Curriculum on management of acute upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

Confirm peptic ulcer disease with EGD, biopsy all gastric ulcers to exclude malignancy, and test every PUD patient for H. pylori. In ulcer bleeding, risk-stratify pre-endoscopy with the Glasgow-Blatchford score (GBS ≤1 may be managed as an outpatient), resuscitate with crystalloid, and transfuse restrictively in hemodynamically stable patients with no history of cardiovascular disease (transfusion threshold hemoglobin ≤7 g/dL, post-transfusion target 7-9 g/dL); in hemodynamically stable patients with a history of acute or chronic cardiovascular disease use a more liberal strategy (transfusion threshold ≤8 g/dL, post-transfusion target ≥10 g/dL); the restrictive strategy applies only to non-massive bleeding, so in exsanguinating or hemodynamically unstable hemorrhage transfuse based on hemodynamics and ongoing blood loss rather than waiting for a hemoglobin threshold. Perform endoscopy within 24 hours of presentation; emergent (≤6 h) or urgent (≤12 h) endoscopy is NOT recommended unless the patient remains hemodynamically unstable despite adequate resuscitation. Give pre-endoscopy IV erythromycin (IV metoclopramide if erythromycin is unavailable, in clinically severe or ongoing active bleeding); pre-endoscopy high-dose IV PPI may be considered but must not delay endoscopy. Treat by Forrest class: Ia/Ib get combination therapy (dilute epinephrine injection plus a second modality, contact/noncontact thermal or mechanical TTS/OTS clip), with over-the-scope clip monotherapy now an accepted first-line alternative to combination therapy given its lower rate of further bleeding, and hemostatic forceps with soft coagulation a further alternative; IIa (nonbleeding visible vessel) gets thermal, mechanical (TTS or OTS clip), or sclerosant injection as monotherapy or combined with epinephrine; IIb (adherent clot) gets clot removal with treatment of underlying stigmata where the endoscopist is technically competent to manage conversion to a higher-risk lesion; IIc/III (flat spot, clean base) get no endoscopic therapy and may be discharged early on oral PPI. Epinephrine injection must never be used as monotherapy, and topical hemostatic agents must not be used as first-line monotherapy (they are reserved, with OTS clips, for bleeding refractory to standard modalities). After hemostasis, give high-dose PPI as 80 mg IV bolus then 8 mg/h infusion for 72 hours (twice-daily IV bolus or twice-daily oral high-dose PPI are acceptable alternatives); the same applies to untreated FIIb clot. Routine second-look endoscopy is not recommended. For recurrent bleeding, repeat endoscopy and consider an OTS clip if not already used; if the second attempt fails, proceed to transcatheter angiographic embolization (TAE), with surgery when TAE is unavailable or unsuccessful. Prophylactic TAE may be considered in selected high-risk cases (hemodynamic instability at presentation, posterior duodenal wall ulcer, ulcer >2 cm, or uncertain durability of hemostasis). Start clear liquids/early oral nutrition within 24 hours of durable hemostasis, and initiate iron therapy before discharge for iron deficiency and/or anemia. Resume anticoagulation as soon as clinically indicated based on thromboembolic risk, resume aspirin for secondary prevention within 24 hours, and give PPI co-therapy to patients continuing DAPT or anticoagulation after a bleed. Test for H. pylori at the index endoscopy and treat if positive; retest patients testing negative acutely (a false-negative is common in the bleeding setting), holding PPI at least 2 weeks before retesting, and document successful eradication in every treated patient. For eradication, first-line therapy in treatment-naive patients with unknown susceptibility is optimized bismuth quadruple therapy for 14 days (PPI twice daily, tetracycline 500 mg four times daily, metronidazole 500 mg three to four times daily, bismuth four times daily); rifabutin triple therapy or vonoprazan-amoxicillin dual therapy for 14 days are acceptable empiric alternatives in patients without penicillin allergy. PPI-clarithromycin triple therapy and levofloxacin-based regimens are recommended against unless susceptibility testing proves the organism is sensitive. Salvage therapy in treatment-experienced patients is optimized bismuth quadruple therapy for 14 days if not previously used, otherwise a susceptibility-guided or non-cross-resistant regimen. Test of cure is required in ALL treated patients by urea breath test, fecal antigen, or biopsy-based test at least 4 weeks after completing antibiotics and at least 2 weeks off PPI. Heal ulcers with PPI (duodenal ulcer 4 weeks, gastric ulcer 8 weeks, with repeat EGD at 8-12 weeks to confirm healing and exclude malignancy), discontinue or mitigate NSAIDs with long-term PPI or PCAB co-therapy if NSAIDs must continue, maintain long-term acid suppression in idiopathic (H. pylori-negative, NSAID-negative) ulcers, and pursue gastrinoma/ZES or refractory-ulcer workup in H. pylori-negative/NSAID-negative or non-healing cases.