Upper Gastrointestinal and Ulcer Bleeding
Publication Date: May 1, 2021
Last Updated: June 3, 2022
GUIDELINE STATEMENTS
Risk stratification
1. We suggest that patients presenting to the emergency department with 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. ( Very Low , Conditional (weak) )
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Red blood cell transfusion
2. We suggest a restrictive policy of red blood cell (RBC) transfusion with a threshold for transfusion at a hemoglobin of 7 g/dL for patients with UGIB. ( Low , Conditional (weak) )
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Pre-endoscopic medical therapy
Prokinetic therapy with erythromycin
3. We suggest an infusion of erythromycin before endoscopy in patients with UGIB. (Very LowConditional (weak))
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PPI therapy
4. We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB. (, )
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Endoscopy for UGIB
Timing of endoscopy
5. We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hours of presentation. ( Very Low , Conditional (weak) )
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Need for endoscopic hemostatic therapy for ulcers with active bleeding or nonbleeding visible vessels
6. We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and nonbleeding visible vessels. ( Moderate , Strong )
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Need for endoscopic hemostatic therapy for ulcers with adherent clot
7. 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. (, )
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Choice of endoscopic hemostatic therapy for bleeding ulcers
8. We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers. (ModerateStrong)
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9. We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers. (, Conditional (weak))
(very-low- to low-quality evidence)
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10. 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)
(very-low- to moderate-quality evidence)
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11. We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers. (Very LowConditional (weak))
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12. We suggest over-the-scope clips as a hemostatic therapy for patients who develop recurrent bleeding due to ulcers after previous successful endoscopic hemostasis. (LowConditional (weak))
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Antisecretory therapy after endoscopic hemostatic therapy for bleeding ulcers
13. We recommend high-dose PPI therapy given continuously or intermittently for 3 days after successful endoscopic hemostatic therapy of a bleeding ulcer. (, Strong)
(moderate- to high-quality evidence)
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14. 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 weeks after index endoscopy. (LowConditional (weak))
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Recurrent ulcer bleeding after successful endoscopic hemostatic therapy
15. 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.
- for comparison with surgery
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- for comparison with transcatheter arterial embolization.
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Failure of endoscopic hemostatic therapy for bleeding ulcer
16. We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization. (Very LowConditional (weak))
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Recommendation Grading
Overview
Title
Upper Gastrointestinal and Ulcer Bleeding
Authoring Organization
American College of Gastroenterology
Publication Month/Year
May 1, 2021
Last Updated Month/Year
July 12, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital
Intended Users
Physician, nurse practitioner, nurse, physician assistant
Scope
Diagnosis, Management
Diseases/Conditions (MeSH)
D041742 - Upper Gastrointestinal Tract, D010438 - Peptic Ulcer Hemorrhage
Keywords
endoscopy, Clinical Guideline, Upper Gastrointestinal, Ulcer Bleeding, Erythromycin infusion, absolute ethanol injection, Endoscopic therapy, proton pump inhibitor therapy, transcatheter embolization, duodenum
Source Citation
Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116(5):899-917. doi: 10.14309/ajg.0000000000001245. Erratum in: Am J Gastroenterol. 2021 Nov 1;116(11):2309. PMID: 33929377.