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Diagnosis and management of nonvariceal upper ...

Guideline a1. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal endoscopy (ESGE) Guideline Authors Ian M. Gralnek1, 2, Jean-Marc Dumonceau3, Ernst J. Kuipers4, Angel Lanas5, David S. Sanders6, Matthew Kurien6, Gianluca Rotondano7, Tomas Hucl8, Mario Dinis-Ribeiro9, Riccardo Marmo10, Istvan Racz11, Alberto Arezzo12, Ralf-Thorsten Hoffmann13, Gilles Lesur14, Roberto de Franchis15, Lars Aabakken16, Andrew Veitch17, Franco Radaelli18, Paulo Salgueiro19, Ricardo Cardoso20, Lu s Maia19, Angelo Zullo21, Livio Cipolletta22, Cesare Hassan23. Institutions Institutions listed at end of article. Bibliography This Guideline is an official statement of the European Society of Gastrointestinal endoscopy (ESGE). It DOI addresses the Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH).

Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline Authors Ian M. Gralnek1,2, Jean-Marc Dumonceau3, Ernst J. Kuipers4, Angel Lanas5, David S. Sanders6, Matthew Kurien6, Gianluca Rotondano7, Tomas Hucl8, Mario Dinis-Ribeiro9, Riccardo Marmo10, Istvan Racz11, Alberto …

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1 Guideline a1. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal endoscopy (ESGE) Guideline Authors Ian M. Gralnek1, 2, Jean-Marc Dumonceau3, Ernst J. Kuipers4, Angel Lanas5, David S. Sanders6, Matthew Kurien6, Gianluca Rotondano7, Tomas Hucl8, Mario Dinis-Ribeiro9, Riccardo Marmo10, Istvan Racz11, Alberto Arezzo12, Ralf-Thorsten Hoffmann13, Gilles Lesur14, Roberto de Franchis15, Lars Aabakken16, Andrew Veitch17, Franco Radaelli18, Paulo Salgueiro19, Ricardo Cardoso20, Lu s Maia19, Angelo Zullo21, Livio Cipolletta22, Cesare Hassan23. Institutions Institutions listed at end of article. Bibliography This Guideline is an official statement of the European Society of Gastrointestinal endoscopy (ESGE). It DOI addresses the Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH).

2 Published online: endoscopy 2015; 47: 1 46. Main Recommendations Georg Thieme Verlag KG MR1. ESGE recommends immediate assessment of patients with clinically severe or ongoing active Stuttgart New York hemodynamic status in patients who present with UGIH. In selected patients, pre-endoscopic infu- ISSN 0013-726X acute upper gastrointestinal hemorrhage (UGIH), sion of erythromycin significantly improves endo- with prompt intravascular volume replacement scopic visualization, reduces the need for second- Corresponding author Ian M. Gralnek, MD, MSHS. initially using crystalloid fluids if hemodynamic look endoscopy , decreases the number of units of Institute of Gastroenterology instability exists (strong recommendation, mod- blood transfused, and reduces duration of hospital and Liver Diseases, Ha'Emek erate quality evidence). stay (strong recommendation, high quality evi- Medical Center MR2.)

3 ESGE recommends a restrictive red blood cell dence). Rappaport Faculty of Medicine, transfusion strategy that aims for a target hemo- MR7. Following hemodynamic resuscitation, ESGE. Technion-Israel Institute of globin between 7 g/dL and 9 g/dL. A higher target recommends early ( 24 hours) upper GI endos- Technology hemoglobin should be considered in patients copy. Very early (< 12 hours) upper GI endoscopy Afula, Israel 18101. Fax: +972-4-6495314. with significant co-morbidity (e. g., ischemic car- may be considered in patients with high risk clini- diovascular disease) (strong recommendation, cal features, namely: hemodynamic instability (ta- moderate quality evidence). chycardia, hypotension) that persists despite on- MR3. ESGE recommends the use of the Glasgow- going attempts at volume resuscitation; in-hospi- Blatchford Score (GBS) for pre- endoscopy risk stra- tal bloody emesis/nasogastric aspirate; or contra- tification.

4 Outpatients determined to be at very indication to the interruption of anticoagulation low risk, based upon a GBS score of 0 1, do not re- (strong recommendation, moderate quality evi- quire early endoscopy nor hospital admission. Dis- dence). charged patients should be informed of the risk of MR8. ESGE recommends that peptic ulcers with recurrent bleeding and be advised to maintain spurting or oozing bleeding (Forrest classification contact with the discharging hospital (strong re- Ia and Ib, respectively) or with a nonbleeding visi- commendation, moderate quality evidence). ble vessel (Forrest classification IIa) receive endo- MR4. ESGE recommends initiating high dose intra- scopic hemostasis because these lesions are at venous proton pump inhibitors (PPI), intravenous high risk for persistent bleeding or rebleeding bolus followed by continuous infusion (80 mg (strong recommendation, high quality evidence).)

