Guideline sources The following summarized guidelines for the evaluation and management of non-variceal upper gastrointestinal bleeding (UGIB) are prepared by our editorial team based on guidelines from the British Society for Haematology (BSH 2022), the American College of Gastroenterology (ACG/CAG 2022), the American College of Gastroenterology (ACG 2021; 2012), the European Society of Intensive Care Medicine (ESICM 2021), the World Society of Emergency Surgery (WSES 2020), and the American Society for Gastrointestinal Endoscopy (ASGE 2010). 1 2 3 4 5 6 7 Calculator Calculator Calculator AIMS65 score for upper GI bleed Complete Rockall score for predi Initial Roc https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 1/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway Guidelines 1. Classification and risk stratification Risk stratification: As per WSES 2020 guidelines, obtain prompt surgical and medical evaluation in patients with bleeding peptic ulcer to prevent further bleeding and to reduce mortality. B Show 2 more As per ACG 2012 guidelines, 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 2. Diagnostic investigations Laboratory testing: obtain blood-typing, Hgb, hematocrit and electrolytes, and coagulation assessment in patients with suspected bleeding peptic ulcer. B Diagnostic imaging: Consider obtaining contrast-enhanced CT in patients with suspected bleeding peptic ulcer, if endoscopy is not available. C Consider obtaining angiography for diagnostic purposes as second-line investigation after a negative endoscopy in patients with bleeding peptic ulcer. C Testing for Helicobacter pylori infection: obtain H. pylori testing in all patients with bleeding peptic ulcer. B 3. Diagnostic procedures Gastric lavage: do not perform routine nasogastric or orogastric lavage in patients with upper gastrointestinal bleeding for diagnosis, prognosis, visualization, or therapeutic purposes. D Upper gastrointestinal endoscopy, timing: As per ACG 2021 guidelines, consider performing endoscopy within 24 hours of presentation in patients admitted to or under observation in hospital for upper gastrointestinal bleeding. C As per WSES 2020 guidelines, consider stratifying patients based on the Blatchford score and adopting a risk-stratified management as follows: C consider performing outpatient endoscopy in the very low-risk group C perform early inpatient endoscopy, within 24 hours of admission, in the low-risk group B perform urgent inpatient endoscopy, within 12 hours of admission, in the high-risk group. B As per WSES 2020 guidelines, perform endoscopy in patients with suspected bleeding peptic ulcer as soon as possible, especially in the high-risk group. B As per ACG 2012 guidelines, consider performing upper gastrointestinal endoscopy within 24 hours of admission in patients with upper gastrointestinal bleeding, following resuscitative efforts https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 2/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway to optimize hemodynamic parameters and other medical problems. C Show 3 more Upper gastrointestinal endoscopy, preparation: As per ACG 2021 guidelines: Consider administering erythromycin before endoscopy in patients with upper gastrointestinal bleeding. C Insufficient evidence to recommend for or against pre-endoscopic PPI therapy in patients with upper gastrointestinal bleeding. I As per WSES 2020 guidelines, consider administering pre-endoscopy erythromycin in patients with bleeding peptic ulcer. C Upper gastrointestinal endoscopy, procedural considerations: As per WSES 2020 guidelines: Consider guiding management decisions according to stigmata of recent hemorrhage during endoscopy because they can predict the risk of further bleeding. B Perform either an immediate or delayed endoluminal biopsy in patients with bleeding peptic ulcer. B As per ACG 2012 guidelines, record stigmata of recent hemorrhage as they predict risk of further bleeding and guide management decisions. Recognize that the stigmata, in descending risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, flat pigmented spot, and clean base. A 4. Medical management Indications for admission: As per ACG 2021 guidelines, consider discharging patients with outpatient follow-up rather than admitting to hospital if presenting to the emergency department with upper gastrointestinal bleeding classified as very low risk, defined as a risk assessment score with 1% false negative rate for