This lack of recommendation for pre-endoscopic PPI does not align with other societies. Both the European Gastroenterology (2021) and an International Consensus Group (2019) recommend for the use of pre-endoscopic PPI use.^4,5 However, the National Institute for Health and Care Excellence (2012) in the United Kingdom recommends against it.⁶

The third and final significant change revolved around the timing of endoscopy. In the 2012 guideline, ACG recommended considering endoscopy within 12 hours for patients with high-risk clinical features (e.g., tachycardia, hypotension, bloody emesis, or bloody nasogastric aspiration within the hospital). The 2021 guideline solely recommends endoscopy within 24 hours without a separate recommendation for high-risk patients. This change is based on new evidence since the 2012 guideline including a RCT of 516 patients, a nationwide cohort study of nearly 4,000 patients, and a single center cohort study of nearly 1,000 patients, all of which show no significant improvement in mortality or rebleeding with early endoscopy.^7,8,9 Inthe body of the guideline, ACG did make an

 anecdotal comment in favor of urgent intervention with endoscopy or interventional radiology in the subset of patients that remain in hypotensive shock after initial resuscitation.

This 2021 update provides important guidance on management of UGIB based on the best available evidence allowing emergency medicine to work in conjunction with gastroenterology to care for our patients. It should be incorporated into our standard practice as emergency physicians.

Dr. Melissa Villars is an emergency medicine resident at Mount Sinai Hospital in New York City.

Dr. Stephen J. Wolf is an emergency medicine physician and professor in Denver, Colorado.

References

1. Laine L, Barkun AN, et. al. (2021). ACG clinical guideline: upper gastrointestinal and ulcer bleeding. Journal of the American College of Gastroenterology. 116(5):899–917.
2. Laine L, Jensen DM. Management of patients with ulcer bleeding. Journal of the American College of Gastroenterology. 107(3):345–360.
3. Shung DL, Au B, Taylor RA, et al. Validation of a machine learning model that outperforms clinical risk scoring systems for upper gastrointestinal bleeding. Gastroenterology. 2020;158:160–167.
4. Gralnek IM, Stanley AJ, Morris AJ, et al. (2021). Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline–Update 2021. Endoscopy. 53(03):300–332.
5. Barkun AN, Almadi M, Kuipers EJ, et al. Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Annals of Internal Medicine. 2019;171(11):805–822.
6. National Institute for Health and Care Excellence. Acute Upper Gastrointestinal Bleeding in Over 16s: Management. CG141. 2012.
7. Lau JYW, Yu Y, Tang RSY, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299–308.
8. Laursen SB, Leontiadis GI, Stanley AJ, et al. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: A nationwide cohort study. Gastrointest Endosc. 2017;85:936–44 e3.
9. Cho SH, Lee YS, Kim YJ, et al. Outcomes and role of urgent endoscopy in high-risk patients with acute nonvariceal gastrointestinal bleeding. Clin Gastroenterol Hepatol. 2018;16:370–377.
10. Osman D, Djibré M, Da Silva D, et al. Management by the intensivist of gastrointestinal bleeding in adults and children. Ann Intensive Care. 2012;2(1):46.