Diagnosis & management of nonvariceal upper gastrointestinal hemorrhage bleeding (nvugih-nvugib) guideline 2015

D R . W A L E E D K H . S . M A H R O U S
G A S T R O E N T E R O L O G Y A N D H E P A T O L O G Y
C O N S U L T A N T
‫محروس‬ ‫خالد‬ ‫وليد‬Waleed Khalid Mahrous
D R . W A L E E D K H . S . M A H R O U S
G A S T R O E N T E R O L O G Y A N D H E P A T O L O G Y
C O N S U L T A N T
Diagnosis & Management of Nonvariceal Upper
Gastrointestinal Hemorrhage - Bleeding
(NVUGIH-NVUGIB)
Guideline
2015

NVIGIH

Main Recommendations

NVUGIH - MR1 - 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).
Nonvariceal upper gastrointestinal hemorrhage: ESGE Guideline 2015

• 46 years old male with no comorbid disease
presented to emergency department (ED) at 8 pm
with history of one day melena suggestive of acute
upper gastrointestinal bleeding , the patient vitally
stable and Hb7.4 after initial resuscitation , on call
GI teams booked the patient for early mooring EGD
as first case of the duty work endoscopy .
• Which Transfusion Strategy Is Best for Acute
Upper Gastrointestinal Bleeding in This Case ?
B - Restrict Blood transfusion until Hb <7

 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) .
NVUGIH – MR2 - 2

• 46 years old male with no comorbid disease
presented to emergency department (ED) at 8 pm
with history of one day melena suggestive of acute
upper gastrointestinal bleeding , the patient vitally
stable and Hb7.4 after initial resuscitation , on call
GI teams booked the patient for early mooring EGD
as first case of the duty work endoscopy .
• Which Transfusion Strategy Is Best for Acute
Upper Gastrointestinal Bleeding in This Case ?
A - Transfuse at lest 1 U PRBC to keep Hb 7-9

SURVIVAL IMPROVED WITH LOWER
TRANSFUSION THRESHOLD IN ACUTE UPPER
INTESTINAL BLEEDS
• 1. A restrictive transfusion strategy
(transfusion threshold at Hb=7) led to
better outcomes in patients with upper
gastrointestinal (UGI) bleeding.
• 2. This strategy reduced the risk of further
bleeding, the need for rescue therapy, and
the complication rate, all while improving
the survival rate.

WHICH TRANSFUSION STRATEGY IS BEST FOR
ACUTE UPPER GASTROINTESTINAL BLEEDING?
NEJM - Transfusion Strategies for Acute
Upper Gastrointestinal Bleeding 2013
• In the restrictive-strategy group, the hemoglobin
threshold for transfusion was 7 g per deciliter, with a
target range for the post-transfusion hemoglobin
level of 7 to 9 g per deciliter.
• In the liberal-strategy group, the hemoglobin threshold
for transfusion was 9 g per deciliter, with a target range
for the post-transfusion hemoglobin level of 9 to 11 g
per deciliter.

• In both groups, 1 unit of red cells was
transfused initially; the hemoglobin
level was assessed after the
transfusion, and an additional unit was
transfused if the hemoglobin level was
below the threshold value.

• The transfusion protocol was applied until
the patient's discharge from the hospital
or death.
• The protocol allowed for a transfusion to
be administered any time symptoms or
signs related to anemia developed,
massive bleeding occurred during follow-
up, or surgical intervention was required.

• Hemoglobin levels were measured
after admission and again every 8
hours during the first 2 days and every
day thereafter.
• Hemoglobin levels were also assessed
when further bleeding was suspected.

• All the patients underwent emergency
gastroscopy within the first 6 hours.
• When endoscopic examination disclosed a
nonvariceal lesion with active arterial bleeding, a
nonbleeding visible vessel, or an adherent clot,
patients underwent endoscopic therapy with
injection of adrenaline plus multipolar
electrocoagulation or application of endoscopic
clips.