the outcome of hospital-based intervention or death (such as Glasgow-Blatchford score = 0-1). C As per ACG 2012 guidelines, 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 Show 4 more Supportive care: As per WSES 2020 guidelines, use several resuscitation targets, similar to those of damage control resuscitation in patients with bleeding trauma. B As per ACG 2012 guidelines, assess hemodynamic status immediately upon presentation and begin resuscitative measures as needed. A Tranexamic acid: https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 3/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway As per BSH 2022 guidelines, do not use tranexamic acid in patients with acute gastrointestinal bleeding. D As per ESICM 2021 guidelines: Avoid using high-dose IV tranexamic acid in critically ill patients with gastrointestinal bleeding. D Insufficient evidence to support the use of low-dose IV tranexamic acid or enteral tranexamic acid in critically ill patients with gastrointestinal bleeding. I Proton pump inhibitors: As per ACG 2021 guidelines, initiate high-dose PPI therapy continuously or intermittently for 3 days after successful endoscopic hemostatic therapy of a bleeding ulcer. B Show 2 more Landmark trials: Omeprazole for peptic ulcer bleeding In patients having undergone endoscopic treatment for bleeding peptic ulcers, omeprazole was superior to placebo with respect to the rate of bleeding recurrence within 30 days. Lau JY et al. N Engl J Med. 2000 Aug 3. As per WSES 2020 guidelines, initiate PPI therapy as soon as possible in patients with bleeding peptic ulcer. B Show 2 more Eradication therapy: offer eradication therapy in patients with H. pylori-positive bleeding peptic ulcer to avoid recurrent bleeding. B Show 4 more Management of anticoagulant and antiplatelet therapy (warfarin): Avoid administering FFP or vitamin K in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. D Insufficient evidence to recommend for or against PCC administration in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. I Consider administering PCC over FFP in patients on warfarin hospitalized or under observation with acute gastrointestinal bleeding. I Management of anticoagulant and antiplatelet therapy (DOACs): avoid administering PCC in patients on direct OACs hospitalized or under observation with acute gastrointestinal bleeding. D Show 2 more Management of anticoagulant and antiplatelet therapy (antiplatelets): avoid administering platelet transfusion in patients on antiplatelet agents hospitalized or under observation with acute gastrointestinal bleeding. D Show 2 more https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 4/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway 5. Therapeutic procedures Endoscopic therapy: As per ACG 2021 guidelines, perform endoscopic therapy in patients with upper gastrointestinal bleeding due to ulcers with active spurting, active oozing, and nonbleeding visible vessels. B Show 7 more As per WSES 2020 guidelines, perform endoscopic therapy in patients with bleeding peptic ulcer to achieve hemostasis and reduce rebleeding, the need for surgery, and mortality. B Show 4 more Angioembolization: consider performing transcatheter angioembolization as an alternative to endoscopic therapy in patients with recurrent bleeding where resources are available. C Show 3 more Blood transfusion: As per ACG 2021 guidelines, consider adopting a restrictive policy of RBC transfusion with a threshold for transfusion at a Hgb of 7 g/dL in patients with upper gastrointestinal bleeding. C Landmark trials: Transfusion strategies for acute upper GI bleeding In patients with severe acute upper gastrointestinal bleeding, restrictive blood transfusion therapy was superior to liberal blood transfusion therapy with respect to death at 45 days. Villanueva C et al. N Engl J Med. 2013 Jan 3. As per ESICM 2021 guidelines, consider setting a restrictive (7 g/dL) RBC transfusion threshold in patients with non-massive gastrointestinal bleeding. C As per WSES 2020 guidelines, maintain an Hgb level of at least > 7 g/dL during the resuscitation phase in patients with bleeding peptic ulcer. B 6. Surgical interventions Indications for surgery: consider performing surgical hemostasis after failure of repeated endoscopy in patients with bleeding peptic ulcer. Consider performing surgical intervention without repeated endoscopy in patients with hypotension and/or hemodynamic instability and/or ulcer > 2 cm at