Abstract: This guideline is an update of the 2021 ESGE Guideline on Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage. The following are the new and/or revised recommendations.
Pre-endoscopy management: 1: ESGE does not recommend the routine use of video capsule endoscopy or telemetric blood-sensing capsules in the management of patients with suspected upper gastrointestinal hemorrhage (UGIH).
Pre-endoscopy management: 2: ESGE suggests, if intravenous erythromycin is unavailable, pre-endoscopy administration of intravenous metoclopramide in selected patients with clinically severe or ongoing active UGIH.
Pre-endoscopy management: 3: ESGE suggests that pre-endoscopy high dose intravenous proton pump inhibitor (PPI) therapy be considered in patients presenting with acute UGIH; however, this should not delay early endoscopy.
Pre-endoscopy management: 4: ESGE does not recommend emergent (≤6 hours) or urgent (≤12 hours) upper GI endoscopy unless the patient remains hemodynamically unstable despite adequate resuscitation.
Endoscopic management: 5: ESGE suggests that patients with peptic ulcers presenting with an adherent clot (Forrest IIb) should undergo endoscopic therapy, with clot removal and subsequent endoscopic hemostasis if indicated, provided that the endoscopist has the technical competence to safely remove the clot and manage potential conversion to a higher risk bleeding lesion.
Endoscopic management: 6: ESGE could not reach a consensus for or against the routine use of a Doppler endoscopic probe in treatment decisions of high risk endoscopic stigmata of peptic ulcer bleeding.
Endoscopic management: 7: ESGE suggests the use of over-the-scope (OTS) clips as monotherapy as an alternative to combination therapy as first-line therapy for peptic ulcer bleeding with high risk stigmata (FIa, FIb) owing to a lower risk of further bleeding compared with standard endoscopic hemostatic therapy.
Endoscopic management: 8: ESGE recommends, for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy (e.g. through-the-scope or OTS clips), or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection.
Endoscopic management: 9: ESGE suggests, for patients with an ulcer with a nonbleeding visible vessel (FIIa), OTS clips may be used as alternative monotherapy.
Endoscopic management: 10: ESGE suggests hemostatic forceps with soft coagulation may be used as monotherapy in the treatment of peptic ulcer bleeding with high risk stigmata (FIa, FIb, and FIIa).
Endoscopic management: 11: ESGE suggests that hemostatic agents should not be used as monotherapy in the first-line treatment of patients with high risk stigmata of peptic ulcer bleeding.
Endoscopic management: 12: ESGE suggests that, in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic agent or OTS clips should be considered.
Endoscopic management: 13: ESGE recommends that, in patients with persistent bleeding refractory to all modalities of endoscopic hemostasis, including topical hemostatic agents and OTS clips, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after unsuccessful TAE.
Postendoscopy management: 14: ESGE suggests that prophylactic TAE be considered in selected high risk cases of peptic ulcer bleeding (e.g. patients with hemodynamic instability at presentation, posterior duodenal wall ulcer location, large ulcer size [>2 cm], or when durable endoscopic hemostasis is considered uncertain).
Postendoscopy management: 15: ESGE could not reach a consensus for or against the routine use of potassium-competitive acid blockers for patients who have undergone endoscopic hemostasis.
Postendoscopy management: 16: ESGE recommends that, for patients with clinical evidence of recurrent peptic ulcer bleeding, use of an OTS clip should be considered. Should this second attempt at endoscopic hemostasis also be unsuccessful, TAE should be considered. Surgery is indicated when TAE is either locally unavailable or after unsuccessful TAE.
Postendoscopy management: 17: ESGE recommends that, in patients with peptic ulcer hemorrhage who require ongoing anticoagulation therapy, anticoagulation should be resumed as soon as clinically indicated based on thromboembolic risk.
Postendoscopy management: 18: ESGE suggests that iron therapy be initiated prior to hospital discharge in patients with peptic ulcer bleeding and iron deficiency and/or anemia.
Postendoscopy management: 19: ESGE suggests that early oral nutrition, within 24 hours following endoscopic hemostasis, be initiated in patients with peptic ulcer bleeding in whom durable hemostasis has been achieved.
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