• Patients with peptic ulcer received a
continuous intravenous infusion of
omeprazole (80 mg per 10-hour period
after an initial bolus of 80 mg) for the
first 72 hours.

CRITICISMS
• In both groups (restrictive-strategy group & iberal-strategy
group) 1 unit of red cells was transfused initially .
• 1 unit of pRBCs was transfused up front in both
groups. Therefore, there was no true conservative
transfusion group. The study suggests that a transfusion
threshold of Hgb 7 is superior, but cannot definitively
answer the question as all patients in the study received
a transfusion.
• (So do not miss to give at least 1U of pRBC initially
and don't ignore the patient until Hb <7 without single
blood transfusion , if the patient collapsed during your
on call you will go directly to the court)

• All patients underwent emergent EGD within mean 5 hours of
admission; therefore, it is unknown whether results would be similar
in patients who do not receive endoscopic therapy as quickly as the
patients in this trial.
• Upper endoscopies within 6 hours is unrealistic outside of a
research setting.
• Whereas gastroscopy in the first 6 hours after admission is feasible
in clinical research trials, time delays of more than 6 hours may
routinely occur in general clinical practice, particularly for patients
with low Rockall scores similar to our case her .
• Theoretically, patients treated with a restrictive transfusion
strategy may have worse outcomes in the setting of
delayed endoscopy with ongoing bleeding.
CRITICISMS

NVUGIH - 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.

 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
NVUGIH – MR3 - 4

Glasgow-
Blatchford
Score (GBS)

NVUGIH – 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).

NVUGIH – 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).

NVUGIH – 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).

NVUGIH – 8
 For patients using antiplatelet agents, ESGE
recommends the management algorithm detailed.

Proton pump inhibitor
treatment initiated prior to
endoscopic diagnosis in
upper gastrointestinal
bleeding

Should we give a PPI IV before
endoscopy in patients with upper
GI bleeding?
Yes
No
Probably Yes
Probably No

Should we give a PPI IV before
endoscopy in patients with upper
GI bleeding?
Yes (ESGE)
No (SIGN, BSG , NICE)
Probably Yes (ACG , ASGE)
Probably No

Interdiction
Experimental data suggest that
acid suppression and increased pH
are important in clot stabilisation
and hence potentially in reducing
rebleeding .

Major Endpoints:
Mortality
Re-bleeding
Need for
surgical intervention.
Minor Endpoints:
- Need for endoscopic
hemostasis,
- Blood transfusion,
- Decrease in Hospital
Days.
Efficacy Endpoints

 Also, a decrease in high risk stigmata on
endoscopic evaluation may represent a
clinically useful outcome if it reduced the
need for hemostatic intervention.
 A study showed that there was a 14%
reduction in endoscopic hemostasis in the
PPI group, with a number needed to
treat to prevent one intervention of 7.
Efficacy Endpoints

 Delaying definitive diagnosis and treatment,
 Direct cost to patient,
 Indirect cost (change in level of care, nursing care,
emergency department flow, etc.)
 Since 37-45% of undifferentiated upper GI bleed is
not from a peptic ulcer1,2 patients can be subject to
unnecessary medications and cost.
Harm Endpoints:

Proton pump inhibitors
 Do not offer acid-suppression drugs
(proton pump inhibitors or H2-
receptor antagonists) before
endoscopy to patients with suspected
non-variceal upper gastrointestinal
bleeding.

 Pre-endoscopic therapy with high-
dose PPI may reduce the numbers
of patients who require
endoscopic therapy, but there is
no evidence that it alters
important clinical outcomes and
there is insufficient evidence to
support this practice.

 A proton pump inhibitors should
not be used prior to diagnosis by
endoscopy in patients presenting
with acute upper gastrointestinal
bleeding.

PRE-ENDOSCOPIC MEDICAL THERAPY
Proton pump inhibitor therapy
 Recommendations.
6. Pre-endoscopic intravenous proton pump
inhibitor (PPI) (e.g., 80 mg bolus followed by 8
mg/h infusion) may be considered to
decrease the proportion of patients who have higher
risk stigmata of hemorrhage at endoscopy and who
receive endoscopic therapy.

 However, PPIs do not improve clinical
outcomes such as further bleeding,
surgery, or death (Conditional
recommendation, high-quality evidence).

 If endoscopy will be delayed or cannot
be performed, intravenous PPI is
recommended to reduce further bleeding
(Conditional recommendation, moderate-
quality evidence).

Before-procedure proton pump inhibitor
therapy
 The role of proton pump inhibitor (PPI)
therapy in patients with suspected acute
UGIB was systematically reviewed in a
Cochrane meta-analysis that included 6
randomized controlled trials (RCT)
published between 1992 and 2007.22

 The analysis found that patients with
nonvariceal UGIB administered
intravenous PPI therapy prior to
endoscopy did not experience any
statistically significant differences in the
outcomes of mortality, rebleeding, or
progression to surgery compared with
patients in the control group.

 However, the analysis did show that
before-procedure PPI therapy resulted in
significantly reduced rates of high-risk
stigmata identified on endoscopy (odds
ratio [OR] 0.67; 95% confidence interval
[CI], 0.54-0.84) and need for endoscopic
therapy (OR 0.68; 95% CI, 0.50-0.93).

 Therefore, intravenous PPI therapy is
recommended for patients who are
suspected of having acute UGIB.

Implications for Practice
 PPI therapy is already widely initiated
before endoscopy in patients with upper
gastrointestinal bleeding.
 The present analysis did not find
significant improvement with PPI
treatment for clinically important
outcomes including rebleeding, surgery or
mortality.

 The reduced rate of serious endoscopic
stigmata of bleeding found at endoscopy
among patients given PPI therapy before
endoscopy and the reduced requirement
for endoscopic haemostatic treatment are
of uncertain clinical significance.
 However, PPI therapy may have a role if
prompt endoscopy is not readily available.

 Among such patients in whom PPI
therapy is initiated before endoscopy,
therapy can obviously be discontinued
if endoscopy finds no evidence of
bleeding or evidence of bleeding from
an alternate source (for example,
oesophageal or gastric varices).

 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).
NVUGIH - MR4 - 9

NVUGIH – 10
 ESGE does not recommend the use of tranexamic
acid in patients with NVUGIH .

NVUGIH – 11
 ESGE does not recommend the use of
somatostatin, or its analogue octreotide, in
patients with NVUGIH.

Erythromycin as a
prokinetic treatment
initiated prior to
endoscopic diagnosis in
bleeding

Yes
No
Probably No
Probably Yes
Should we routinely administer
erythromycin before endoscopy in
patients with upper GI bleeding?

Visibility during
endoscopic hemostasis

Should we routinely administer
erythromycin before endoscopy in
patients with upper GI bleeding?
Yes
No
Probably No
Probably Yes

Answer : No , Probably not.
 Among patients who present with UGIB,
only a small percentage are likely to have
a stomach full of blood necessitating
gastric emptying before endoscopy.
 Most guidelines do not recommend the
routine use of erythromycin because there
are no additional clinical benefits aside
from improving endoscopic visibility and
reducing the need for second-look EGDs.

 Nevertheless, the use of
erythromycin is recommended for
patients who are suspected of
having poor visibility due to the
presence of large amounts of blood
or clots in their stomachs.