first endoscopy. B Show 4 more 7. Specific circumstances Patients with H. pylori-associated ulcers: 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 https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 5/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway Patients with NSAID-associated ulcers: 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 Landmark trials: Celecoxib vs. diclofenac in arthritis with recent ulcer bleeding In patients with arthritis and a recent history of ulcer bleeding, celecoxib was noninferior to diclofenac plus omeprazole with respect to the rate of probability of recurrent bleeding during the 6-month period. Chan FK et al. N Engl J Med. 2002 Dec 26. Patients with aspirin-associated ulcers: reevaluate the need for aspirin in patients with low-dose aspirin-associated ulcers. B Show 2 more Patients with idiopathic ulcers: administer long-term anti-ulcer therapy (e.g., daily PPI) in patients with idiopathic, non-H. pylori, non-NSAID related ulcers. B 8. Follow-up and surveillance Follow-up endoscopy: do not perform routine second-look (24 hours after initial endoscopic hemostatic therapy) endoscopy. D Management of rebleeding: As per ACG 2021 guidelines: 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 As per WSES 2020 guidelines: Perform endoscopic therapy as first-line treatment in patients with recurrent bleeding from peptic ulcer. B Consider performing transcatheter angioembolization as an alternative to endoscopic therapy in patients with recurrent bleeding where resources are available. C As per ASGE 2010 guidelines, perform repeat endoscopic therapy before considering surgical or radiologic intervention in patients with rebleeding after initial endoscopic hemostasis. B Clinical findings https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 6/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway Patient demographics Symptoms Age Abdominal cramps Dizziness Past medical history Epigastric pain Fainting Cancer Fatigue Iron use Melena Liver cirrhosis Shortness of breath Peptic ulcer disease Unconsciousness Upper gastrointestinal bleeding Vomiting of blood Warfarin use Weakness Integument exam Vital signs Pale skin Hypotension Hematological findings Tachycardia Anemia secondary to blood loss Lab findings blood Hgb serum serum BUN to serum creatinine Endoscopic findings Angiodysplasia Esophagitis/esophageal ulcer Studies 2020 HALT-IT In adult patients with significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding, tranexamic acid was not superior to placebo with respect to the rate of death due to bleeding within 5 days. HALT-IT Trial Collaborators. Lancet. 2020 Jun 20. 2020 Timing of endoscopy for AUGB In patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score 12, urgent-endoscopy was not superior to early-endoscopy with respect to death from any cause at 30 days. James Y W Lau et al. N Engl J Med. 2020 Apr 2. Show 4 more https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 7/8 6/30/23, 1:18 AM Non-variceal upper gastrointestinal bleeding Pathway References 1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107 3 345 60. Open 2. Antonio Tarasconi, Federico Coccolini, Walter L Biffl et al. Perforated and bleeding peptic ulcer: WSES guidelines. World J Emerg Surg. 2020 Jan 7;15 3. Open 3. Simon J Stanworth, Kerry Dowling, Nikki Curry et al. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. Open 4. Loren Laine, Alan N Barkun, John R Saltzman et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol. 2021 May 1;116 5 899 917. Open 5. Neena S Abraham, Alan N Barkun, Bryan G Sauer et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022 Mar 17. Open 6. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 7. ASGE Standards of Practice Committee, Subhas Banerjee, Brooks D Cash et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010 Apr;71 4 663 8. Open 8. Simel D, Rennie D. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. Mayo Clin Proc. 2009 Nov; 84 11 1045. Open 9. Srygley FD, Gerardo CJ, Tran T et al. Does this patient have a severe upper gastrointestinal bleed?. JAMA. 2012 Mar 14;307 10 1072 9. Open 10. Halvorsen S, Storey RF, Rocca B et al. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J. 2017 May 14;38 19 1455 1462. Open 11. Angel Lanas, Jean-Marc Dumonceau, Richard H Hunt et al. Non-variceal upper gastrointestinal bleeding. Nat Rev Dis Primers. 2018 Apr 19;4 18020. Open https://web.pathway.md/diseases/recMIuGXaL9tyeLvv 8/8