Upper GI Bleeding (non variceal) ASGE,ESGE, and WSES Guidelines American Society of Gastrointestinal Endoscopy, European Society of Gastrointestinal Endoscopy, and, World Society of Emergency Surgery.

1. UPPER GI BLEEDING (NON VARICEAL) ASGE,ESGE,AND WSES
GUIDELINES
Dr Nasib Al Shibli
Senior Registrar GS,
Price Mutaib in Abdulaziz hospital Saudi Arabia
FACS, FRCSI, MRCSEng, ABHS(GS)

2. • ESSENTIALS OF DIAGNOSIS
• Symptoms: Coffee ground vomiting,
hematemesis, melena, hematochezia,
anemic symptoms
• Past medical history: Liver cirrhosis, use
of non-steroidal anti-inflammatory drugs
• Signs: Hypotension, tachycardia, pallor,
altered mental status, melena or blood
per rectum, decreased urine output
• Bloods: Anemia, raised urea, high urea
to creatinine ratio
• Endoscopy: Ulcers, varices, Mallory-
Weiss tear, erosive disease, neoplasms,
vascular ectasia, and vascular
malformations
• Epidemiology
• 48 to 160 cases per 100 000 adults per
year
• Mortality generally from 6% to 14%
Barkun et al. Ann Intern Med
2010;152:101-13.

3. US KSA
Annual incidence:
100 per 100,000 adults
Peptic ulcer was the most common
cause
Annual incidence:
31 per 100,000
The most common cause esophageal
varices
duodenal ulcer
Longstreth GF. Am J Gastroenterol 1995; 90:206
Ahmed ME et al. J R Coll Physicians Lond 1997; 31 (1):62-4
Alam MK. Saudi J gastroenterol 2000;6:87-91
Al Karawi MA et al. Ann Saudi Med 1995;

5. MANAGEMENT STEP
INITIAL ASSESSMENT. HAEMODYNAMIC STATUS
AND RESUSCITATION.
BLOOD TRANSFUSIONS. RISK ASSESSMENT AND
STRATIFACTION.
PREENDOSCOPIC
MEDICAL THERAPY.
POST ENDOSCOPY. ENDOSCOPIC THERAPY

6. Early intensive hemodynamic resuscitation of patients with acute UGIB has been shown to
significantly decrease mortality
The role of transfusion in clinically stable patients with mild GI bleeding remains
controversial, with uncertainty at which hemoglobin level transfusion should be initiated
Literature suggesting poor outcomes in patients managed with a liberal transfusion
The restrictive RBC transfusion had significantly improved survival and reduced rebleeding
Baradarian R et al. Am J Gastroenterol 2004; 99: 619 – 622
Marik PE, Corwin HL. Crit Care Med 2008; 36: 2667 – 2674
Restellini S, Kherad O, Jairath V et al. Aliment Pharmacol Ther 2013; 37: 316 – 322
Villanueva C, Colomo A, Bosch A et al. N Engl J Med 2013; 368: 11 – 21

9. Hearnshaw et al. Aliment Pharmacol Ther 2010;32:215-24.
RiskStratification

11. RISK STRATIFICATION (CONT’D)
GBS (Glasgow-Blatchford score)
• Patients with Score of 2 or less can be safely
discharged for out patient management
• Scores of more than 6 are associated with the
need for transfusion of blood products and
urgent inpatient investigation
Mart Schiefer et al. European Journal of Gastroenterology &
Hepatology 2012,24:382–387
J Stevenson, K Bowling et al. Gut 2013;62:A21-A22
Rockall Score
Can predict rebleeding, surgery and
mortality
But cannot be used to identify safely
those suitable for outpatient
endoscopy
Chang-Yuan Wang et al. World J Gastroenterol 2013 Jun 14; 19(22):
3466-3472

12. RISK
STRATIFACTION
( CONTD)
GBS vs Rockall
• GBS is more sensitive in
identifying low risk
patients suitable for
out-patient management
• GBS is superior to
Rockall score in
predicting need for
transfusion and
intervention
• The GBS is as effective
as the Rockall score in
predicting mortalitiy
Stanley AJ. World J Gastroenterol 2012; 18(22): 2739-2744
J. Stanley et al. Aliment Pharmacol Ther 2011; 34: 470–475
GBS vs AIMS65
• The GBS has superior
sensitivity in identifying
patients who were not likely
to require interventions or
emergency endoscopy
• The GBS is superior for
predicting blood
transfusion
• The AIMS65 score is
superior to the GBS in
predicting inpatient
mortality