However, there was no improvement in other
clinical outcomes, such as duration of
hospitalization, transfusion requirements, or
surgery.
Although the routine use of prokinetic agents is
not recommended, use in patients with a high
probability of having fresh blood or a clot in the
stomach when undergoing endoscopy may result
in a higher diagnostic yield.
American Society for Gastrointestinal Endoscopy 2012

 Promotility agents should not be used
routinely before endoscopy to increase the diagnostic
yield.
 (Agree, 82. Grade: Moderate, 2b, “probably don’t
do it”)
 Although the use of preendoscopy promotility agents
may improve diagnostic yield in selected patients with
suspected blood in the stomach, they are not
warranted for routine use in all patients who present
with UGIB.
American College of Physicians 2010

 Promotility agents are not promoted
for routine use, but can be used to
improve visualization in patients
suspected to have large amounts of
blood or food residue in the stomach.
2012 by the AGA Institute

Pre-endoscopic medical therapy
 Intravenous infusion of erythromycin (250 mg
~30 min before endoscopy) should be
considered to improve diagnostic yield and
decrease the need for repeat endoscopy.
 However, erythromycin has not
consistently been shown to
improve clinical outcomes (Conditional
recommendation).
Am J Gastroenterol 2012

Visibility during
endoscopic hemostasis
Based on the results of this study, we hope to develop guidelines on the use of
prokinetics before emergency EGD that will assist in improving visibility during
endoscopic hemostasis procedures.

NVUGIH – MR5 - 12
 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.

Is nasogastric tube lavage
in patients with acute
upper GI bleeding
indicated or antiquated?
Why We Do What We Do: NG Tubes

 Nasogastric lavage (NGL) was once a standard
initial procedure for all patients with acute
gastrointestinal (GI) bleeding, but its use is now
under debate.
 Although some data suggest that patients with a
bloody NGL are more likely to have severe
bleeding, the test's presumed benefits — confirming
an upper GI source of bleeding, clearing the stomach
for better endoscopic visualization, and reducing the
risk for aspiration — have not been tested.
Why We Do What We Do: NG Tubes

 Nasogastric lavage (NGL) seems to be a logical procedure
in the evaluation of patients with suspected upper GI
bleeding, but does the evidence support the logic?
 Most studies state that endoscopy should occur within 24
hours of presentation, but the optimal timing within the
first 24 hours is unclear.
 Rebleeding is the greatest predictor of mortality,
and these patients benefit from aggressive, early
endoscopic hemostatic therapy and/or surgery.
 So what are the arguments for and
against NGL?
To Lavage or Not to Lavage?

Nasogastric (NG) lavage
Nasogastric (NG) lavage is an intuitively logical
procedure for evaluation of stable patients without
hematemesis suspected of having acute upper GI
bleeding.
Indeed, a bloody NG aspirate is a good predictor of
finding a high-risk lesion on upper endoscopy.
Patients undergoing NG lavage for suspected upper GI
bleeding found that 45% of patients with a bloody
aspirate had high-risk lesions on endoscopy versus
15% of those with only a clear or bilious aspirate.
Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.

Prediction of high-risk lesions is important because it
is those patients who have the worst outcomes and in
whom early endoscopic therapy would be of most
benefit.
Patients undergoing endoscopic therapy for high-risk
lesions will be successfully managed in 80% to 90% of
cases with control of active and prevention of further GI
bleeding.
Rebleeding is the greatest predictor of poor
outcomes including mortality.
Gastrointest Endosc. 2011 Nov;74(5):981-4. doi: 10.1016/j.gie.2011.07.007.

Studies suggests that finding red blood in the NG
lavage predicts significant association with high-
risk lesions and poor outcome vs. coffee ground.
So this studies demonstrates the benefit of a NG tube
in risk stratification.
This studies suggests that early identification of high
risk lesions by endoscopy decrease both re-
bleeding rates and requirements for surgical
intervention.

Studies shows that placement of a NGT tube, even with
suggestion of a lower GI bleed can help localize
the source of bleeding.
Studies shows that lavage through a NG tube can help
clear the stomach contents of blood, allowing a
more effective procedure during endoscopy.
From an endoscopic perspective, the fundus is
typically the area of the stomach most likely to be
obscured by retained blood in any bleeding scenario.

So, there is good evidence demonstrating that
positive NG lavage tends to identify the presence of
high-risk lesions found on subsequent endoscopy.
There is also evidence that endoscopic treatment of high-
risk lesions decreases rebleeding and mortality.
So, if NG lavage identifies high-risk lesions, and
endoscopic treatment of high-risk lesions decreases
mortality, then patients who undergo NG lavage for their
upper GI bleeds should have lower mortality, right?!!

