Upper Gastrointestinal and Ulcer Bleeding
Official guideline from the American College of Gastroenterology, updated May 2021.
Risk Stratification
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.
Conditional recommendation
Very low quality evidence
Red Blood Cell Transfusion
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.
Conditional recommendation
Low quality evidence
Pre-endoscopic Medical Therapy
Prokinetic Therapy with Erythromycin
We suggest an infusion of erythromycin before endoscopy in patients with UGIB.
Conditional recommendation
Very low quality evidence
Proton Pump Inhibitor (PPI) Therapy
We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.
Endoscopy for UGIB
Timing of Endoscopy
We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hr of presentation.
Conditional recommendation
Very low quality evidence
Endoscopic Hemostatic Therapy
We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and non-bleeding visible vessels.
Strong recommendation
Moderate quality evidence
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
We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers.
Strong recommendation
Moderate quality evidence
We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers.
Conditional recommendation
We recommend that epinephrine injection not be used alone for patients with UGIB due to ulcers but rather in combination with another hemostatic modality.
Strong recommendation
We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers.
Conditional recommendation
Very 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.
Conditional recommendation
Low quality evidence
Hemostatic Therapy for Bleeding Ulcers
Antisecretory Therapy After Endoscopic 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.
Strong recommendation
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.
Conditional recommendation
Low quality evidence
Recurrent Ulcer Bleeding After Successful Endoscopic Hemostatic Therapy
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.
Conditional recommendation
Failure of Endoscopic Hemostatic Therapy for Bleeding Ulcers
We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization.
Conditional recommendation
Very low quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.Not applicable
Strength of recommendation is not applicable.
Moderate-high quality evidence
Between high and moderate levels of evidence.
Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Very low-moderate quality evidence
Between moderate and very low levels of evidence.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Low-very low quality evidence
Between low and very low levels of evidence.
Very low quality evidence
Effect is very uncertain.Not applicable
Level of evidence is not applicable.
