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    Upper Gastrointestinal and Ulcer Bleeding (beta)

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

    Strength
    Strong recommendation
    Conditional recommendation
    Not applicable
    Evidence
    Moderate-high quality evidence
    Moderate quality evidence
    Very low-moderate quality evidence
    Low quality evidence
    Low-very low quality evidence
    Very low quality evidence
    Not applicable

    Risk Stratification

    Risk Stratification
    1. 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
    1. 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
    1. We suggest an infusion of erythromycin before endoscopy in patients with UGIB.
    Proton Pump Inhibitor (PPI) Therapy
    1. We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.

    Endoscopy for UGIB

    Timing of Endoscopy
    1. We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hr of presentation.
    Endoscopic Hemostatic Therapy
    1. We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and non-bleeding visible vessels.
    2. 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
    1. We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers.
    2. We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers.
    3. We recommend that epinephrine injection not be used alone for patients with UGIB due to ulcers but rather in combination with another hemostatic modality.
    4. We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers.
    5. 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
    1. We recommend high-dose PPI therapy given continuously or intermittently for 3 d after successful endoscopic hemostatic therapy of a bleeding ulcer.
    2. 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
    1. 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
    1. We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization.
    What do the icons mean?  
    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.