Conclusion
ER feel that it is both helpful to the gastroenterologist, and
more importantly, beneficial for the patient to place a NG tube
and perform a lavage.
The following should be reported to the
gastroenterologist when you call them:
 Was bloody material spontaneously returned upon
placement of the tube.
 What was the color of the material that was
lavaged, bright blood red, maroon, clear with
coffee-ground specks, etc.

Conclusion
 If you find evidence of bleeding, please lavage at
least 1-2 liters and tell us if the gastric contents
clear of the bloody contents.
 If there is no evidence of blood in the gastric
contents, please continue to lavage until you see
bilious material returned, so the gastroenterologist
can be sure that you are sampling contents beyond
the pylorus, a common site of peptic ulcers.

Can I simply avoid this procedure?

 A negative NG lavage in an unstable patient with
suspected Upper GI bleed does not rule out a
bleed passed a closed pyloric sphincter, and a
positive NG lavage (that clears) in a stable patient
does not warrant more urgent EGD than an
unstable patient.
 It is common in my experience for GI docs to use
lack of NGT, or negative or equivocal lavages as a
way of delaying consultation till the
morning.

Incidentally, it is usually
the least experienced
member of the team
(medical student) who is
given the job of passing an
NGT without adequate
supervision.

 How good a diagnostic test is an NG tube?
Usefulness and Validity of Diagnostic Nasogastric
Aspiration in Patients Without Hematemesis.
 Ann Emerg Med 2004 gives us a sensitivity of 42%
and a specificity of 91%.
 A 42% sensitivity stinks. So if you are doing this test to
make sure that there is no upper GI bleeding, a negative
test would not rule this out.
 If you do get blood back then it is probably an upper GI
bleed.
 So the next obvious question is how does
this change management?

 One of the worst-tolerated procedures in Emergency
Medicine - placement of the NG tube.
 Unfortunately, when ER call GI fellow on-call for any
upper GI bleeding, the first question is invariably -
what did the NG lavage show?

 Patients who underwent NGL were more likely to
have an endoscopy and to receive it sooner than
other patients.
 Lavage did not affect mortality, length of hospital
stay, or the need for transfusions or surgery. Bloody
aspirates were associated with high-risk lesions at
endoscopy.
 Conclude that NGL is associated with receiving early
endoscopy and might be useful in triage but does not
affect clinical outcomes.

 The procedure increased the likelihood of early
endoscopy but not better patient outcomes, such as
lower mortality.
 Nasogastric tube insertion can be a traumatic
experience to the patient. May traumatize the
esophageal varices , mucosa and the gastric mucosa .
 The trauma marks can act as confounders to the
endoscopist

Comparison of patient and practitioner assessments of pain
from commonly performed emergency department procedures.
1. It is painful
What they did:
 Prospective, observational study
 1,171 procedures, from the 15 most common procedures
performed in the ED
 Patients recorded a pain score
What they found:
 The most painful procedure according to
patients was NG tube placement.
 NG tube placement was more painful than
intubation, abscess drainage, fracture reduction, and
urethral catheterization.
Ann Emerg Med. 1999 Jun;33(6):652-8.

 So, it has been rated the most painful
procedure we perform on a patient.
 There are many ways to lesson this pain like
local or systemic analgesia but it still stinks
for the patient.
 The gagging and spitting are not great for
the provider who is trying to keep the fragile
patient doctor bond intact.
Comparison of patient and practitioner assessments of pain
from commonly performed emergency department procedures.

Conclusion
 The most painful
procedure for ED
patients is NG tube
placement.
Ann Emerg Med. 1999 Jun;33(6):652-8.

