Upper Gastrointestinal and Ulcer Bleeding
Official guideline from the American College of Gastroenterology, updated May 2021.
These guideline summaries are shared for educational purposes only and are not intended to direct patient care. For detail on the specific recommendations and information about the evidence considered by the guideline developer, we encourage you to go to the original guideline statement cited below.
Risk Stratification
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
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
We suggest an infusion of erythromycin before endoscopy in patients with UGIB.
We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.
Endoscopy for UGIB
We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hr of presentation.
We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and non-bleeding visible vessels.
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.
We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers.
We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers.
We recommend that epinephrine injection not be used alone for patients with UGIB due to ulcers but rather in combination with another hemostatic modality.
We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers.
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
We recommend high-dose PPI therapy given continuously or intermittently for 3 d after successful endoscopic hemostatic therapy of a bleeding ulcer.
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.
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.
We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization.