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Endoscopic Diagnosis and Management of Nonvariceal Upper Guidelines Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021 Authors Ian M. Gralnek1, 2,AdrianJ.Stanley3, A. John Morris3, Marine Camus4,JamesLau5,AngelLanas6,StigB.Laursen7 , Franco Radaelli8, Ioannis S. Papanikolaou9, Tiago Cúrdia Gonçalves10,11,12,MarioDinis-Ribeiro13,14,HalimAwadie1 , Georg Braun15, Nicolette de Groot16, Marianne Udd17, Andres Sanchez-Yague18, 19,ZivNeeman2,20,JeaninE.van Hooft21 Institutions 17 Gastroenterological Surgery, University of Helsinki and 1 Institute of Gastroenterology and Hepatology, Emek Helsinki University Hospital, Helsinki, Finland Medical Center, Afula, Israel 18 Gastroenterology Unit, Hospital Costa del Sol, 2 Rappaport Faculty of Medicine, Technion-Israel Marbella, Spain Institute of Technology, Haifa, Israel 19 Gastroenterology Department, Vithas Xanit 3 Department of Gastroenterology, Glasgow Royal International Hospital, Benalmadena, Spain Infirmary, Glasgow, UK 20 Diagnostic Imaging and Nuclear Medicine Institute, 4 Sorbonne University, Endoscopic Unit, Saint Antoine Emek Medical Center, Afula, Israel Hospital Assistance Publique Hopitaux de Paris, Paris, 21 Department of Gastroenterology and Hepatology, France Leiden University Medical Center, Leiden, The 5 Department of Surgery, Prince of Wales Hospital, The Netherlands Chinese University of Hong Kong, Hong Kong SAR, China published online 10.2.2021 6 Digestive Disease Services, University Clinic Hospital, University of Zaragoza, IIS Aragón (CIBERehd), Spain Bibliography 7 Department of Gastroenterology, Odense University Endoscopy 2021; 53: 300–332 Hospital, Odense, Denmark DOI 10.1055/a-1369-5274 8 Department of Gastroenterology, Valduce Hospital, ISSN 0013-726X Como, Italy © 2021. European Society of Gastrointestinal Endoscopy 9 Hepatogastroenterology Unit, Second Department of All rights reserved. Internal Medicine – Propaedeutic, Medical School, This article ist published by Thieme. National and Kapodistrian University of Athens, Attikon Georg Thieme Verlag KG, Rüdigerstraße 14, University General Hospital, Athens, Greece 70469 Stuttgart, Germany 10 Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal Supplementary material 11 School of Medicine, University of Minho, Braga/ Supplementary material is available under Guimarães, Portugal https://doi.org/10.1055/a-1369-5274 12 ICVS/3B’s–PT Government Associate Laboratory, Braga/Guimarães, Portugal 13 Center for Research in Health Technologies and Corresponding author Information Systems (CINTESIS), Faculty of Medicine, Ian M. Gralnek, MD MSHS, Rappaport Faculty of Medicine, Porto, Portugal Technion-Israel Institute of Technology, Institute of 14 Gastroenterology Department, Portuguese Oncology Gastroenterology and Hepatology, Emek Medical Center, Institute of Porto, Portugal Afula, Israel 18101 15 Medizinische Klinik 3, Universitätsklinikum Augsburg, [email protected] Augsburg, Germany. 16 Red Cross Hospital Beverwijk, Beverwijk, The Netherlands Gralnek Ian M et al. Endoscopic diagnosis and … Endoscopy 2021; 53| © 2021. European Society of Gastrointestinal Endoscopy. All rights reserved. MAIN RECOMMENDATIONS 7 ESGE suggests that in patients with persistent bleeding 1 ESGE recommends in patients with acute upper gastro- refractory to standard hemostasis modalities, the use of a intestinal hemorrhage (UGIH) the use of the Glasgow– topical hemostatic spray/powder or cap-mounted clip Blatchford Score (GBS) for pre-endoscopy risk stratification. should be considered. Patients with GBS≤ 1 are at very low risk of rebleeding, mor- Weak recommendation, low quality evidence. tality within 30 days, or needing hospital-based interven- tion and can be safely managed as outpatients with out- 8 ESGE recommends that for patients with clinical evidence patient endoscopy. of recurrent peptic ulcer hemorrhage, use of a cap-mounted Strong recommendation, moderate quality evidence. clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angio- 2 ESGE recommends that in patients with acute UGIH who graphic embolization (TAE) should be considered. Surgery are taking low-dose aspirin as monotherapy for secondary is indicated when TAE is not locally available or after failed cardiovascular prophylaxis, aspirin should not be interrup- TAE. ted. If for any reason it is interrupted, aspirin should be re- Strong recommendation, moderate quality evidence. started as soon as possible, preferably within 3–5days. Strong recommendation, moderate quality evidence. 