13.  Pre-endoscopic therapy
Nasogastric aspirate is useful in predicting
high-risk lesions
(bloody NGT aspirate > high-risk lesions)
 Aliebreen AM, Fallone CA, Barkun AN. Gastrointest
Endosc 2004; 59:

14. Pre-endoscopic therapy
PPI treatment initiated before endoscopy
reduce requirement for endoscopic therapy
Sreedharan A, Martin J, Leontiadis Gl et al. Cochrane Database Svst Rev 2010 (7):
CD005415Gl Leontiadis, A Sreedharan et al. Health Technology Assessment 2007; Vol. 11:
No. 51Lau JY, Leung WK, Wu JCY et al. N Eng Med 2007;356:1631-40
This Photo by Unknown Author is licensed under CC BY

15. Timing of endoscopy
Early endoscopy
Aids risk stratification
Reduces hospitalization,
Increase use of therapeutic endoscopy
No evidence exists that very early endoscopy (within a few hours of presentation) can
improve clinical outcomes
Most patients with acute UGIB can be effectively managed by endoscopy within 24 h
 Tsoi KKF, Ma TKW, Sung JJY. Gastroenterol Hepatol 2009; 6: 463 -

17. Admission to a ICU
For at least the first 24 hours
on the basis of risk or clinical
condition
Hemodynamic instability
Increasing age
Severe comorbidity
Active bleeding at endoscopy
Large ulcer size (>2 cm)
 Barkun et al. Ann Intern
Med

18. Percutaneous or transcatheter arterial embolization
Technical success range from 52% to 98%
Recurrent bleeding in about 10% to 20%
Complications include
Bowel ischemia
Secondary duodenal stenosis
Gastric, hepatic, and splenic infarction
A second attempt at endoscopic therapy remains the preferred
strategy
Barkun et al. Ann Intern Med

20. GUIDELINE
STATEMENTS AND
RECOMMENDATIONS.
DIAGNOSIS AND
MANAGEMENT OF
NONVARICEAL UPPER
GASTROINTESTINAL
HEMORRHAGE:
European Society of
Gastrointestinal
Endoscopy (ESGE)
Guideline

21. INITIAL PATIENT EVALUATION
AND HEMODYNAMIC
RESUSCITATION
1 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).
2 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).

22. RISK
STRATIFICATION
3 ESGE recommends the use of a validated risk
stratification tool to stratify patients into high
and low risk groups. Risk stratification can aid
clinical decision making regarding timing of
endoscopy and hospital discharge (strong
recommendation, moderate quality evidence).
4 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).

23. PRE-ENDOSCOPY
MANAGEMENT
5 For patients taking vitamin K antagonists (VKAs), ESGE
recommends withholding the VKA and correcting coagulopathy while
taking into account the patient's cardiovascular risk in consultation
with a cardiologist. In patients with hemodynamic instability,
administration of vitamin K, supplemented with intravenous
prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP)
if PCC is unavailable, is recommended (strong recommendation, low
quality evidence).
6 If the clinical situation allows, ESGE suggests an international
normalized ratio (INR) value < 2.5 before performing endoscopy with
or without endoscopic hemostasis (weak recommendation, moderate
quality evidence).
7 ESGE recommends temporarily withholding new direct oral
anticoagulants (DOACs) in patients with suspected acute NVUGIH in
coordination/consultation with the local hematologist/cardiologist
(strong recommendation, very low quality evidence).
8 For patients using antiplatelet agents, ESGE recommends the
management algorithm detailed (strong recommendation, moderate
quality evidence).
9 ESGE recommends initiating high dose intravenous proton pump
inhibitors (PPI), intravenous bolus followed by continuous infusion

25. 10 ESGE does not recommend the use of tranexamic acid in patients with NVUGIH (strong
recommendation, low quality evidence).
11 ESGE does not recommend the use of somatostatin, or its analogue octreotide, in
patients with NVUGIH (strong recommendation, low quality evidence).
12 ESGE recommends intravenous erythromycin (single dose, 250mg given 30 – 120
minutes prior to upper 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). Metoclopramide??
13 ESGE does not recommend the routine use of nasogastric or orogastric
aspiration/lavage in patients presenting with acute UGIH (strong recommendation,
moderate quality evidence).
14 In an effort to protect the patient's airway from potential aspiration of gastric contents,
ESGE suggests endotracheal intubation prior to endoscopy in patients with ongoing active
hematemesis, encephalopathy, or agitation (weak recommendation, low quality evidence).