Erythromycin infusion or gastric lavage for upper
gastrointestinal bleeding: a multicenter randomized controlled
trial.
2. NGL IS NOT the only way to get good
visualization during endoscopy
What they did:
 Prospective, randomized, multicenter study
 6 EDs, 253 patients with an upper GI bleed (UGIB)
 IV erythromycin (84 pts) vs NGT without erythromycin (85
pts) vs NGT with erythromycin (84 pts) for visualization
during endoscopy
What they found:
 No difference in visualization between groups
 No difference in duration of endoscopic procedure,
rebleeding, need for 2nd endoscopy, number of transfused
PRBCs, or mortality at 2, 7, and 30 days
Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

Conclusion
 In acute UGIB, administration of IV erythromycin
provides satisfactory endoscopic visualization
without need for a NGL.
Ann Emerg Med. 2011 Jun;57(6):582-9. doi: 10.1016/j.annemergmed.2011.01.001. Epub 2011 Feb 17.

Impact of nasogastric lavage on outcomes in acute GI
bleeding
3. NGL DOES NOT improve mortality, length
of stay, or transfusion requirements
What they did:
 Retrospective analysis
 632 patients with GI bleeding to evaluate 30-day
mortality, mean hospital length of stay (LOS), and
transfusion requirements.
What they found:
 No statistical difference in 30 day mortality, mean
LOS, or transfusion requirements.
 NGL was associated with earlier time to
endoscopy.

Conclusion
 NGL is associated with earlier
performance of endoscopy, but NO
difference in clinical outcomes.

 The placement of a nasogastric tube should be considered
in select patients who have suspected active UGIB.
 The presence of bright red blood in a gastric aspirate can
be useful in identifying patients with high-risk
lesions, but is not as useful if coffee ground material or other
findings are present without red blood.
 It should be noted that the absence of blood in a gastric
aspirate does not exclude the presence of active UGIB,
because approximately 15% of patients with active bleeding
can have a negative result for nasogastric lavage.
 Because of these limitations, and the potential
patient discomfort, use of a nasogastric tube remains
controversial.
GASTROINTESTINAL ENDOSCOPY Volume 75, No. 6 : 2012

NVUGIH – ESGE GL 2015
 In distinguishing upper from lower GI
bleeding, nasogastric aspiration has low
sensitivity 44% , high specificity 95% .
 In identifying severe UGIH, its sensitivity and
specificity are 77 % and 76%, respectively .
 Clinical signs and laboratory findings (e.g.,
hemodynamic shock and hemoglobin < 8 g/dL)
compared to nasogastric aspiration/lavage, had
similar ability to identify severe UGIH .

NVUGIH – ESGE GL 2015
 Others have reported that nasogastric
aspiration/lavage failed to assist clinicians in
correctly predicting the need for endoscopic
hemostasis, did not improve visualization of
the stomach at endoscopy, or improve
clinically relevant outcomes such as
rebleeding, need for second-look endoscopy,
or blood transfusion requirements.
 It also should be noted that nasogastric
aspiration/lavage is a very uncomfortable
procedure that is not well tolerated or desired by
patients.

 A3. Consider placement of a nasogastric
tube in selected patients because the
findings may have prognostic value.

Researchers argued here
 Placement of a nasogastric tube for
determining treatment of patients with upper
gastrointestinal bleeding may be unnecessary
since almost all these patients will eventually
undergo an endoscopic procedure.
 We found that the clinical judgment of the
clinician was just about as good as a nasogastric
tube examination - and didn't cause harm to
the patient," .

 "Since there is going to be an endoscopic follow-
up to confirm the diagnosis and perform
definitive treatment if necessary, there is no need to
continue to torture our patients with nasogastric tube
placement,”
 Placement of nasogastric tubes cause pain and epistaxis
in as many as 25% of patients undergoing the
procedure; in another 10% of patients, the tube
cannot be inserted due to some form of anatomic
problem.
 In the study ,pain, nasal bleeding, or nasogastric tube
failure occurred in 35% patients assigned to that
procedure.

 Many patients refused to undergo the
nasogastric tube placement." Those patients
who refused were also followed as to their
outcomes, and their clinical diagnosis
turned out to be similar to the others.

