PMID- 26417980
OWN - NLM
STAT- MEDLINE
DCOM- 20160816
LR  - 20220410
IS  - 1438-8812 (Electronic)
IS  - 0013-726X (Linking)
VI  - 47
IP  - 10
DP  - 2015 Oct
TI  - Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: 
      European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
PG  - a1-46
LID - 10.1055/s-0034-1393172 [doi]
AB  - 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).
CI  - (c) Georg Thieme Verlag KG Stuttgart . New York.
FAU - Gralnek, Ian M
AU  - Gralnek IM
AD  - Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, 
      Israel.
FAU - Dumonceau, Jean-Marc
AU  - Dumonceau JM
AD  - Gedyt Endoscopy Center, Buenos Aires, Argentina.
FAU - Kuipers, Ernst J
AU  - Kuipers EJ
AD  - Departments of Internal Medicine and Gastroenterology and Hepatology, Erasmus MC 
      University Medical Center, Rotterdam, The Netherlands.
FAU - Lanas, Angel
AU  - Lanas A
AD  - University of Zaragoza, Aragon Health Research Institute (IIS Aragon), CIBERehd, 
      Spain.
FAU - Sanders, David S
AU  - Sanders DS
AD  - Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom.
FAU - Kurien, Matthew
AU  - Kurien M
AD  - Department of Gastroenterology, Sheffield Teaching Hospitals, United Kingdom.
FAU - Rotondano, Gianluca
AU  - Rotondano G
AD  - Division of Gastroenterology and Digestive Endoscopy, Maresca Hospital, Torre del 
      Greco, Italy.
FAU - Hucl, Tomas
AU  - Hucl T
AD  - Department of Gastroenterology and Hepatology, Institute for Clinical and 
      Experimental Medicine, Prague, Czech Republic.
FAU - Dinis-Ribeiro, Mario
AU  - Dinis-Ribeiro M
AD  - Department of Gastroenterology, IPO Porto, Portugal and CINTESIS, Porto Faculty 
      of Medicine, Portgal.
FAU - Marmo, Riccardo
AU  - Marmo R
AD  - Division of Gastroenterology, Hospital Curto, Polla, Italy.
FAU - Racz, Istvan
AU  - Racz I
AD  - First Department of Internal Medicine and Gastroenterology, Petz Aladar, 
      Hospital, Gyor, Hungary.
FAU - Arezzo, Alberto
AU  - Arezzo A
AD  - Department of Surgical Sciences, University of Torino, Torino, Italy.
FAU - Hoffmann, Ralf-Thorsten
AU  - Hoffmann RT
AD  - Institute and Polyclinic for Diagnostic Radiology, University Hospital 
      Dresden-TU, Dresden, Germany.
FAU - Lesur, Gilles
AU  - Lesur G
AD  - Department of Gastroenterology, Ambroise Pare Hospital, Boulogne, France.
FAU - de Franchis, Roberto
AU  - de Franchis R
AD  - Department of Biomedical and Clinical Sciences, University of Milan, 
      Gastroenterology Unit, Luigi Sacco University Hospital, Milan, Italy.
FAU - Aabakken, Lars
AU  - Aabakken L
AD  - Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, 
      Norway.
FAU - Veitch, Andrew
AU  - Veitch A
AD  - Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, 
      Wolverhampton, United Kingdom.
FAU - Radaelli, Franco
AU  - Radaelli F
AD  - Department of Gastroenterology, Valduce Hospital, Como, Italy.
FAU - Salgueiro, Paulo
AU  - Salgueiro P
AD  - Department of Gastroenterology, Centro Hospitalar do Porto, Portugal.
FAU - Cardoso, Ricardo
AU  - Cardoso R
AD  - Department of Gastroenterology, Centro Hospitalar e Universitario de Coimbra, 
      Portugal.
FAU - Maia, Luis
AU  - Maia L
AD  - Department of Gastroenterology, Centro Hospitalar do Porto, Portugal.
FAU - Zullo, Angelo
AU  - Zullo A
AD  - Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
FAU - Cipolletta, Livio
AU  - Cipolletta L
AD  - Gastroenterology and Endoscopy Department, Antonio Cardarelli Hospital, Naples, 
      Italy.
FAU - Hassan, Cesare
AU  - Hassan C
AD  - Digestive Endoscopy Unit, Catholic University, Rome, Italy.
LA  - eng
PT  - Journal Article
PT  - Practice Guideline
DEP - 20150929
PL  - Germany
TA  - Endoscopy
JT  - Endoscopy
JID - 0215166
SB  - IM
MH  - *Disease Management
MH  - Endoscopy, Gastrointestinal/*standards
MH  - Europe
MH  - *Gastroenterology
MH  - Gastrointestinal Hemorrhage/*diagnosis/*therapy
MH  - Hemostasis, Endoscopic/*methods/standards
MH  - Humans
MH  - *Societies, Medical
EDAT- 2015/09/30 06:00
MHDA- 2016/08/17 06:00
CRDT- 2015/09/30 06:00
PHST- 2015/09/30 06:00 [entrez]
PHST- 2015/09/30 06:00 [pubmed]
PHST- 2016/08/17 06:00 [medline]
AID - 10.1055/s-0034-1393172 [doi]
PST - ppublish
SO  - Endoscopy. 2015 Oct;47(10):a1-46. doi: 10.1055/s-0034-1393172. Epub 2015 Sep 29.