Management of Nonvariceal Upper Gastrointestinal Bleeding
Publication Date: December 1, 2019
Last Updated: March 14, 2022
Consensus Recommendations
Resuscitation, risk assessment, and preendoscopy management
For patients with acute upper gastrointestinal bleeding (UGIB) and hemodynamic instability, resuscitation should be initiated.
(good practice statement)
612
For patients with acute UGIB, we suggest using a Glasgow Blatchford score of ≤1 to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy.
612
For patients with acute UGIB, we suggest against using the AIMS65 prognostic score to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy.
612
Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value.
612
In patients with acute UGIB without underlying cardiovascular disease, we suggest giving blood transfusions for those with a hemoglobin level <80 g/L.
612
In patients with acute UGIB with underlying cardiovascular disease, we suggest giving blood transfusions at a higher hemoglobin threshold than for those without cardiovascular disease.
612
In patients with acute UGIB receiving anticoagulants (vitamin K antagonists, direct oral anticoagulants [DOACs]), we suggest not delaying endoscopy (with or without endoscopic hemostatic therapy).
612
Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.
612
Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.
612
Pre-endoscopic proton-pump inhibitor (PPI) therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy.
(No recommendation)612
Endoscopic management
Develop institution-specific protocols for multidisciplinary management. Include access to an endoscopist trained in endoscopic hemostasis.
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Have support staff trained to assist in endoscopy available on an urgent basis.
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For patients admitted with acute UGIB, we suggest performing early endoscopy (within 24 hours of presentation).
612
Endoscopic hemostatic therapy is not indicated for patients with low-risk stigmata (a clean-based ulcer or a nonprotuberant pigmented dot in an ulcer bed).
612
A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.
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The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.
612
Endoscopic hemostatic therapy is indicated for patients with high-risk stigmata (active bleeding or a visible vessel in an ulcer bed).
612
Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.
612
No single method of endoscopic thermal coaptive therapy is superior to another.
612
For patients with acutely bleeding ulcers with high-risk stigmata, we recommend endoscopic therapy with thermocoagulation or sclerosant injection.
612
For patients with acutely bleeding ulcers with high-risk stigmata, we suggest endoscopic therapy with (through-the-scope) clips.
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In patients with actively bleeding ulcers, we suggest using TC-325 as a temporizing therapy to stop bleeding when conventional endoscopic therapies are not available or fail.
612
In patients with actively bleeding ulcers, we suggest against using TC-325 as a single therapeutic strategy vs. conventional endoscopic therapy (clips alone, thermocoagulation alone, or combination therapy).
612
Routine second-look endoscopy is not recommended.
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A second attempt at endoscopic therapy is generally recommended in cases of rebleeding.
612
Pharmacologic management
H2RAs are not recommended for patients with acute ulcer bleeding.
612
Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding.
612
For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, we recommend using PPI therapy via intravenous loading dose followed by continuous intravenous infusion (as opposed to no treatment or H2RAs).
612
For patients who present with ulcer bleeding at high risk for rebleeding (that is, an ulcer requiring endoscopic therapy followed by 3 days of high-dose PPI therapy), we suggest using twice-daily oral PPIs (vs. once-daily) through 14 days, followed by once daily.
612
Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying cause.
612
Nonendoscopic and nonpharmacologic in-hospital management
Patients at low risk after endoscopy can be fed within 24 hours.
612
Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.
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Seek surgical consultation for patients for whom endoscopic therapy has failed.
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Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.
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Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication.
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Negative H pylori diagnostic tests obtained in the acute setting should be repeated.
612
Secondary prophylaxis
In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional nonsteroidal anti-inflammatory drug (NSAID) plus a PPI or COX-2 inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.
612
In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.
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In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.
612
In patients with previous ulcer bleeding receiving cardiovascular prophylaxis with single- or dual-antiplatelet therapy, we suggest using PPI therapy vs. no PPI therapy.
612
In patients with previous ulcer bleeding requiring continued cardiovascular prophylaxis with anticoagulant therapy (vitamin K antagonists, DOACs), we suggest using PPI therapy vs. no PPI therapy.
612
No recommendation statements
For patients with acute UGIB, the consensus group could not make a recommendation for or against using the preendoscopic Rockall prognostic scale to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy.
612
For patients with acute UGIB at high risk for rebleeding or mortality, the consensus group could not make a recommendation for or against performing endoscopy within 12 hours vs. performing endoscopy later.
612
In patients with acutely bleeding ulcers who have undergone endoscopic therapy, the consensus group could not make a recommendation for or against using Doppler endoscopic probe (DEP) vs. no DEP to assess the need for further endoscopic therapy.
612
For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, the consensus group could not make a recommendation for or against using non–high-dose PPI therapy (as opposed to no treatment or H2RAs).
612
Recommendation Grading
Overview
Title
Management of Nonvariceal Upper Gastrointestinal Bleeding
Authoring Organization
Consensus and Physician Experts
Endorsing Organizations
American College of Gastroenterology
American Society for Gastrointestinal Endoscopy
European Society of Gastrointestinal Endoscopy
National Institute for Health and Care Excellence
Publication Month/Year
December 1, 2019
Last Updated Month/Year
January 31, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Medical transportation, Operating and recovery room
Intended Users
Physician, nurse, nurse practitioner, physician assistant
Scope
Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D041742 - Upper Gastrointestinal Tract
Keywords
Upper Gastrointestinal bleeding, Fluid resuscitation
Supplemental Methodology Resources
Methodology
Number of Source Documents
118
Literature Search Start Date
April 2, 2018
Literature Search End Date
May 1, 2018