteroscopy for bleeding angiodysplasias of small intestine. Surg Gynecol Obstet. 1989 Apr;168(4):341–344. [PubMed] [Google Scholar]
  43. Lewis B. S., Waye J. D. Total small bowel enteroscopy. Gastrointest Endosc. 1987 Dec;33(6):435–438. doi: 10.1016/s0016-5107(87)71682-4. [DOI] [PubMed] [Google Scholar]
  44. Lewis B. S., Wenger J. S., Waye J. D. Small bowel enteroscopy and intraoperative enteroscopy for obscure gastrointestinal bleeding. Am J Gastroenterol. 1991 Feb;86(2):171–174. [PubMed] [Google Scholar]
  45. Longstreth G. F. Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol. 1995 Feb;90(2):206–210. [PubMed] [Google Scholar]
  46. Macri G., Milani S., Surrenti E., Passaleva M. T., Salvadori G., Surrenti C. Eradication of Helicobacter pylori reduces the rate of duodenal ulcer rebleeding: a long-term follow-up study. Am J Gastroenterol. 1998 Jun;93(6):925–927. doi: 10.1111/j.1572-0241.1998.00278.x. [DOI] [PubMed] [Google Scholar]
  47. Mathus-Vliegen E. M., Tytgat G. N. Intraoperative endoscopy: technique, indications, and results. Gastrointest Endosc. 1986 Dec;32(6):381–384. doi: 10.1016/s0016-5107(86)71915-9. [DOI] [PubMed] [Google Scholar]
  48. Podila P. V., Ben-Menachem T., Batra S. K., Oruganti N., Posa P., Fogel R. Managing patients with acute, nonvariceal gastrointestinal hemorrhage: development and effectiveness of a clinical care pathway. Am J Gastroenterol. 2001 Jan;96(1):208–219. doi: 10.1111/j.1572-0241.2001.03477.x. [DOI] [PubMed] [Google Scholar]
  49. Rockall T. A., Logan R. F., Devlin H. B., Northfield T. C. Incidence of and mortality from acute upper gastrointestinal haemorrhage in the United Kingdom. Steering Committee and members of the National Audit of Acute Upper Gastrointestinal Haemorrhage. BMJ. 1995 Jul 22;311(6999):222–226. doi: 10.1136/bmj.311.6999.222. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Rockall T. A., Logan R. F., Devlin H. B., Northfield T. C. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996 Mar;38(3):316–321. doi: 10.1136/gut.38.3.316. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Rockall T. A., Logan R. F., Devlin H. B., Northfield T. C. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet. 1996 Apr 27;347(9009):1138–1140. doi: 10.1016/s0140-6736(96)90607-8. [DOI] [PubMed] [Google Scholar]
  52. Rockey D. C., Cello J. P. Evaluation of the gastrointestinal tract in patients with iron-deficiency anemia. N Engl J Med. 1993 Dec 2;329(23):1691–1695. doi: 10.1056/NEJM199312023292303. [DOI] [PubMed] [Google Scholar]
  53. Rutgeerts P., Rauws E., Wara P., Swain P., Hoos A., Solleder E., Halttunen J., Dobrilla G., Richter G., Prassler R. Randomised trial of single and repeated fibrin glue compared with injection of polidocanol in treatment of bleeding peptic ulcer. Lancet. 1997 Sep 6;350(9079):692–696. doi: 10.1016/s0140-6736(97)03233-9. [DOI] [PubMed] [Google Scholar]
  54. Saba H. I., Morelli G. A., Logrono L. A. Brief report: treatment of bleeding in hereditary hemorrhagic telangiectasia with aminocaproic acid. N Engl J Med. 1994 Jun 23;330(25):1789–1790. doi: 10.1056/NEJM199406233302504. [DOI] [PubMed] [Google Scholar]
  55. Sacks H. S., Chalmers T. C., Blum A. L., Berrier J., Pagano D. Endoscopic hemostasis. An effective therapy for bleeding peptic ulcers. JAMA. 1990 Jul 25;264(4):494–499. doi: 10.1001/jama.264.4.494. [DOI] [PubMed] [Google Scholar]
  56. Sahay R., Scott B. B. Iron deficiency anaemia--how far to investigate? Gut. 1993 Oct;34(10):1427–1428. doi: 10.1136/gut.34.10.1427. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Schaffalitzky de Muckadell O. B., Havelund T., Harling H., Boesby S., Snel P., Vreeburg E. M., Eriksson S., Fernström P., Hasselgren G. Effect of omeprazole on the outcome of endoscopically treated bleeding peptic ulcers. Randomized double-blind placebo-controlled multicentre study. Scand J Gastroenterol. 1997 Apr;32(4):320–327. doi: 10.3109/00365529709007679. [DOI] [PubMed] [Google Scholar]
