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Upper Gastrointestinal and Ulcer Bleeding

Official guideline from the American College of Gastroenterology, updated May 2021.

Risk Stratification

Risk Stratification
Conditional recommendation
Very low quality evidence
We suggest that patients presenting to the emergency department with upper gastrointestinal bleeding (UGIB) who are classified as very low risk, defined as a risk assessment score with ≤1% false negative rate for the outcome of hospital-based intervention or death (e.g., Glasgow-Blatchford score = 0–1), be discharged with outpatient follow-up rather than admitted to hospital.

Red Blood Cell Transfusion

Red Blood Cell Transfusion
Conditional recommendation
Low quality evidence
We suggest a restrictive policy of red blood cell transfusion with a threshold for transfusion at a hemoglobin of 7 g/dL for patients with UGIB.

Pre-endoscopic Medical Therapy

Prokinetic Therapy with Erythromycin
Conditional recommendation
Very low quality evidence
We suggest an infusion of erythromycin before endoscopy in patients with UGIB.
Proton Pump Inhibitor (PPI) Therapy
Not applicable
Not applicable
We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.

Endoscopy for UGIB

Timing of Endoscopy
Conditional recommendation
Very low quality evidence
We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hr of presentation.
Endoscopic Hemostatic Therapy
Strong recommendation
Moderate quality evidence
We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and non-bleeding visible vessels.
Not applicable
Not applicable
We could not reach a recommendation for or against endoscopic therapy in patients with UGIB due to ulcers with adherent clot resistant to vigorous irrigation.
Choice of Endoscopic Hemostatic Therapy for Bleeding Ulcers
Strong recommendation
Moderate quality evidence
We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers.
Conditional recommendation
Low-very low quality evidence
We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers.
Strong recommendation
Very low-moderate quality evidence
We recommend that epinephrine injection not be used alone for patients with UGIB due to ulcers but rather in combination with another hemostatic modality.
Conditional recommendation
Very low quality evidence
We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers.
Conditional recommendation
Low quality evidence
We suggest over-the-scope clips as a hemostatic therapy for patients who develop recurrent bleeding due to ulcers after previous successful endoscopic hemostasis.

Hemostatic Therapy for Bleeding Ulcers

Antisecretory Therapy After Endoscopic Hemostatic Therapy for Bleeding Ulcers
Strong recommendation
Moderate-high quality evidence
We recommend high-dose PPI therapy given continuously or intermittently for 3 d after successful endoscopic hemostatic therapy of a bleeding ulcer.
Conditional recommendation
Low quality evidence
We suggest that high-risk patients with UGIB due to ulcers who received endoscopic hemostatic therapy followed by short-term high-dose PPI therapy in hospital continue on twice-daily PPI therapy until 2 week after index endoscopy.
Recurrent Ulcer Bleeding After Successful Endoscopic Hemostatic Therapy
Conditional recommendation
Low-very low quality evidence
We suggest that patients with recurrent bleeding after endoscopic therapy for a bleeding ulcer undergo repeat endoscopy and endoscopic therapy rather than undergo surgery or transcatheter arterial embolization.
Failure of Endoscopic Hemostatic Therapy for Bleeding Ulcers
Conditional recommendation
Very low quality evidence
We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization.
Literature
Original/Primary Reference
Research PaperLaine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. Acg clinical guideline: upper gastrointestinal and ulcer bleeding. Am J Gastroenterol. 2021;116(5):899-917.