<aside> 📘 Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

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Flowcharts

Patient with antiplatelet
Patient with anticoagulant
Management of ulcer bleeding

Hemoglobin management

Patients	Hemoglobin Concentration Goal
Patients with no history of cardiovascular disease	7-9 g/dL
Patients with a history of acute or chronic cardiovascular disease	≥ 10 g/dL

Risk stratification/indication

Glasgow-Blatchford Bleeding Score (GBS)

Calculator Link here

Glasgow-Blatchford Score (GBS)	Risk Level	Recommendation
GBS ≤ 1	Very Low	Can be safely managed as outpatients with outpatient endoscopy.
GBS > 1	Higher	More likely to need admission to hospital and intervention.

Antithrombotics management

Anti-platelet

	Purpose of Antithrombotics	Scenario of Antithrombotics	Act	Resume
High risk (≥ Forrest class IIb)	primary prophylaxis	Low-dose aspirin monotherapy	withhold	Resume low dose aspirin after careful
re-evaluation of its clinical indication
	secondary prophylaxis (known risk)	Low-dose aspirin monotherapy	Do not interrupt	If interrupted, restart preferably within 3-5 days.
		Dual antiplatelet therapy (DAPT)	Continue low dose aspirin without interruption	Restart the second APA preferably within 5 days. Consult with a cardiologist. Second-look endoscopy prior to restarting the second APA.
Low risk (≤ Forrest class IIc)	primary prophylaxis	Low-dose aspirin monotherapy	withhold	Resume low dose aspirin after careful
re-evaluation of its clinical indication
	secondary prophylaxis (known risk)	Low-dose aspirin monotherapy	Do not interrupt
		Dual antiplatelet therapy (DAPT)	Do not interrupt

Anti-coagulant

Scenario of Antithrombotics	Act	Resume	Other explanation
VKAs	low dose vitamin K supplemented, prothrombin complex concentrate (PCC), or fresh frozen plasma (FFP)	Patients at high thrombotic risk, resume anticoagulation within the first 7 days following an acute bleeding event is appropriate.	Should not delay endoscopy. Studies have shown that endoscopy outcomes were similar in patients with normal INR compared with those with elevated INR at hospital admission, or in those where INR was corrected to a value < 2.5 prior to endoscopy.
DOACs	use of a DOAC reversal agent or intravenous PCC should be considered in severe ongoing bleeding	preferably within or soon after 7 days of the bleeding event	Choose a DOAC with less bleeding risk or a VKA with tight INR control should be prescribed later.

Medication recommendation