  58. Silverstein F. E., Faich G., Goldstein J. L., Simon L. S., Pincus T., Whelton A., Makuch R., Eisen G., Agrawal N. M., Stenson W. F. Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA. 2000 Sep 13;284(10):1247–1255. doi: 10.1001/jama.284.10.1247. [DOI] [PubMed] [Google Scholar]
  59. Strodel W. E., Eckhauser F. E., Knol J. A., Nostrant T. T., Dent T. L. Intraoperative fiberoptic endoscopy. Am Surg. 1984 Jun;50(6):340–344. [PubMed] [Google Scholar]
  60. Sugawa C., Benishek D., Walt A. J. Mallory-Weiss syndrome. A study of 224 patients. Am J Surg. 1983 Jan;145(1):30–33. doi: 10.1016/0002-9610(83)90162-9. [DOI] [PubMed] [Google Scholar]
  61. Sugawa C., Steffes C. P., Nakamura R., Sferra J. J., Sferra C. S., Sugimura Y., Fromm D. Upper GI bleeding in an urban hospital. Etiology, recurrence, and prognosis. Ann Surg. 1990 Oct;212(4):521–527. doi: 10.1097/00000658-199010000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Tryba M. Side effects of stress bleeding prophylaxis. Am J Med. 1989 Jun 9;86(6A):85–93. doi: 10.1016/0002-9343(89)90165-4. [DOI] [PubMed] [Google Scholar]
  63. Voeller G. R., Bunch G., Britt L. G. Use of technetium-labeled red blood cell scintigraphy in the detection and management of gastrointestinal hemorrhage. Surgery. 1991 Oct;110(4):799–804. [PubMed] [Google Scholar]
  64. Vreeburg E. M., Levi M., Rauws E. A., Deventer S. J., Snel P., Bartelsman J. W., Ten Cate J. W., Tytgat G. N. Enhanced mucosal fibrinolytic activity in gastroduodenal ulcer haemorrhage and the beneficial effect of acid suppression. Aliment Pharmacol Ther. 2001 May;15(5):639–646. doi: 10.1046/j.1365-2036.2001.00978.x. [DOI] [PubMed] [Google Scholar]
  65. Weil J., Colin-Jones D., Langman M., Lawson D., Logan R., Murphy M., Rawlins M., Vessey M., Wainwright P. Prophylactic aspirin and risk of peptic ulcer bleeding. BMJ. 1995 Apr 1;310(6983):827–830. doi: 10.1136/bmj.310.6983.827. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Welch G. H., McArdle C. S., Anderson J. R. Balloon tamponade for the control of Mallory-Weiss haemorrhage in patients with coagulation defects. Br J Surg. 1987 Jul;74(7):610–611. doi: 10.1002/bjs.1800740723. [DOI] [PubMed] [Google Scholar]
  67. Whelan R. L., Buls J. G., Goldberg S. M., Rothenberger D. A. Intra-operative endoscopy. University of Minnesota experience. Am Surg. 1989 May;55(5):281–286. [PubMed] [Google Scholar]
  68. Wong R. C., Chak A., Kobayashi K., Isenberg G. A., Cooper G. S., Carr-Locke D. L., Sivak M. V., Jr Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy? Gastrointest Endosc. 2000 Sep;52(3):315–321. doi: 10.1067/mge.2000.106688. [DOI] [PubMed] [Google Scholar]
  69. Yamaguchi Y., Yamato T., Katsumi N., Morozumi K., Abe T., Ishida H., Takahashi S. Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome. Gastrointest Endosc. 2001 Apr;53(4):427–430. doi: 10.1067/mge.2001.111774. [DOI] [PubMed] [Google Scholar]
  70. Yeomans N. D., Tulassay Z., Juhász L., Rácz I., Howard J. M., van Rensburg C. J., Swannell A. J., Hawkey C. J. A comparison of omeprazole with ranitidine for ulcers associated with nonsteroidal antiinflammatory drugs. Acid Suppression Trial: Ranitidine versus Omeprazole for NSAID-associated Ulcer Treatment (ASTRONAUT) Study Group. N Engl J Med. 1998 Mar 12;338(11):719–726. doi: 10.1056/NEJM199803123381104. [DOI] [PubMed] [Google Scholar]
  71. Zuckerman G. R., Trellis D. R., Sherman T. M., Clouse R. E. An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding. Dig Dis Sci. 1995 Aug;40(8):1614–1621. doi: 10.1007/BF02212679. [DOI] [PubMed] [Google Scholar]
  72. van Cutsem E., Rutgeerts P., Vantrappen G. Treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone. Lancet. 1990 Apr 21;335(8695):953–955. doi: 10.1016/0140-6736(90)91010-8. [DOI] [PubMed] [Google Scholar]

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