Endoscopy 2015; 47(10): a1-a46
DOI: 10.1055/s-0034-1393172
© Georg Thieme Verlag KG Stuttgart · New York

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Ian M. Gralnek
1   Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel
2   Rappaport Faculty of Medicine Technion-Israel Institute of Technology, Haifa, Israel
Jean-Marc Dumonceau
3   Gedyt Endoscopy Center, Buenos Aires, Argentina
Ernst J. Kuipers
4   Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
Angel Lanas
5   University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, Spain
David S. Sanders
6   Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
Matthew Kurien
6   Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
Gianluca Rotondano
7   Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del Greco, Italy
Tomas Hucl
8   Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
Mario Dinis-Ribeiro
9   Department of Gastroenterology, IPO Porto, Portugal and CINTESIS, Porto Faculty of Medicine, Portgal
Riccardo Marmo
10   Division of Gastroenterology, Hospital Curto, Polla, Italy
Istvan Racz
11   First Department of Internal Medicine and Gastroenterology, Petz Aladar, Hospital, Gyor, Hungary
Alberto Arezzo
12   Department of Surgical Sciences, University of Torino, Torino, Italy
Ralf-Thorsten Hoffmann
13   Institute and Polyclinic for Diagnostic Radiology, University Hospital Dresden-TU, Dresden, Germany
Gilles Lesur
14   Department of Gastroenterology, Ambroise Paré Hospital, Boulogne, France
Roberto de Franchis
15   Department of Biomedical and Clinical Sciences, University of Milan, Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy
Lars Aabakken
16   Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway
Andrew Veitch
17   Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
Franco Radaelli
18   Department of Gastroenterology, Valduce Hospital, Como, Italy
Paulo Salgueiro
19   Department of Gastroenterology, Centro Hospitalar do Porto, Portugal
Ricardo Cardoso
20   Department of Gastroenterology, Centro Hospitalar e Universitário de Coimbra, Portugal
Luís Maia
19   Department of Gastroenterology, Centro Hospitalar do Porto, Portugal
Angelo Zullo
21   Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
Livio Cipolletta
22   Gastroenterology and Endoscopy Department, Antonio Cardarelli Hospital, Naples, Italy
Cesare Hassan
23   Digestive Endoscopy Unit, Catholic University, Rome, Italy
› Author Affiliations
Further Information

Publication History

Publication Date:
29 September 2015 (online)

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH).

Main Recommendations

MR1. ESGE recommends immediate assessment of hemodynamic status in patients who present with acute upper gastrointestinal hemorrhage (UGIH), with prompt intravascular volume replacement initially using crystalloid fluids if hemodynamic instability exists (strong recommendation, moderate quality evidence).

MR2. ESGE recommends a restrictive red blood cell transfusion strategy that aims for a target hemoglobin between 7 g/dL and 9 g/dL. A higher target hemoglobin should be considered in patients with significant co-morbidity (e. g., ischemic cardiovascular disease) (strong recommendation, moderate quality evidence).

MR3. ESGE recommends the use of the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk stratification. Outpatients determined to be at very low risk, based upon a GBS score of 0 – 1, do not require early endoscopy nor hospital admission. Discharged patients should be informed of the risk of recurrent bleeding and be advised to maintain contact with the discharging hospital (strong recommendation, moderate quality evidence).

MR4. ESGE recommends initiating high dose intravenous proton pump inhibitors (PPI), intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour), in patients presenting with acute UGIH awaiting upper endoscopy. However, PPI infusion should not delay the performance of early endoscopy (strong recommendation, high quality evidence).

MR5. ESGE does not recommend the routine use of nasogastric or orogastric aspiration/lavage in patients presenting with acute UGIH (strong recommendation, moderate quality evidence).

MR6. ESGE recommends intravenous erythromycin (single dose, 250 mg given 30 – 120 minutes prior to upper gastrointestinal [GI] endoscopy) in patients with clinically severe or ongoing active UGIH. In selected patients, pre-endoscopic infusion of erythromycin significantly improves endoscopic visualization, reduces the need for second-look endoscopy, decreases the number of units of blood transfused, and reduces duration of hospital stay (strong recommendation, high quality evidence).

MR7. Following hemodynamic resuscitation, ESGE recommends early (≤ 24 hours) upper GI endoscopy. Very early (< 12 hours) upper GI endoscopy may be considered in patients with high risk clinical features, namely: hemodynamic instability (tachycardia, hypotension) that persists despite ongoing attempts at volume resuscitation; in-hospital bloody emesis/nasogastric aspirate; or contraindication to the interruption of anticoagulation (strong recommendation, moderate quality evidence).

MR8. ESGE recommends that peptic ulcers with spurting or oozing bleeding (Forrest classification Ia and Ib, respectively) or with a nonbleeding visible vessel (Forrest classification IIa) receive endoscopic hemostasis because these lesions are at high risk for persistent bleeding or rebleeding (strong recommendation, high quality evidence).

MR9. ESGE recommends that peptic ulcers with an adherent clot (Forrest classification IIb) be considered for endoscopic clot removal. Once the clot is removed, any identified underlying active bleeding (Forrest classification Ia or Ib) or nonbleeding visible vessel (Forrest classification IIa) should receive endoscopic hemostasis (weak recommendation, moderate quality evidence).

MR10. In patients with peptic ulcers having a flat pigmented spot (Forrest classification IIc) or clean base (Forrest classification III), ESGE does not recommend endoscopic hemostasis as these stigmata present a low risk of recurrent bleeding. In selected clinical settings, these patients may be discharged to home on standard PPI therapy, e. g., oral PPI once-daily (strong recommendation, moderate quality evidence).

MR11. ESGE recommends that epinephrine injection therapy not be used as endoscopic monotherapy. If used, it should be combined with a second endoscopic hemostasis modality (strong recommendation, high quality evidence).

MR12. ESGE recommends PPI therapy for patients who receive endoscopic hemostasis and for patients with adherent clot not receiving endoscopic hemostasis. PPI therapy should be high dose and administered as an intravenous bolus followed by continuous infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy (strong recommendation, high quality evidence).

MR13. ESGE does not recommend routine second-look endoscopy as part of the management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH). However, in patients with clinical evidence of rebleeding following successful initial endoscopic hemostasis, ESGE recommends repeat upper endoscopy with hemostasis if indicated. In the case of failure of this second attempt at hemostasis, transcatheter angiographic embolization (TAE) or surgery should be considered (strong recommendation, high quality evidence).

MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE recommends investigating for the presence of Helicobacter pylori in the acute setting with initiation of appropriate antibiotic therapy when H. pylori is detected. Re-testing for H. pylori should be performed in those patients with a negative test in the acute setting. Documentation of successful H. pylori eradication is recommended (strong recommendation, high quality evidence).

MR15. In patients receiving low dose aspirin for secondary cardiovascular prophylaxis who develop peptic ulcer bleeding, ESGE recommends aspirin be resumed immediately following index endoscopy if the risk of rebleeding is low (e. g., FIIc, FIII). In patients with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction of aspirin by day 3 after index endoscopy is recommended, provided that adequate hemostasis has been established (strong recommendation, moderate quality evidence).