26. 15 ESGE recommends adopting the following definitions regarding the timing of
upper GI endoscopy in acute overt UGIH relative to patient presentation: very early <
12 hours, early ≤ 24 hours, and delayed > 24 hours (strong recommendation,
moderate quality evidence).
16 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).
 17 ESGE recommends the availability of both an on-call GI endoscopist proficient in
endoscopic hemostasis and on-call nursing staff with technical expertise in the use of
endoscopic devices to allow performance of endoscopy on a 24 /7 basis (strong

27. ENDOSCOPIC
THERAPY (PEPTIC
ULCER BLEEDING)
18 ESGE recommends that peptic ulcers with spurting or oozing
bleeding or with a nonbleeding visible vessel receive endoscopic
hemostasis because these lesions are at high risk for persistent
bleeding or rebleeding (strong recommendation, high quality
evidence).
19 ESGE recommends that peptic ulcers with an adherent clot be
considered for endoscopic clot removal. Once the clot is removed,
any identified underlying active bleeding or nonbleeding visible
vessel should receive endoscopic hemostasis (weak
recommendation, moderate quality evidence).
20 In patients with peptic ulcers having a flat pigmented spot or
clean base 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).
21 ESGE does not recommend the routine use of Doppler
ultrasound or magnification endoscopy in the evaluation of
endoscopic stigmata of peptic ulcer bleeding (strong
recommendation, low quality evidence).
22 For patients with actively bleeding ulcers ESGE recommends
combining epinephrine injection with a second hemostasis

28. INITIAL PATIENT EVALUATION
AND HEMODYNAMIC
RESUSCITATION
24 For patients with nonbleeding visible vessel
,ESGE recommends mechanical therapy,
thermal therapy, or injection of a sclerosing
agent as monotherapy or in combination with
epinephrine injection. ESGE recommends that
epinephrine injection therapy not be used as
endoscopic monotherapy (strong
recommendation, high quality evidence).
25 For patients with active NVUGIH bleeding
not controlled by standard endoscopic
hemostasis therapies, ESGE suggests the use
of a topical hemostatic spray as salvage
endoscopic therapy (weak recommendation,
low quality evidence).

29. ENDOSCOPIC THERAPY
(OTHER CAUSES OF
NVUGIH)
26 For patients with acid-related causes of NVUGIH different from
peptic ulcers (e. g., erosive esophagitis, gastritis, duodenitis), ESGE
recommends treatment with high dose PPI. Endoscopic hemostasis
is usually not required and selected patients may be discharged
early (strong recommendation, low quality evidence).
27 ESGE recommends that patients with a Mallory – Weiss lesion
that is actively bleeding receive endoscopic hemostasis. There is
currently inadequate evidence to recommend a specific endoscopic
hemostasis modality. Patients with a Mallory – Weiss lesion and no
active bleeding can receive high dose PPI therapy alone (strong
recommendation, moderate quality evidence).
28 ESGE recommends that a Dieulafoy lesion receive endoscopic
hemostasis using thermal, mechanical (hemoclip or band ligation),
or combination therapy (dilute epinephrine injection combined
with contact thermal or mechanical therapy) (strong
recommendation, moderate quality evidence). Transcatheter
angiographic embolization (TAE) or surgery should be considered
if endoscopic treatment fails or is not technically feasible (strong
recommendation, low quality evidence).
29 In patients bleeding from upper GI Angio ectasias, ESGE
recommends endoscopic hemostasis therapy. However, there is
currently inadequate evidence to recommend a specific endoscopic
hemostasis modality (strong recommendation, low quality
evidence).

30. ENDOSCOPY/ENDOSCOPIC
HEMOSTASIS
MANAGEMENT
31 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 (80mg then 8mg /hour) for 72 hours post endoscopy
(strong recommendation, high quality evidence).
32 ESGE suggests considering PPI therapy as intermittent
intravenous bolus dosing (at least twice-daily) for 72 hours post
endoscopy for patients who receive endoscopic hemostasis and for
patients with adherent clot not receiving endoscopic hemostasis. If
the patient’s condition permits, high dose oral PPI may also be an
option in those able to tolerate oral medications (weak
recommendation, moderate quality evidence).
33 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).
34 ESGE does not recommend routine second-look endoscopy as
part of the management of NVUGIH. However, second-look
endoscopy may be considered in selected patients at high risk for
rebleeding (strong recommendation, high quality evidence).
35 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

31. 36 ESGE recommends restarting anticoagulant therapy following
NVUGIH in patients with an indication for long-term anticoagulation.
The timing for resumption of anticoagulation should be assessed on a
patient-by-patient basis. Resuming warfarin between 7 and 15 days
following the bleeding event appears safe and effective in preventing
thromboembolic complications for most patients. Earlier resumption,
within the first 7 days, may be indicated for patients at high
thrombotic risk (strong recommendation, moderate quality evidence).
37 In patients receiving low dose aspirin for primary cardiovascular
prophylaxis who develop peptic ulcer bleeding, ESGE recommends
withholding aspirin, re-evaluating the risks/benefits of ongoing
aspirin use in consultation with a cardiologist, and resuming low dose
aspirin following ulcer healing or earlier if clinically indicated (strong
recommendation, low quality evidence).
38 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 In patients with high-risk peptic ulcer, early
reintroduction of aspirin by day 3 after index endoscopy is
recommended, provided that adequate hemostasis has been
established (strong recommendation, moderate quality evidence).
39 In patients receiving dual antiplatelet therapy (DAPT) who develop
peptic ulcer bleeding, ESGE recommends continuing low dose aspirin
therapy. Early cardiology consultation should be obtained regarding
the timing of resuming the second antiplatelet agent (strong
recommendation, low quality evidence).
40 In patients requiring dual antiplatelet therapy (DAPT) and who

32. BLEEDING PEPTIC ULCER
CLINICAL PRACTICE
GUIDELINES (2020)
bleeding peptic ulcer clinical practice guidelines were
released in January 2020 by the World Society of
Emergency Surgery WSES.
The recommended biochemical and imaging/procedural investigations in
the diagnosis of suspected bleeding peptic ulcer are as follows:
 Blood-typing; hemoglobin, hematocrit, and electrolyte values; and
coagulation assessment
 Performing endoscopy as soon as possible, particularly in high-risk patients
(Management decisions can be guided based on the damage noted from
recent hemorrhage during endoscopy, as this can help predict further
bleeding risk.)
The recommended parameters for evaluation at emergency department
referral and the criteria for defining an unstable patient are as follows:
 Rapid, careful medical/surgical evaluation to prevent further bleeding and
reduce mortality
 Upon emergency department referral, evaluation of signs, symptoms, and
laboratory findings to assess stability versus instability
 Evaluation according to Rockall and Glasgow-Blatchford scoring systems to
assess disease severity and guide therapy

33. The recommended nonoperative and endoscopic
strategies in patients with bleeding peptic ulcer are as
follows:
 Nonoperative management as first-line management
after endoscopy
 Endoscopic treatment to achieve hemostasis and to
help prevent rebleeding, the need for surgery, and
mortality
 Administration of pre-endoscopy erythromycin
 Initiation of proton-pump inhibitor therapy as soon
as possible
 Post successful endoscopic hemostasis, high-dose
proton-pump inhibitor therapy as a continuous
infusion for the first 72 hours
 Proton-pump inhibitor therapy for 6-8 weeks
following endoscopic treatment
 (Long-term proton-pump inhibitor therapy is not
recommended except in patients with ongoing
NSAID use.)
Indications for surgical treatment and the appropriate
approach for surgery in patients with bleeding peptic
ulcer are as follows:
 Surgical hemostasis, or, if equipment and qualified
personnel are available, angiographic embolization,
after failure of repeated endoscopy
 Refractory bleeding peptic ulcer: Surgical
intervention with open surgery

