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Non-variceal upper gastrointestinal bleeding

Guidelines

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 American College of Chest Physicians (ACCP 2024), the American Society of Health-System Pharmacists (ASHP/SCCM 2024), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the American College of Gastroenterology (ACG/CAG 2022), the British Society ...
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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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Diagnostic investigations

Laboratory testing: as per WSES 2020 guidelines, 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

Diagnostic procedures

Gastric lavage: as per ACG 2012 guidelines, 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)

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)

Therapeutic procedures

Endoscopic therapy: as per ESAIC 2023 guidelines, perform endoscopic therapy combined with high-dose PPIs in patients with UGIB due to peptic ulcer.
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  • Angioembolization

  • Blood transfusion

Surgical interventions

Indications for surgery: as per ESAIC 2023 guidelines, consider performing angioembolization and/or surgery in patients with bleeding peptic ulcer if endoscopic therapy has failed.
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Specific circumstances

Patients with H. pylori-associated ulcer: as per ACG 2012 guidelines, 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 ulcer

  • Patients with stress ulcer (risk assessment)

  • Patients with stress ulcer (indications for prophylaxis)

  • Patients with stress ulcer (choice of prophylaxis)

  • Patients with stress ulcer (discontinuation of prophylaxis)

  • Patients with idiopathic ulcer

Follow-up and surveillance

Follow-up endoscopy: as per ACG 2012 guidelines, do not perform routine second-look (24 hours after initial endoscopic hemostatic therapy) endoscopy.
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  • Management of rebleeding