5 Then 8 mg/hour), in patients presenting with acute MR9. ESGE recommends that peptic ulcers with an UGIH awaiting upper endoscopy . However, PPI in- adherent clot (Forrest classification IIb) be consid- fusion should not delay the performance of early ered for endoscopic clot removal. Once the clot is endoscopy (strong recommendation, high quality removed, any identified underlying active bleed- evidence). ing (Forrest classification Ia or Ib) or nonbleeding MR5. ESGE does not recommend the routine use of visible vessel (Forrest classification IIa) should re- nasogastric or orogastric aspiration/lavage in pa- ceive endoscopic hemostasis (weak recommenda- tients presenting with acute UGIH (strong recom- tion, moderate quality evidence). mendation, moderate quality evidence). MR10. In patients with peptic ulcers having a flat MR6. ESGE recommends intravenous erythromy- pigmented spot (Forrest classification IIc) or clean cin (single dose, 250 mg given 30 120 minutes base (Forrest classification III), ESGE does not re- prior to upper gastrointestinal [GI] endoscopy ) in commend endoscopic hemostasis as these stigma- Gralnek Ian M et al.

6 nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline endoscopy 2015; 47: a1 a46. a2 Guideline ta present a low risk of recurrent bleeding. In selected clinical set- sis if indicated. In the case of failure of this second attempt at he- tings, these patients may be discharged to home on standard PPI mostasis, transcatheter angiographic embolization (TAE) or sur- therapy, e. g., oral PPI once-daily (strong recommendation, moder- gery should be considered (strong recommendation, high quality ate quality evidence). evidence). MR11. ESGE recommends that epinephrine injection therapy not MR14. In patients with NVUGIH secondary to peptic ulcer, ESGE re- be used as endoscopic monotherapy. If used, it should be combined commends investigating for the presence of Helicobacter pylori in with a second endoscopic hemostasis modality (strong recom- the acute setting with initiation of appropriate antibiotic therapy mendation, high quality evidence).

7 When H. pylori is detected. Re-testing for H. pylori should be per- MR12. ESGE recommends PPI therapy for patients who receive formed in those patients with a negative test in the acute setting. endoscopic hemostasis and for patients with adherent clot not re- Documentation of successful H. pylori eradication is recommended ceiving endoscopic hemostasis. PPI therapy should be high dose (strong recommendation, high quality evidence). and administered as an intravenous bolus followed by continuous MR15. In patients receiving low dose aspirin for secondary cardio- infusion (80 mg then 8 mg/hour) for 72 hours post endoscopy vascular prophylaxis who develop peptic ulcer bleeding, ESGE re- (strong recommendation, high quality evidence). commends aspirin be resumed immediately following index MR13. ESGE does not recommend routine second-look endoscopy endoscopy if the risk of rebleeding is low (e.)

8 G., FIIc, FIII). In patients as part of the management of nonvariceal upper gastrointestinal with high risk peptic ulcer (FIa, FIb, FIIa, FIIb), early reintroduction hemorrhage (NVUGIH). However, in patients with clinical evi- of aspirin by day 3 after index endoscopy is recommended, provid- dence of rebleeding following successful initial endoscopic hemo- ed that adequate hemostasis has been established (strong recom- stasis, ESGE recommends repeat upper endoscopy with hemosta- mendation, moderate quality evidence). Abbreviations Introduction ! ! APC argon plasma coagulation Acute upper gastrointestinal hemorrhage (UGIH) is a common ASA American Society of Anesthesiologists condition worldwide that has an estimated annual incidence of DAPT dual antiplatelet therapy 40 150 cases per 100 000 population [1, 2], frequently leads to CHADS2 congestive heart failure, hypertension, age 75 years, hospital admission, and has significant associated morbidity and diabetes mellitus, and previous stroke or transient mortality, especially in the elderly.

9 The most common causes of ischemic attack [risk score] acute UGIH are nonvariceal [1, 2]. This includes peptic ulcers, 28. CI confidence interval % 59 % (duodenal ulcer 17 % 37 % and gastric ulcer 11 % 24 %);. DOAC direct oral anticoagulant mucosal erosive disease of the esophagus/stomach/duodenum, ESGE European Society of Gastrointestinal endoscopy 1 % 47 %; Mallory Weiss syndrome, 4 % 7 %; upper GI tract ma- FFP fresh frozen plasma lignancy, 2 % 4 %; other Diagnosis , 2 % 7 %; or no exact cause GBS Glasgow-Blatchford Score identified, 7 % 25 % [1, 2]. Moreover, in 16 % 20 % of acute UGIH. GI gastrointestinal cases, more than one endoscopic Diagnosis may be identified as GRADE Grading of Recommendations Assessment, the cause of bleeding. The aim of this evidence-based consensus Development and Evaluation guideline is to provide medical caregivers with a comprehensive HR hazard ratio review and recommendations on the clinical and endoscopic INR international normalized ratio management of NVUGIH.

10 NBVV nonbleeding visible vessel NNT number needed to treat NOAC non-VKA oral anticoagulant Methods NVUGIH nonvariceal upper gastrointestinal hemorrhage ! PAR protease-activated receptor The ESGE commissioned this guideline on NVUGIH and appoin- PCC prothrombin complex concentrate ted a guideline leader ( ) who in collaboration with the Chair PICO patients, interventions, controls, outcomes of the ESGE Guidelines Committee ( ), invited the listed au- PPI proton pump inhibitor thors to participate in the guideline development and review. OR odds ratio Key questions were prepared by the coordinating team ( PUB peptic ulcer bleeding and ) and reviewed and approved by all task force members. RBC red blood cell The coordinating team formed four task force subgroups, each RCT randomized controlled trial with its own coordinator, and divided the key topics/questions RR relative risk or risk ratio amongst these four task force subgroups (see Appendix e1, on- TAE transcatheter angiographic embolization line-only).


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