Thirty-day Mortality Among Jehovah's Witness Patients with Gastrointestinal Bleeding Who Decline Blood Transfusion: A Retrospective Cohort Study.

ACG 2021 (statement numbers are the guideline's own): Endoscopic therapy is RECOMMENDED for UGIB due to ulcers with active spurting, active oozing, or a nonbleeding visible vessel (strong, moderate-quality) [#6]. For ulcers with an adherent clot resistant to vigorous irrigation the panel COULD NOT REACH a recommendation for or against endoscopic therapy [#7]. Recommended hemostatic modalities are bipolar electrocoagulation, heater probe, or injection of absolute ethanol (strong, moderate-quality) [#8]; clips, argon plasma coagulation, and soft monopolar electrocoagulation are only SUGGESTED (conditional, very-low- to low-quality) [#9]. Epinephrine injection must NOT be used alone, but in combination with another hemostatic modality (strong, very-low- to moderate-quality) [#10], note the guideline does not require that epinephrine be part of therapy; the three strongly recommended modalities are effective as monotherapy. TC-325 hemostatic powder spray is suggested for actively bleeding ulcers (conditional, very-low-quality) [#11]. Over-the-scope clips are suggested for RECURRENT ulcer bleeding after previous successful endoscopic hemostasis (conditional, low-quality) [#12]. After successful endoscopic hemostasis, high-dose PPI given continuously OR intermittently for 3 days is recommended (strong, moderate- to high-quality) [#13]; high-risk patients then continue twice-daily PPI until 2 weeks after the index endoscopy (conditional, low-quality) [#14]. Peri-procedural care: restrictive RBC transfusion at a threshold of hemoglobin 7 g/dL (conditional, low-quality) [#2]; erythromycin infusion (250 mg IV) before endoscopy (conditional, very-low-quality) [#3]; no recommendation for or against pre-endoscopic PPI [#4]; endoscopy within 24 hours of presentation for patients admitted or under observation (conditional, very-low-quality) [#5], the 2021 panel explicitly DECLINED to carry forward the 2012 ACG suggestion that endoscopy within 12 hours 'may be considered' in high-risk patients, and an RCT of endoscopy <6 h vs 6-24 h after consultation in patients with GBS ≥12 showed no reduction in further bleeding or mortality; resuscitation and attention to active comorbidities should be undertaken before endoscopy. Rebleeding pathway is ordered: recurrent bleeding after endoscopic therapy → REPEAT endoscopy with endoscopic therapy rather than surgery or transcatheter arterial embolization (conditional, low-quality) [#15]; only if endoscopic therapy FAILS → transcatheter arterial embolization (conditional, very-low-quality) [#16]. Very-low-risk patients (Glasgow-Blatchford score 0-1) may be discharged from the ED with outpatient follow-up (conditional, very-low-quality) [#1]. For nonpeptic-ulcer causes, the Canadian Association of Gastroenterology (CAG) Clinical Practice Guideline for the Endoscopic Management of Nonvariceal Nonpeptic Ulcer Upper Gastrointestinal Bleeding (Barkun AN et al., Gastroenterology 2025;169(5); DOI 10.1053/j.gastro.2025.04.041; ASGE/ESGE/SIED/WEO- and AGA-endorsed) (all recommendations conditional, very low certainty): active bleeding malignant UGI tumors, conventional hemostatic therapy over none [1A], topical hemostatic agents (THAs) over none [1B], no recommendation among conventional modalities [2], THAs suggested OVER conventional hemostatic therapy [3], oncologic therapy after endoscopic hemostasis [4]; Mallory-Weiss tears, hemostatic therapy for ACTIVE bleeding (spurting/oozing) over none [5], EBL or through-the-scope clip over epinephrine injection alone [6A/6B], and suggested AGAINST endoscopic hemostatic therapy for MWTs with nonbleeding visible vessels [7A], nonbleeding adherent clots [7B], or nonbleeding clean-based ulcers/flat pigmented spots [7C]; Dieulafoy lesions, EBL or TTSC (each ± epinephrine), or contact thermal devices ± epinephrine, or sclerosant injection ± epinephrine [8A/8B/8D], no recommendation on cap-mounted clips [8C], suggested against epinephrine injection alone versus mechanical [9A] or thermal [9B] devices; GAVE, suggested against RFA relative to APC [10], and EBL suggested over APC [11].