34. WSES Guidelines contd:
Indications for antimicrobial therapy and for Helicobacter
pylori testing in patients with bleeding peptic ulcer are as
follows:
 Empirical antimicrobial therapy not recommended
 H pylori testing in all patients
 If positive for H pylori, eradication therapy recommended
 First-line eradication therapy: Standard triple therapy (ie,
amoxicillin, clarithromycin, proton-pump inhibitor)
 First-line therapy if high clarithromycin resistance detected:
Ten-day sequential therapy with four drugs (ie, amoxicillin,
clarithromycin, metronidazole, proton-pump inhibitor)
 Second-line therapy if first-line failed: Ten-day levofloxacin-
amoxicillin triple therapy
 Start standard triple therapy after 72-96 hours of intravenous
proton-pump inhibitor, for 14-day duration

35. Medication Summary
Rebleeding in patients with upper gastrointestinal (GI)
hemorrhage (UGIB) is associated with increased morbidity
and mortality; therefore, prevention of rebleeding is the
major goal of therapy.
Proton pump inhibitors (PPIs)
There are two approved intravenous (IV) PPIs in use in the
United States, pantoprazole (Protonix IV formulation) and
esomeprazole magnesium (Nexium IV formulation).
These agents suppress gastric acid secretion by specifically
inhibiting the H+/K+/ATPase enzyme system at the
secretory surface of gastric parietal cells.
Use of the IV preparation has been studied only for short-
term therapy (ie, 7-10 d) and may be a useful adjunct via
stabilization of the clot by increasing intragastric pH. High-
dose IV treatment is the norm; however, high-dose oral
therapy may be able to maintain the intragastric pH at
about 6 as well.
In severe acute upper GI bleeding (UGIB), IV proton pump
inhibition should be initiated once the patient's
hemodynamic status has been addressed and appropriate
resuscitation measures have been implemented.
The use of H2-receptor antagonists has not been shown to
be effective in altering the course of UGIB. A meta-analysis
concluded that there was a possible minor benefit with
intravenous H2 antagonists in bleeding gastric ulcers but
no benefit in duodenal ulcers.

36. Aspirin, NSAIDs, and anti-thrombotics
Aspirin and nonsteroidal anti-inflammatory agents (NSAIDs) are
very common causes of ulcer bleeding. Antiplatelet drugs are
often associated with an increased severity of UGIB and may
pose unique challenges in management.
Discontinue NSAIDs when feasible in patients with bleeding
from gastric or duodenal ulcers. Selective cyclooxygenase
(COX)-2 inhibitors could be substituted, with a reduction in the
risk of recurrent ulcer bleeding. Continued concomitant use of
PPIs also reduces the risk of recurrent ulcer bleeding.
Take into account concerns for an associated risk of increased
cardiovascular and/or cerebrovascular side effects in patients
taking selective COX-2 inhibitors and the potential side effects
associated with long-term PPI use when managing relative risk
reduction
As noted earlier, al-Assi et al demonstrated that the
combination of H pylori infection and NSAID use may increase
the risk of ulcer hemorrhage; however, the treatment of H
pylori in patients who are taking NSAIDs remains controversial.
In general, aspirin and antithrombotic agents should be
withheld until the bleeding is controlled, particularly if serious
or life-threatening bleeding is apparent. In patients with
significant risk factors or known cardiovascular indications for
antithrombotic use, however, these agents should be started
back as soon as possible. A study by Sung et al showed that in
patients who had their aspirin held after treatment for a
bleeding peptic ulcer, there was a clear increase in 30-day
mortality, whereas those who continued taking their aspirin
had no increased risk of postprocedure bleeding.
Iron supplementation
Iron supplementation therapy is commonly used for anemia
following UGIB. Oral iron and parenteral iron are both effective
when compared with placebo.
GI tolerance, cost, and availability should be considered when
determining the best regimen for supplementation, if utilized.

37. H pylori eradication:
Eradication of H pylori can reduce the risk of rebleeding.
The treatment regimens approved by FDA have 70%-90% H
pylori eradication rates. The common regimens of “triple
therapy” with a PPI, clarithromycin, and amoxicillin, or
bismuth “quadruple therapy” consisting of a PPI, bismuth,
tetracycline, and a nitroimidazole for 10-14 days remain as
options for first-line therapy.
Clarithromycin resistance should be taken into
consideration, as should previous macrolide exposure and
penicillin allergy when considering a H pylori eradication
regimen.
The 2017 American College of Gastroenterology (ACG)
clinical guideline endorses additional regimens as potential
first-line H pylori eradication therapy as follows :
 Sequential therapy: A PPI and amoxicillin for 5-7 days,
followed by a PPI, clarithromycin, and a nitroimidazole
for 5-7 days
 Hybrid therapy: A PPI and amoxicillin for 7 days,
followed by a PPI, amoxicillin, clarithromycin, and a
nitroimidazole for 7 days
 Fluoroquinolone sequential therapy: A PPI and
amoxicillin for 5-7 days, followed by a PPI,
fluoroquinolone, and nitroimidazole for 5-7 days

