Endoscopy 2021; 53(03): 300-332
DOI: 10.1055/a-1369-5274
Guidelines

Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

Ian M. Gralnek
 1  Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
 2  Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
,
Adrian J. Stanley
 3  Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
,
A. John Morris
 3  Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
,
Marine Camus
 4  Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France
,
James Lau
 5  Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
,
Angel Lanas
 6  Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain
,
 7  Department of Gastroenterology, Odense University Hospital, Odense, Denmark
,
Franco Radaelli
 8  Department of Gastroenterology, Valduce Hospital, Como, Italy
,
Ioannis S. Papanikolaou
 9  Hepatogastroenterology Unit, Second Department of Internal Medicine – Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
,
Tiago Cúrdia Gonçalves
10  Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal
11  School of Medicine, University of Minho, Braga/Guimarães, Portugal
12  ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal
,
Mario Dinis-Ribeiro
13  Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
14  Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
,
 1  Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
,
Georg Braun
15  Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany.
,
Nicolette de Groot
16  Red Cross Hospital Beverwijk, Beverwijk, The Netherlands
,
Marianne Udd
17  Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
,
Andres Sanchez-Yague
18  Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain
19  Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain
,
Ziv Neeman
 2  Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
20  Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel
,
Jeanin E. van Hooft
21  Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
› Author Affiliations

MAIN RECOMMENDATIONS

1 ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow–Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.

Strong recommendation, moderate quality evidence.

2 ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3–5 days.

Strong recommendation, moderate quality evidence.

3 ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed.

Strong recommendation, high quality evidence.

4 ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved.

Strong recommendation, high quality evidence.

5 ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy).

Strong recommendation, high quality evidence.

6 ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection.

Strong recommendation, high quality evidence.

7 ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered.

Weak recommendation, low quality evidence.

8 ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE.

Strong recommendation, moderate quality evidence.

9 ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically.

(a) PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy.

(b) High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.

Strong recommendation, high quality evidence.

10 ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.

Strong recommendation, low quality evidence.

Supplementary material



Publication History

Publication Date:
10 February 2021 (online)

© 2021. European Society of Gastrointestinal Endoscopy. All rights reserved.

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