9 ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis 3 ESGE recommends that following hemodynamic resusci- and for patients with FIIb ulcer stigmata (adherent clot) tation, early (≤ 24 hours) upper gastrointestinal (GI) endos- not treated endoscopically. copy should be performed. (a) PPI therapy should be administered as an intravenous Strong recommendation, high quality evidence. bolus followed by continuous infusion (e.g., 80mg then 8mg/hour) for 72 hours post endoscopy. 4 ESGE does not recommend urgent (≤ 12 hours) upper GI (b) High dose PPI therapies given as intravenous bolus dos- endoscopy since as compared to early endoscopy, patient ing (twice-daily) or in oral formulation (twice-daily) can be outcomes are not improved. considered as alternative regimens. Strong recommendation, high quality evidence. Strong recommendation, high quality evidence. 5 ESGE recommends for patients with actively bleeding ul- 10 ESGE recommends that in patients who require ongoing cers (FIa, FIb), combination therapy using epinephrine in- anticoagulation therapy following acute NVUGIH (e.g., jection plus a second hemostasis modality (contact thermal peptic ulcer hemorrhage), anticoagulation should be re- or mechanical therapy). sumed as soon as the bleeding has been controlled, prefer- Strong recommendation, high quality evidence. ably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct 6 ESGE recommends for patients with an ulcer with a non- oral anticoagulants (DOACS), as compared to vitamin K an- bleeding visible vessel (FIIa), contact or noncontact thermal tagonists (VKAs), must be considered in this context. therapy, mechanical therapy, or injection of a sclerosing Strong recommendation, low quality evidence. agent, each as monotherapy or in combination with epine- phrine injection. Strong recommendation, high quality evidence. SOURCE AND SCOPE Introduction This Guideline is an official statement from the European The most common causes of acute upper gastrointestinal he- Society of Gastrointestinal Endoscopy (ESGE). It is an up- morrhage (UGIH) are nonvariceal. These include gastric and date of the previously published 2015 ESGE Clinical duodenal peptic ulcers, mucosal erosive disease of the esopha- Guideline addressing the role of gastrointestinal endos- gus/stomach/duodenum, malignancy, Mallory–Weiss syn- copy in the diagnosis and management of acute nonvari- drome, Dieulafoy lesion, “other” diagnosis, or no identifiable ceal upper gastrointestinal hemorrhage (NVUGIH). The cause [1]. This ESGE Guideline focuses on the pre-endoscopic, evidence statements and recommendations specifically endoscopic, and post-endoscopic management of patients pre- pertaining to endoscopic hemostasis therapies are lim- senting with acute nonvariceal upper gastrointestinal hemor- ited to peptic ulcer hemorrhage. Endoscopic hemostasis rhage (NVUGIH), specifically peptic ulcer hemorrhage. therapy recommendations for nonulcer NVUGIH etiolo- gies, can be found in the 2015 ESGE Guideline. Gralnek Ian M et al. Endoscopic diagnosis and … Endoscopy 2021; 53 | © 2021. European Society of Gastrointestinal Endoscopy. All rights reserved. Guidelines ABBREVIATIONS APA antiplatelet agent NGT nasogastric tube APC argon plasma coagulation NNT number needed to treat ASA American Society of Anesthesiologists NVUGIH nonvariceal upper gastrointestinal AUROC area under receiver operating characteristic hemorrhage DAPT dual antiplatelet therapy OR odds ratio CHADS2 congestive heart failure, hypertension, age OTS over-the-scope ≥ 75 years, diabetes mellitus, and previous PCC prothrombin complex concentrate stroke or transient ischemic attack [risk score] PCI percutaneous coronary intervention CI confidence interval PICO patients, interventions, controls, outcomes DOAC direct oral anticoagulant PNED Progetto Nazionale Emorragia Digestive ESGE European Society of Gastrointestinal PPI proton pump inhibitor Endoscopy PUB peptic ulcer bleeding FFP freshfrozenplasma RBC red blood cell GBS Glasgow–Blatchford Score RCT randomized controlled trial GI gastrointestinal RD risk difference GRADE Grading of Recommendations Assessment, RR relative risk or risk ratio Development and Evaluation TAE transcatheter angiographic embolization HR hazard ratio TTS through-the-scope ICU intensive care unit TXA tranexamic acid INR international normalized ratio UGIH upper gastrointestinal hemorrhage IRR incident rate ratio VKA vitamin K antagonist NBVV nonbleeding visible vessel The results of the literature search and answers to PICO Methods questions were presented to all guideline group members dur- ESGE commissioned this Guideline (ESGE Guideline Committee ing two online face-to-face meetings conducted on June 27 and chair, J.V.H.) and appointed a guideline leader (I.M.G.). The 28, 2020.Subsequently,
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