Upper G.I bleeding- ACG clinical guideline update.

Summary of new guidelines-

For patients presenting to ER with UGIB are to be classified using risk assessment tools, and those with very low risk can be discharged with outpatient follow-up rather than admitted to the hospital.

The risk assessment score for the likelihood of intervention is the Glasgow-Blatchford score.

Risk factors at admission	Factor score
BUN- blood urea nitrogen (mg/dL)
18.2 to <22.4	2
22.4 to <28.0	3
28 to <70	4
≥70.0	6
Haemoglobin (g/dL)
12.0 to <13.0 (men); 10.0 to <12.0 (women)	1
10.0 to <12.0	3
<10.0	6
Systolic blood pressure (mm of Hg)
100-109	1
90-99	2
<90	3
Heart rate (beats per minute)
≥100	1
Melena	1
Syncope	1
Hepatic disease	2
Cardiac failure	2

Glasgow-Blatchford score

Patients with Glasgow-Blatchford score 0-1 can be discharged with outpatient follow-up rather than admission.

1. RBC transfusion- transfuse RBC if Hb<7g/dL.
2. Infusion of prokinetic before endoscopy.
   • This likely helps in propelling the blood and clot distally and helps in better visualisation of the field area.
   • Inj. Erythromycin 250mg, 20-90 min before endoscopy may reduce repeat endoscopy due to poor visualisation.
3. PPI therapy-
   • Could not recommend pre endoscopy PPI.
     • There is no enough evidence to say that pre endoscopy PPI is beneficial.
     • However, this may reduce the need for endoscopy treatment, which may be tried in resource-limited settings.
     • Hence, they didn’t go against the use of PPI’s pre endoscopy.
4. Timing of endoscopy-
   • Patients admitted with UGIB to the hospital should under UGI endoscopy within 24hrs of admission.
     • This is not easy always in all settings, in resource-limited settings, sometimes endoscopy takes more than a day after admission.
     • The potential harm in early endoscopy may include death and other complications if it is performed before resuscitation.
     • While early endoscopy may be beneficial in a way to help us make an accurate prognosis in guiding management.
     • So just making an early diagnosis doesn’t justify the early endoscopy, we have to consider benefit clinical, economical and patient-centred outcomes.
5. Endoscopy therapy- 
   • Recommended in spurting ulcers, active oozing, non-bleeding visible ulcers.
   • Could not reach recommendation for or against endoscopic therapy in patients with UGIB due to ulcers with adherent clot resistant to vigorous irrigation.
6. Choice of Endoscopic haemostatic therapy-
   • Bipolar electrocoagulation, heater probe, injection of absolute ethanol for patients with UGIB due to ulcers.  strong recommendation.
   • Clips, argon plasma coagulation, soft monopolar electrocoagulation also can be used. (low-quality evidence)
   • Epinephrine not to be used alone for patients with UGIB bleeding but with other haemostatic therapies.
   • Endoscopic haemostatic powder spray TC-325 may be used in active bleeding ulcer (low-quality ulcer).
   • Over the scope clips as a haemostatic therapy for patients who develop recurrent bleeding due to ulcers after previous successful endoscopic haemostasis.
7. High dose PPI therapy is given continuously or intermittently for 3 days after successful endoscopic haemostatic therapy of a bleeding ulcer. (strong recommendation)
   • ≥80mg daily for ≥3days of PPI, either continuously or intermittently.
   • 80mg bolus and then 8mg/hr infusion.
   • Intermittent boluses with 80mg initial bolus followed by 40mg 2-4 times daily can be used.
8. Patients with recurrent ulceration after successful endoscopic haemostatic therapy should undergo repeat endoscopy and therapy rather than surgery of transcatheter arterial embolization.
9. Failure of endoscopic haemostatic therapy should be next treated with transcatheter arterial embolization.

Summary of Guidance

Ref- ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding, Am J Gastroenterol 2021;116:899–917. https://doi.org/10.14309/ajg.0000000000001245