38. Bleeding peptic ulcer: WSES guidelines
Diagnosis
In patients with suspected bleeding peptic
ulcer, which biochemical and imaging
investigations should be requested?
In patients with suspected bleeding peptic
ulcer, we recommend blood-typing,
determinations of hemoglobin, hematocrit
and electrolytes, and coagulation
assessment (strong recommendation based
on very low-quality evidences, 1D).
In patients with suspected bleeding peptic
ulcer, what is the diagnostic role of
endoscopy?
In patients with suspected bleeding peptic,
ulcer, we recommend performing
endoscopy as soon as possible, especially
in high-risk patients (Strong
recommendation based on low-quality

39. In patients with bleeding peptic ulcer, are the
endoscopic findings useful to determine the risk for
rebleeding and how do they affect the clinical
management?
We suggest guiding management decisions according
to stigmata of recent hemorrhage during endoscopy
because they can predict the risk of further bleeding
(strong recommendation based on low-quality
evidences, 1C)
Resuscitation
In patients with bleeding peptic ulcer, which
parameters should be evaluated at ED referral and
which criteria should be adopted to define an
unstable patient?
We recommend a rapid and careful surgical/medical
evaluation of bleeding peptic ulcer disease patients
to prevent further bleeding and to reduce mortality
(strong recommendation based on very low-quality
evidences, 1D)
We recommend evaluating several elements
(symptoms, signs, and laboratory findings) to assess
the stability/instability of patients with bleeding

40. In patients with bleeding peptic ulcer, which are the appropriate
targets for resuscitation (hemoglobin level, blood pressure/heart rate,
lactates level, others)?
We recommend several resuscitation targets, similar to those of
damage control resuscitation in the bleeding trauma patient (weak
recommendation based on low-quality evidences, 1C).
In patients with bleeding peptic ulcer, we recommend to maintain an
Hb level of at least > 7g/dl during the resuscitation phase (strong
recommendation based on moderate-quality evidences, 1B).
Resuscitation must proceed simultaneously with endoscopic and
surgical procedures .
A rapid ABC (airway, breathing, and circulation) evaluation should be
done immediately. Appropriate targets for resuscitation in bleeding
peptic ulcer patients can be considered the same used in bleeding
trauma patients (systolic blood pressure of 90–100mmHg until major
bleeding has been stopped; normalization of lactate and base deficit;
hemoglobin 7–9g/dl; correction/prevention of coagulopathy); for this
reason, we refer to the abovementioned guideline Regarding
hemoglobin level, a randomized controlled trial comparing the efficacy
and safety of a restrictive transfusion strategy (transfusion with an Hb
> 7g/dl) with those of a liberal transfusion strategy (transfusion with
an Hb > 9g/dl) in severe acute gastrointestinal bleeding has been
performed .The restrictive strategy, compared with the liberal strategy,

41. Non-operative management—
endoscopic treatment
In patients with bleeding peptic ulcer,
which are the indications for non-
operative management?
In patients with bleeding peptic ulcer,
we recommend non-operative
management as the first line of
management after endoscopy (strong
recommendation based on low-quality
evidences, 1C).
Non-operative management of
bleeding peptic ulcer incorporates
principles of ABCDE :
 Airway control
 Breathing—ventilation and
oxygenation
 Circulation—fluid resuscitation and
control of bleeding
 Drugs—pharmacotherapy with PPIs,
prokinetics, etc.
 Endoscopy (diagnostic and
therapeutic) or embolization
(therapeutic)
In acutely bleeding ulcers, endoscopy
is a part of resuscitation.

