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

Abstract

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.

Conflict of interest statement

N. de Groot has worked with the NUMDL group on a national guideline on GI bleeding (January to June 2017). M. Dinis-Ribeiro has provided consultancy to Medtronic (October 2020); he is a Co-Editor-in-Chief of the journal Endoscopy. I.M. Gralnek is a consultant to Boston Scientific, Medtronic, Motus GI, Vifor Pharma, Simbionix, and Neurogastrx; he is also on the medical advisory board of Motus GI and has received research funding from them and from OnePass, AstraZeneca and CheckCap; he has also been a speaker for Vifor Pharma and 3D Matrix. A. Lanas has provided consultancy to Bayer AG (2018 to 2020). A.J. Morris serves on an advisory board for Medtronic (October 2020, ongoing); he is an unpaid committee member and a guideline lead for the British Society of Gastroenterology (BSG); he has received a fee for a commissioned article in Medicine International journal (2019). I.S. Papanikolaou has received a consultancy fee from Boston Scientific (25 January 2018 and 21 October 2018); he has received travel grants from Takeda Hellas (10–13 October 2019 and 3–6 December 2020). F. Radaelli has served on an advisory board and been a speaker for Pfizer/BMS (2019 to 2020); he has been a speaker for Boehringer Ingelheim (2019 to 2020). A. Sanchez-Yague has received consultancy fees from Boston Scientific (2017 to 2019). J.E. van Hooft has received lecture fees from Medtronic (2014 to 2015, 2019) and Cook Medical (2019), and consultancy fees from Boston Scientific (2014 to 2017); her department has received research grants from Cook Medical (2014 to 2019), and Abbott (2014 to 2017). H. Awadie, G. Braun, M. Camus, T. Cúrdia Gonçalves, J. Lau, S.B. Laursen, Z. Neeman, A.J. Stanley, and M. Udd declare no competing interests.

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