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Non-variceal upper gastrointestinal bleeding

Key sources
The following summarized guidelines for the evaluation and management of non-variceal upper gastrointestinal bleeding 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).
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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.
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2.Diagnostic investigations

Laboratory testing: obtain blood-typing, hemoglobin, hematocrit and electrolytes, and coagulation assessment in patients with suspected bleeding peptic ulcer.
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  • Diagnostic imaging

  • Testing for H. pylori infection

3.Diagnostic procedures

Gastric lavage: do not perform routine nasogastric or orogastric lavage in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic purposes.
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  • Upper gastrointestinal endoscopy (timing)

  • Upper gastrointestinal endoscopy (preparation)

  • Upper gastrointestinal endoscopy (procedural considerations)

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 UGIB 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).
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  • Supportive care

  • Tranexamic acid

  • PPIs

  • Eradication therapy

  • Management of anticoagulant and antiplatelet therapy (warfarin)

  • Management of anticoagulant and antiplatelet therapy (DOACs)

  • Management of anticoagulant and antiplatelet therapy (antiplatelets)

5.Therapeutic procedures

Endoscopic therapy: as per ACG 2021 guidelines, perform endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and nonbleeding visible vessels.
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  • Angioembolization

  • Blood transfusion

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.
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7.Specific circumstances

Patients with Helicobacter 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.
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  • Patients with NSAID-associated ulcers

  • Patients with aspirin-associated ulcers

  • Patients with idiopathic ulcers

8.Follow-up and surveillance

Follow-up endoscopy: do not perform routine second-look (24 hours after initial endoscopic hemostatic therapy) endoscopy.
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  • Management of rebleeding