FINAL THOUGHTS
So what should we say to our gastroenterology
colleagues about NGL and UGIB?
 European Society of Gastrointestinal Endoscopy (ESGE)
Guideline 2015 guidelines, and
American College of Gastroenterology 2012 guidelines state NGL is
not recommended in patients with UGIB for diagnosis, prognosis,
visualization, or therapeutic effect .
 NG lavage DOES NOT help patients in the
emergency department with acute upper GI
bleed and is an outdated practice.
 It looks like there is no dilemma any longer.

 ESGE does not recommend the routine use of
nasogastric or orogastric aspiration/lavage in
patients presenting with acute UGIH .
NVUGIH – MR6 - 13

NVUGIH – 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).

NVUGIH – 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.

 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.
NVUGIH - MR7 - 16

NVUGIH - 17
 ESGE recommends the availability of both an on-call
GI endoscopist proficient in endoscopic hemostasis
and on-call nursing staff with technical expertisein
the use of endoscopic devices to allow performance
of endoscopy on a 24 /7 basis .

NVUGIH - 18
 ESGE recommends the Forrest (F) classification
be used in all patients with peptic ulcer
hemorrhage in order to differentiate low and high
risk endoscopic stigmata .

NVUGIH - MR8 - 19
 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 .

NVUGIH – MR9 - 20
 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.

NVUGIH – MR10 - 21
 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 .

NVUGIH – 22
 ESGE does not recommend the routine use of
Doppler ultrasound or magnification
endoscopy in the evaluation of endoscopic stigmata
of peptic ulcer bleeding.

NVUGIH – MR11 – 23 - 24
 For patients with actively bleeding ulcers (FIa,
FIb), ESGE recommends combining epinephrine
injection with a second hemostasis modality
(contact thermal, mechanical therapy, or injection of a
sclerosing agent).
 ESGE recommends that epinephrine injection therapy
not be used as endoscopic monotherapy.

NVUGIH – 25
 For patients with active NVUGIH bleeding not
controlled by standard endoscopic
hemostasis therapies, ESGE suggests the use of a
topical hemostatic spray or over-the-scope
clip as salvage endoscopic therapy.

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.

NVUGIH – 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.

NVUGIH – 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).

NVUGIH – 29
 In patients bleeding from upper GI angioectasias,
ESGE recommends endoscopic hemostasis
therapy.
 However, there is currently inadequate evidence to
recommend a specific endoscopic hemostasis
modality.

NVUGIH – 30
 In patients bleeding from upper GI neoplasia,
ESGE recommends considering endoscopic
hemostasis in order to avert urgent surgery and
reduce blood transfusion requirements.
 However, no currently available endoscopic
treatment appears to have long-term efficacy.

NVUGIH – 30
 Transcatheter angiographic embolization
(TAE) or surgery should be considered if
endoscopic treatment fails or is not technically
feasible .

Main Recommendations

NVUGIH – MR12 -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 (80 mg then 8 mg/hour) for 72 hours post
endoscopy

NVUGIH – 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.

NVUGIH – MR13 – 33- 34
 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 .

 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.
 Retesting 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 .

NVUGIH – 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.

NVUGIH – 37
 In patients receiving low dose aspirin for primary
cardiovascular prophylaxis who develop peptic
ulcer bleeding, ESGE recommends withholding
aspirin, revaluating 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.

 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 .

Algorithm for the
management of
patients with acute
hemorrhage who are
using antiplatelet
agent(s)

NVUGIH – MR39
 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.

NVUGIH – MR40
 In patients requiring dual antiplatelet therapy
(DAPT) and who have had NVUGIH, ESGE
recommends the use of a PPI as co-therapy.

Diagnosis & management of nonvariceal upper gastrointestinal hemorrhage bleeding (nvugih-nvugib) guideline 2015

Diagnosis & management of nonvariceal upper gastrointestinal hemorrhage bleeding (nvugih-nvugib) guideline 2015

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