Table 1.
Summary of Consensus Recommendations for the Management of UGIB*
| A. Resuscitation, risk assessment, and preendoscopy management |
| A1. For patients with acute UGIB and hemodynamic instability, resuscitation should be initiated. |
| Designated a good practice statement (see PICO question 1 in Supplement Appendix 2, available at Annals.org) |
| A2a. For patients with acute UGIB, we suggest using a Glasgow Blatchford score of ≤1 to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy. |
| GRADE: conditional recommendation, low-quality evidence. Vote on PICO question: yes, 76%; uncertain/neutral, 18%; no, 6% (see PICO question 2 in Supplement Appendix 2) |
| A2b. For patients with acute UGIB, we suggest against using the AIMS65 prognostic score to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy. |
| GRADE: conditional recommendation, low-quality evidence. Vote on PICO question: no, 100% (see PICO question 2 in Supplement Appendix 2) |
| A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value.† |
| A4. In patients with acute UGIB without underlying cardiovascular disease, we suggest giving blood transfusions for those with a hemoglobin level <80 g/L. |
| GRADE: conditional recommendation, low-quality evidence. Vote on PICO question: yes, 75%; uncertain/neutral, 15%; no, 10% (see PICO question 3a in Supplement Appendix 2) |
| A5. In patients with acute UGIB with underlying cardiovascular disease, we suggest giving blood transfusions at a higher hemoglobin threshold than for those without cardiovascular disease. |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 80%; uncertain/neutral, 5%; no, 15% (see PICO question 3b in Supplement Appendix 2) |
| A6. In patients with acute UGIB receiving anticoagulants (vitamin K antagonists, DOACs), we suggest not delaying endoscopy (with or without endoscopic hemostatic therapy). |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 100% (see PICO question 4 in Supplement Appendix 2) |
| A7. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield.‡ |
| A8. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy.‡ |
| A9. Pre-endoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy.‡ |
| B. Endoscopic management |
| B1. Develop institution-specific protocols for multidisciplinary management. Include access to an endoscopist trained in endoscopic hemostasis.† |
| B2. Have support staff trained to assist in endoscopy available on an urgent basis.† |
| B3: For patients admitted with acute UGIB, we suggest performing early endoscopy (within 24 hours of presentation). |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 100% (see PICO question 5a in Appendix 2) |
| B4. Endoscopic hemostatic therapy is not indicated for patients with low-risk stigmata (a clean-based ulcer or a nonprotuberant pigmented dot in an ulcer bed).† |
| B5. A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion.‡ |
| B6. The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient.‡ |
| B7. Endoscopic hemostatic therapy is indicated for patients with high-risk stigmata (active bleeding or a visible vessel in an ulcer bed).† |
| B8. Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method.‡ |
| B9. No single method of endoscopic thermal coaptive therapy is superiorto another.† |
| B10a. For patients with acutely bleeding ulcers with high-risk stigmata, we recommend endoscopic therapy with thermocoagulation or sclerosant injection. |
| GRADE: strong recommendation, low-quality evidence. Vote on PICO question: yes, 94%; uncertain/neutral, 6% (see PICO question 6a1 in Supplement Appendix 2) |
| B10b. For patients with acutely bleeding ulcers with high-risk stigmata, we suggest endoscopic therapy with (through-the-scope) clips. |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 94%; uncertain/neutral, 6% (see PICO question 6a2 in Supplement Appendix 2) |
| B11a. In patients with actively bleeding ulcers, we suggest using TC-325 as a temporizing therapy to stop bleeding when conventional endoscopic therapies are not available or fail. |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 82%; uncertain/neutral, 18% (see PICO question 6b2 in Supplement Appendix 2) |
| B11b. In patients with actively bleeding ulcers, we suggest against using TC-325 as a single therapeutic strategy vs. conventional endoscopic therapy (clips alone, thermocoagulation alone, or combination therapy). |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 12%; uncertain/neutral, 12%; no, 76% (see PICO question 6b1 in Supplement Appendix 2) |
| B12. Routine second-look endoscopy is not recommended.‡ |
| B13. A second attempt at endoscopic therapy is generally recommended in cases of rebleeding.† |
| C. Pharmacologic management |
| C1. H2RAs are not recommended for patients with acute ulcer bleeding.† |
| C2. Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding.† |
| C3. For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, we recommend using PPI therapy via intravenous loading dose followed by continuous intravenous infusion (as opposed to no treatment or H2RAs). |
| GRADE: strong recommendation, moderate-quality evidence. Vote on PICO question: yes, 100% (see PICO question 8a in Supplement Appendix 2) |
