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 |
Patients with Glasgow-Blatchford score 0-1 can be discharged with outpatient follow-up rather than admission.
- RBC transfusion- transfuse RBC if Hb<7g/dL.
- 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.
- 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.
- Could not recommend pre endoscopy PPI.
- 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.
- Patients admitted with UGIB to the hospital should under UGI endoscopy within 24hrs of admission.
- 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.
- 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.
- 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.
- Patients with recurrent ulceration after successful endoscopic haemostatic therapy should undergo repeat endoscopy and therapy rather than surgery of transcatheter arterial embolization.
- Failure of endoscopic haemostatic therapy should be next treated with transcatheter arterial embolization.

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