Non-variceal upper gastrointestinal bleeding Management Supportive care Assess hemodynamic status immediately upon presentation and begin resuscitative measures as needed. A Risk stratification Stratify patients into low risk and high risk categories to assist in decisions such as timing of endoscopy, time of discharge, and level of care. B Upper gastrointestinal endoscopy Timing Q Is the patient tachycardic or hypotensive? Q Does the patient have bloody emesis? Q Does the patient have a bloody nasogastrict aspirate? Yes to any Perform endoscopy within 12 hours of hospital admission in patients with upper gastrointestinal bleeding who display higher risk clinical features (such as tachycardia, hypotension, bloody emesis, or bloody nasogastric aspirate). B No to all Consider performing upper gastrointestinal endoscopy within 24 hours of admission in patients with upper gastrointestinal bleeding, following resuscitative efforts to optimize hemodynamic parameters and other medical problems. C Perform endoscopy in hemodynamically stable patients without serious comorbidities as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic findings who can be safely discharged. B Consider performing endoscopy within 12 hours in patients with higher risk clinical features (such as tachycardia, hypotension, hematemesis or nasogastric aspirate in hospital) to potentially improve clinical outcomes. C Endoscopic therapy ACG Q Does the patient have high-risk stigmata on endoscopy? Yes Perform endoscopic therapy in patients with upper gastrointestinal bleeding due to ulcers with active spurting, active oozing, and nonbleeding visible vessels. B Insufficient evidence to recommend for or against endoscopic therapy in patients with upper gastrointestinal bleeding due to ulcers with adherent clot resistant to vigorous irrigation. I Perform endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol in patients with upper gastrointestinal bleeding due to ulcers. B Consider performing endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation in patients with upper gastrointestinal bleeding due to ulcers. C Do not administer epinephrine injection alone in patients with upper gastrointestinal bleeding due to ulcers. Administer epinephrine injection in combination with another hemostatic modality. D Consider performing endoscopic hemostatic therapy with hemostatic powder spray TC- 325 in patients with actively bleeding ulcers. C Consider using over-the-scope clips as a hemostatic therapy in patients developing recurrent bleeding due to ulcers after previous successful endoscopic hemostasis. C No Avoid endoscopic therapy in patients who have an ulcer with a clean base or a flat pigmented spot. D Proton pump inhibitors ACG Q Does the patient have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot on endoscopy? Yes Initiate high-dose PPI therapy continuously or intermittently for 3 days after successful endoscopic hemostatic therapy of a bleeding ulcer. B Consider continuing PPI therapy BID until 2 weeks after index endoscopy in high-risk patients with upper gastrointestinal bleeding due to ulcers received endoscopic hemostatic therapy followed by short-term high-dose PPI therapy in hospital. C No Administer standard PPI therapy (e.g., oral PPI once daily) to patients with ulcers that have flat pigmented spots or clean bases. A Indications for admission ACG Q Does the patient have high-risk stigmata on endoscopy? Yes Consider hospitalizing patients with high-risk stigmata for 72 hours of inpatient observation, assuming no rebleeding and no other reasons for longer admission. Consider giving them clear liquids soon after endoscopy. C Consider advising patients with clean-based ulcers to receive a regular diet and discharge them after endoscopy, assuming they are hemodynamically stable, their Hgb is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult. B Consider discharging patients from the emergency department without inpatient endoscopy if the urea nitrogen < 18.2 mg/dL, Hgb 13.0 g/dL for males (12.0 g/dL for females), systolic BP 110 mmHg, pulse < 100 bpm, and absence of melena, syncope, cardiac failure, and liver disease, as they have < 1% chance of requiring intervention. C No Discharge patients with clean-based ulcers after endoscopy, assuming they are hemodynamically stable. A Consider discharging patients from the emergency department without inpatient endoscopy, if they meet the following criteria: serum urea < 18.2 mg/dL hgb 13.0 g/dL for men or 12.0 g/dL for women systolic BP 110 mmHg pulse < 100 beats/min absence of melena, syncope, cardiac failure, and liver disease. C Management of rebleeding ACG Q Does the patient have a clinical evidence of recurrent bleeding? Yes Consider performing repeat endoscopy and endoscopic therapy rather than surgery C or transcatheter arterial embolization in patients with recurrent bleeding after endoscopic therapy for a bleeding ulcer. C Consider performing transcatheter arterial embolization in patients with bleeding ulcers failed endoscopic therapy. C No Patients with idiopathic ulcers Q Does the patient have an idiopathic (non-H. pylori, non-NSAID) ulcer? Yes Administer long-term anti-ulcer therapy (e.g., daily PPI) in patients with idiopathic, non- H. pylori, non-NSAID related ulcers. B No Patients with aspirin-associated ulcers Q Does the patient have a low-dose aspirin-associated bleeding ulcer? Yes Reevaluate the need for aspirin in patients with low-dose aspirin-associated ulcers. B Resume aspirin after bleeding ceases, ideally within 1-3 days and certainly within 7 days, if given for secondary prevention in patients with established CVD. B Consider initiating long-term daily PPI therapy as secondary prophylaxis. C No Patients with NSAID-associated ulcers Q Does the patient have an NSAID-associated bleeding ulcer? Yes Reevaluate the need for NSAIDs carefully in patients with NSAIDs-associated bleeding ulcers, and avoid resuming NSAIDs if possible. In patients who must resume NSAIDs, use a COX-2 selective NSAID at the lowest effective dose plus daily PPI. A No Patients with H. pylori-associated ulcers Q Does the patient have an H. pylori-associated bleeding ulcer? Yes Administer H. pylori therapy to patients with H. pylori-associated bleeding ulcers. After documentation of eradication, avoid maintenance antisecretory therapy unless the patient also requires NSAIDs or antithrombotics. A No Continue management and follow-up as clinically appropriate.