| C4. For patients who present with ulcer bleeding at high risk for rebleeding (that is, an ulcer requiring endoscopic therapy followed by 3 days of high-dose PPI therapy), we suggest using twice-daily oral PPIs (vs. once-daily) through 14 days, followed by once daily. |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 95%; uncertain/neutral, 5% (see PICO question 10 in Supplement Appendix 2) |
| C5. Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying cause.‡ |
| D. Nonendoscopic and nonpharmacologic in-hospital management |
| D1. Patients at low risk after endoscopy can be fed within 24 hours.† |
| D2. Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter.‡ |
| D3. Seek surgical consultation for patients for whom endoscopic therapy has failed.† |
| D4. Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed.‡ |
| D5. Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication.‡ |
| D6. Negative H pylori diagnostic tests obtained in the acute setting should be repeated.‡ |
| E. Secondary prophylaxis§ |
| E1. In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus a PPI or COX-2 inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding.‡ |
| E2. In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone.‡ |
| E3. In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding.‡ |
| E4. In patients with previous ulcer bleeding receiving cardiovascular prophylaxis with single- or dual-antiplatelet therapy, we suggest using PPI therapy vs. no PPI therapy. |
| GRADE: conditional recommendation, low-quality evidence. Vote on PICO question (single): yes, 95%; uncertain/neutral: 5%. Vote on PICO question (double): yes, 100% (see PICO questions 9a and 9c in Supplement Appendix 2) |
| E5. In patients with previous ulcer bleeding requiring continued cardiovascular prophylaxis with anticoagulant therapy (vitamin K antagonists, DOACs), we suggest using PPI therapy vs. no PPI therapy. |
| GRADE: conditional recommendation, very low-quality evidence. Vote on PICO question: yes, 85%; uncertain/neutral, 15% (see PICO question 9b in Supplement Appendix 2) |
| No recommendation statements∥ |
| No recommendation A: For patients with acute UGIB, the consensus group could not make a recommendation for or against using the preendoscopic Rockall prognostic scale to identify patients who are at very low risk for rebleeding or mortality and thus may not require hospitalization or inpatient endoscopy. |
| GRADE: no recommendation, very low-quality evidence. Vote on PICO question: yes, 12%; uncertain/neutral, 18%; no, 71% (see PICO question 2 in Supplement Appendix 2) |
| No recommendation B: For patients with acute UGIB at high risk for rebleeding or mortality, the consensus group could not make a recommendation for or against performing endoscopy within 12 hours vs. performing endoscopy later. |
| GRADE: no recommendation, very low-quality evidence. Vote on PICO question: yes, 41%; uncertain/neutral, 47%; no, 12% (see PICO question 5b in Supplement Appendix 2) |
| No recommendation C: In patients with acutely bleeding ulcers who have undergone endoscopic therapy, the consensus group could not make a recommendation for or against using DEP vs. no DEP to assess the need for further endoscopic therapy. |
| GRADE: no recommendation, very low-quality evidence. Vote on PICO question: yes, 47%; uncertain/neutral, 41%; no, 12% (see PICO question 7 in Supplement Appendix 2) |
| No recommendation D: For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, the consensus group could not make a recommendation for or against using non-high-dose PPI therapy (as opposed to no treatment or H2RAs). |
| GRADE: no recommendation, very low-quality evidence. Vote on PICO question: yes, 24%; uncertain/neutral, 47%; no, 29% (see PICO question 8b in Supplement Appendix 2) |
ASA = acetylsalicylic acid; COX-2 = cyclooxygenase-2; DEP = Doppler endoscopic probe; DOAC = direct oral anticoagulant; GRADE = Grading of Recommendations Assessment, Development and Evaluation; H2RA = H2-receptor antagonist; NSAID = nonsteroidal anti-inflammatory drug; PICO = patient population, intervention, comparator, and outcome; PPI = proton-pump inhibitor; UGIB = upper gastrointestinal bleeding.
*
The strength of each recommendation was assigned by the consensus group, according to the GRADE system, as strong (“we recommend...”) or conditional (“we suggest...”) on the basis of 4 components: QoE, benefit-harm balance, patients’ values and preferences, and resource requirements (18). However, when quality of evidence was low or very low, the strength of the recommendation would typically default (without a vote) to conditional, unless at least 1 of the other 3 factors was overwhelmingly strong.
†
Recommendation unchanged from the 2003 guidelines. See reference 3 for supporting evidence and discussions.
‡
Recommendation unchanged from the 2010 guidelines. See reference 4 for supporting evidence and discussions.
§
Section was titled “Postdischarge, ASA, and NSAIDs” in the 2010 consensus recommendations (4).
∥
Voting threshold of ≥75 for either yes or no was not reached.