• Alan N Barkun, Majid Almadi, Ernst J Kuipers, Loren Laine, Joseph Sung, Frances Tse, Grigorios I Leontiadis, Neena S Abraham, Xavier Calvet, ChanFrancis K LFKLChinese University of Hong Kong, Hong Kong SAR (J.S., F.K.C., J.L.)., James Douketis, Robert Enns, Ian M Gralnek, Vipul Jairath, Dennis Jensen, James Lau, LipGregory Y HGYHUniversity of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom, and Aalborg University, Aalborg, Denmark (G.Y.L.)., Romaric Loffroy, Fauze Maluf-Filho, Andrew C Meltzer, Nageshwar Reddy, John R Saltzman, John K Marshall, and Marc Bardou.
• McGill University, Montreal, Quebec, Canada (A.N.B.).
• Ann. Intern. Med. 2019 Dec 3; 171 (11): 805-822.

DescriptionThis update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations.MethodsAn international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional.RecommendationsPreendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.

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