42. In patients with bleeding peptic ulcer, which are the
indications for endoscopic treatment?
In patients with bleeding peptic ulcer, we recommend
endoscopic treatment to achieve hemostasis and reduce
re-bleeding, the need for surgery, and mortality (strong
recommendation based on low-quality evidences, 1C).
We suggest stratifying patients based on the Blatchford
score and adopting a risk-stratified management (weak
recommendation based on very low-quality evidences, 2D):
 In the very low-risk group, we suggest outpatient
endoscopy (weak recommendation based on low-
quality evidences, 2C)
 In the low-risk group, we recommend early inpatient
endoscopy (≤ 24h of admission) (strong
recommendation based on low-quality evidences, 1C).
 In the high-risk group, we recommend urgent inpatient
endoscopy (≤ 12h of admission) (strong
recommendation based on low-quality evidences, 1C).
In patients with spurting ulcer (Forrest 1a), oozing ulcer
(Forrest 1b), and ulcer with non-bleeding visible vessel
(Forrest 2a), endoscopic hemostasis is recommended
(strong recommendation based on low-quality evidences,
1C)
In patients with bleeding peptic ulcer, we suggest dual
modality for endoscopic hemostasis (weak
recommendation based on moderate-quality evidences, 2B)

43. In patients with bleeding peptic ulcer, what is the appropriate pharmacological
regimen (erythromycin, PPI, terlipressin, others)?
In patients with bleeding peptic ulcer, we suggest administering pre-endoscopy
erythromycin (weak recommendation based on moderate-quality evidences, 2B).
In patients with bleeding peptic ulcer, we suggest starting PPI therapy as soon as
possible (weak recommendation based on moderate-quality evidences, 2B),
In patients with bleeding peptic ulcer, after successful endoscopic hemostasis, we
suggest administration of high-dose PPI as continuous infusion for the first 72h
(weak recommendation based on moderate-quality evidences, 2B).
In patients with bleeding peptic ulcer, we recommend PPI for 6–8weeks following
endoscopic treatment. Long-term PPI is not recommended unless the patient has
ongoing NSAID use (strong recommendation based on moderate-quality evidences,
1B)
In patients with recurrent bleeding from peptic ulcer, what is the role of non-
operative management?
In patients with recurrent bleeding from peptic ulcer, we recommend endoscopy as a
first-line treatment (strong recommendation based on low-quality evidences, 1C).
In patients with recurrent bleeding, we suggest transcatheter angioembolization as an
alternative option where resources are available (weak recommendation based on very
low-quality evidences, 2D).

44. Angiography, embolization
In patients with bleeding peptic ulcer, which are the indications for
angiography?
In patients with bleeding peptic ulcer, we suggest considering angiography
for diagnostic purposes as a second-line investigation after a negative
endoscopy (weak recommendation based on low-quality evidences, 2C).
No recommendation can be made regarding the role of provocation
angiography.
Angiography may assist both the diagnosis and the treatment of hemorrhage
associated with peptic ulcer disease. However, endoscopy remains the first-
line investigation of choice for an undifferentiated upper gastrointestinal
hemorrhage Similarly, endoscopy is the first-line diagnostic modality for
patients with suspected upper gastrointestinal hemorrhage from ulcer
disease
In patients with bleeding peptic ulcer, which are the indications for
angioembolization?
In hemodinamically stable bleeding peptic ulcer patients, where endoscopic
hemostasis fails twice or is not possible/feasible, we suggest angiography
with angioembolization where technical skills and equipment are available
(weak recommendation based on very low-quality evidences, 2D)

45. Should embolization be considered for unstable patients with bleeding peptic ulcer?
We suggest against a routinely use of angioembolization unstable patients. Angioembolization in
unstable patients could be s considered only in selected cases and in selected facilities (weak
recommendation based on very low-quality evidences, 2D).
In patients with recurrent bleeding peptic ulcer, which are the indications for
angioembolization?
In patients with rebleeding peptic ulcer, we suggest angioembolization as a feasible option (weak
recommendation based on low-quality evidences, 2C).
In patients with bleeding peptic ulcer who underwent angioembolization, which are the
most appropriate embolization techniques and materials?
Varied techniques and materials exist for the use in the embolization of bleeding duodenal ulcer
disease. A tailored approach, guided by the multidisciplinary team, incorporating patient, pathology,
and environmental factors is suggested (weak recommendation based on low-quality evidences, 2C).
In patients with bleeding peptic ulcer and non-evident bleeding during angiography, is
there a role for prophylactic embolization?
No recommendation can be made on the role of prophylactic embolization.

