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

Ian M. Gralnek; Adrian J. Stanley; A. John Morris; Marine Camus; James Lau; Angel Lanas; Stig B. Laursen; Franco Radaelli; Ioannis S. Papanikolaou; Tiago Cúrdia Gonçalves; Mario Dinis-Ribeiro; Halim Awadie; Georg Braun; Nicolette de Groot; Marianne Udd; Andres Sanchez-Yague; Ziv Neeman; Jeanin E. van Hooft

doi:10.1055/a-1369-5274

Endoscopy, Table of Contents

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

¹Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel

²Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

,

Adrian J. Stanley

³Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK

,

A. John Morris

³Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK

,

Marine Camus

⁴Sorbonne University, Endoscopic Unit, Saint Antoine Hospital Assistance Publique Hopitaux de Paris, Paris, France

,

James Lau

⁵Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

,

Angel Lanas

⁶Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain

,

Stig B. Laursen

⁷Department of Gastroenterology, Odense University Hospital, Odense, Denmark

,

Franco Radaelli

⁸Department of Gastroenterology, Valduce Hospital, Como, Italy

,

Ioannis S. Papanikolaou

⁹Hepatogastroenterology Unit, Second Department of Internal Medicine – Propaedeutic, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece

,

Tiago Cúrdia Gonçalves

¹⁰Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal

¹¹School of Medicine, University of Minho, Braga/Guimarães, Portugal

¹²ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal

,

Mario Dinis-Ribeiro

¹³Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal

¹⁴Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal

,

Halim Awadie

¹Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel

,

Georg Braun

¹⁵Medizinische Klinik 3, Universitätsklinikum Augsburg, Augsburg, Germany.

,

Nicolette de Groot

¹⁶Red Cross Hospital Beverwijk, Beverwijk, The Netherlands

,

Marianne Udd

¹⁷Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland

,

Andres Sanchez-Yague

¹⁸Gastroenterology Unit, Hospital Costa del Sol, Marbella, Spain

¹⁹Gastroenterology Department, Vithas Xanit International Hospital, Benalmadena, Spain

,

Ziv Neeman

²Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

²⁰Diagnostic Imaging and Nuclear Medicine Institute, Emek Medical Center, Afula, Israel

,

Jeanin E. van Hooft

²¹Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands

› Author Affiliations

Abstract

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.

Full Text

References

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