title: Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
abstract: This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). Main Recommendations MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence). MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence). MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 - 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence). MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence). MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence). MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 - 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence). MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence). MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence). MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence). MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence). MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence). MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence). MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence). MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).
authors.affiliation: Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel.
authors.forename: Ian M
authors.initials: IM
authors.lastname: Gralnek
authors.affiliation: Gedyt Endoscopy Center, Buenos Aires, Argentina.
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Dumonceau
authors.affiliation: Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Kuipers
authors.affiliation: University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, Spain.
authors.forename: Angel
authors.initials: A
authors.lastname: Lanas
authors.affiliation: Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom.
authors.forename: David S
authors.initials: DS
authors.lastname: Sanders
authors.affiliation: Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom.
authors.forename: Matthew
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authors.lastname: Kurien
authors.affiliation: Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del Greco, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rotondano
authors.affiliation: Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
authors.forename: Tomas
authors.initials: T
authors.lastname: Hucl
authors.affiliation: Department of Gastroenterology, IPO Porto, Portugal and CINTESIS, Porto Faculty of Medicine, Portgal.
authors.forename: Mario
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authors.lastname: Dinis-Ribeiro
authors.affiliation: Division of Gastroenterology, Hospital Curto, Polla, Italy.
authors.forename: Riccardo
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authors.lastname: Marmo
authors.affiliation: First Department of Internal Medicine and Gastroenterology, Petz Aladar, Hospital, Gyor, Hungary.
authors.forename: Istvan
authors.initials: I
authors.lastname: Racz
authors.affiliation: Department of Surgical Sciences, University of Torino, Torino, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Arezzo
authors.affiliation: Institute and Polyclinic for Diagnostic Radiology, University Hospital Dresden-TU, Dresden, Germany.
authors.forename: Ralf-Thorsten
authors.initials: RT
authors.lastname: Hoffmann
authors.affiliation: Department of Gastroenterology, Ambroise Paré Hospital, Boulogne, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Lesur
authors.affiliation: Department of Biomedical and Clinical Sciences, University of Milan, Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: de Franchis
authors.affiliation: Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway.
authors.forename: Lars
authors.initials: L
authors.lastname: Aabakken
authors.affiliation: Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Veitch
authors.affiliation: Department of Gastroenterology, Valduce Hospital, Como, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Radaelli
authors.affiliation: Department of Gastroenterology, Centro Hospitalar do Porto, Portugal.
authors.forename: Paulo
authors.initials: P
authors.lastname: Salgueiro
authors.affiliation: Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Cardoso
authors.affiliation: Department of Gastroenterology, Centro Hospitalar do Porto, Portugal.
authors.forename: Luís
authors.initials: L
authors.lastname: Maia
authors.affiliation: Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
authors.forename: Angelo
authors.initials: A
authors.lastname: Zullo
authors.affiliation: Gastroenterology and Endoscopy Department, Antonio Cardarelli Hospital, Naples, Italy.
authors.forename: Livio
authors.initials: L
authors.lastname: Cipolletta
authors.affiliation: Digestive Endoscopy Unit, Catholic University, Rome, Italy.
authors.forename: Cesare
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authors.lastname: Hassan
mesh_terms: D019468:Disease Management; D016099:Endoscopy, Gastrointestinal / Q000592:standards*; D005060:Europe; D005762:Gastroenterology; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis* / Q000628:therapy*; D016558:Hemostasis, Endoscopic / Q000379:methods* / Q000592:standards; D006801:Humans; D012955:Societies, Medical