46. Surgery
In patients with bleeding peptic ulcer, which are the indications for surgical treatment and which is the appropriate
timing for surgery?
In patients with bleeding peptic ulcer, we suggest surgical hemostasis (or angiographic embolization if immediately
available and with appropriate skills) after failure of repeated endoscopy. In patients with hypotension and/or
hemodynamic instability and/or ulcer larger than 2 cm at first endoscopy, we suggest surgical intervention without
repeated endoscopy (strong recommendation based on very low-quality evidences, 1D).
In patients with bleeding peptic ulcer, what is the most appropriate surgical approach (open vs laparoscopy) and
what are the most appropriate surgical procedures?
In patients with refractory bleeding peptic ulcer, we suggest surgical intervention with open surgery (weak
recommendation based on very low-quality evidences, 2D).
In patients operated for bleeding peptic ulcer, we suggest intra-operative endoscopy to facilitate the localization of the
bleeding site (weak recommendation based on very low-quality evidences, 2D).
We suggest choosing the surgical procedure according to the location and extension of the ulcer and the characteristics of
the bleeding vessel (weak recommendation based on low-quality evidences, 2C)
An immediate or delayed biopsy is recommended (weak recommendation based on low-quality evidences, 2C)
A refractory bleeding peptic ulcer is defined as an ulcer still bleeding after repeated endoscopy/angioembolization. Open surgery is
recommended when endoscopic treatments have failed and there is evidence of ongoing bleeding, plus or minus hemodynamic
instability. The choice of the appropriate surgical procedure for bleeding peptic ulcer should be made on the basis of the location and
extension of the ulcer and the characteristics of the bleeding vessel. Surgical approach involves ulcer oversew or resection. Bleeding
gastric ulcers should be resected or at least biopsied for the possibility of neoplasms. Conversely, most duodenal ulcers requiring surgery
for persistent bleeding are usually large and posterior lesions, and the bleeding is often from the gastro-duodenal artery.

47. Antimicrobial therapy
In patients with bleeding peptic ulcer, which are the indications for
antimicrobial therapy and for Helicobacter pylori testing?
In patients with bleeding peptic ulcer, empirical antimicrobial therapy
is not recommended (strong recommendation based on low-quality
evidences, 1C)
We recommend performing Helicobacter pylori testing in all patients
with bleeding peptic ulcer (strong recommendation based on low-
quality evidences, 1C).
In patients with bleeding peptic ulcer and positive tests for HP
infection, which are the therapeutic options?
In H. pylori-positive, eradication therapy is recommended to avoid
recurrent bleeding (strong recommendation based on low-quality
evidences, 1C)
In patients with HP positive tests, standard triple therapy (amoxicillin,
clarithromycin, and PPI) regimen is recommended as first-line
therapy if low clarithromycin resistance is present (strong
recommendation based on moderate-quality evidences, 1B)
10days of sequential therapy with four drugs (amoxicillin,
clarythromicin, metronidazole, and PPI) is recommended in selected
cases, if compliance to the scheduled regimen can be maintained,
and if clarithromycin high resistance is detected (strong
recommendation based on low-quality evidences, 1C).
In patients with HP positive tests, a 10-day levofloxacin-amoxicillin
triple therapy is recommended as second-line therapy if first-line
therapy failed (strong recommendation based on moderate-quality
evidences, 1B).
We recommend to start standard triple therapy (STT) after 72–96h of
intravenous administration of PPI and to administer it for 14days
(strong recommendation based on low-quality evidences, 1C)

48. Conclusions:
Resuscitation should be initiated prior to any
diagnostic procedure .
Gastrointestinal endoscopy allows visualization of
the stigmata, accurate assessment of the level of
risk and treatment of the underlying lesion .
Intravenous PPI therapy after endoscopy is crucial to
decrease the recurrence of bleeding .
Helicobacter pylori testing should be performed in
the acute setting .

49. Institutions
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
3 Gedyt Endoscopy Center, Buenos Aires, Argentina
4 Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC University
Medical Center, Rotterdam, The Netherlands
5 University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, Spain
6 Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom
7 Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del Greco, Italy
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3 Guyatt GH, Oxman AD, Vist GE et al. GRADE: an emerging consensus on rating quality of
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50. Thank
s for
your