Endoscopy for GI Bleeding
Active bleeding or high-risk stigmata identified
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GastroenterologyManagement
GI Bleed Endoscopic Hemostasis (ACG/ASGE)
GI Bleed Endoscopic Hemostasis (ACG/ASGE): Endoscopy for GI Bleeding → Classify Stigmata (Forrest for Ulcers) → Endoscopic Therapy Indicated? → High-Ris...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Classify Stigmata (Forrest for Ulcers)
Determines need for endoscopic therapy
- Ia: Spurting hemorrhage (90% rebleed)
- Ib: Oozing hemorrhage (50% rebleed)
- IIa: Visible vessel, non-bleeding (43% rebleed)
- IIb: Adherent clot (22% rebleed)
- IIc: Flat pigmented spot (7% rebleed)
- III: Clean base (3% rebleed)
03Decision Endoscopic Therapy Indicated?
Based on stigmata and clinical context
04Action High-Risk Stigmata (Ia, Ib, IIa)
ENDOSCOPIC THERAPY REQUIRED
- Active bleeding (Ia, Ib)
- Non-bleeding visible vessel (IIa)
- Combination therapy recommended
- PPI infusion post-procedure
05Decision Endoscopic Modality Selection
Choose based on lesion and availability
06Action Injection Therapy
Epinephrine - adjunctive only
- Epinephrine 1:10,000-1:20,000
- Inject 1-2 mL in 4 quadrants
- NEVER as monotherapy
- Combine with thermal or clips
07Action Combination Therapy (Preferred)
Epinephrine + thermal/mechanical
- Epi injection FIRST (tamponade, visualization)
- THEN thermal or clips
- Reduces rebleeding vs monotherapy
- Standard of care for high-risk lesions
08Action Post-Endoscopy Management
PPI and monitoring
- High-risk: PPI infusion (80mg bolus + 8mg/hr) x 72h
- Then PPI BID x 2 weeks
- NPO initially, advance diet as tolerated
- Repeat EGD in 24h if concern for rebleeding
09Outcome Hemostasis Achieved
Continue PPI, address etiology, H. pylori testing
10Warning ⚠️ Rebleeding
Repeat endoscopy vs IR/surgery
- Second attempt at endoscopic hemostasis reasonable
- If failed twice → IR embolization
- Surgery for uncontrolled bleeding
- Consider H. pylori treatment (reduces recurrence)
11Outcome IR Embolization/Surgery
For refractory bleeding after failed endoscopy
12Action Thermal Coagulation
Contact or non-contact
- Bipolar/multipolar probe (BICAP)
- Heater probe (20-30J per application)
- APC (non-contact, 40-60W)
- Apply until vessel flattened
- Path rejoins step 07Shared downstream outcome
13Action Mechanical Hemostasis
Clips - increasingly preferred
- Through-the-scope clips (TTS)
- Over-the-scope clip (OTSC) for larger defects
- Place on vessel, not just next to it
- Rotation for optimal positioning
- Path rejoins step 08Shared downstream outcome
14Action Topical Hemostatic Agents
Hemospray/TC-325
- Nanopowder spray
- Good for diffuse bleeding, malignancy
- Rescue therapy if other modalities fail
- Temporary - may need repeat intervention
- Path rejoins step 08Shared downstream outcome
15Action Intermediate Risk (IIb - Adherent Clot)
Controversial - consider therapy
- May attempt clot removal with irrigation
- If underlying vessel → treat
- If flat spot after removal → may observe
- Many endoscopists treat presumptively
- Path rejoins step 05Shared downstream outcome
16Action Low-Risk (IIc, III)
No endoscopic therapy needed
- Flat pigmented spot or clean base
- PPI therapy oral sufficient
- Early discharge in 24-48h if stable
- Low rebleed risk (<5%)
- Path rejoins step 08Shared downstream outcome
Guideline Source
ACG/ASGE Guidelines on Endoscopic Management of GI Bleeding
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Equipment availability varies by institution
- Operator experience critical for outcomes
- Hemospray/topical agents have variable availability
- Combination therapy often preferred
Applicable Regions
USEUGlobal
EU: ESGE guidelines similar approach
US: ACG/ASGE guidelines current standard
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the GI Bleed Endoscopic Hemostasis (ACG/ASGE)?
The GI Bleed Endoscopic Hemostasis (ACG/ASGE) is a management clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on ACG/ASGE Guidelines on Endoscopic Management of GI Bleeding.
What guideline is the GI Bleed Endoscopic Hemostasis (ACG/ASGE) based on?
This algorithm is based on ACG/ASGE Guidelines on Endoscopic Management of GI Bleeding (DOI: 10.14309/ajg.0000000000001529).
What are the limitations of the GI Bleed Endoscopic Hemostasis (ACG/ASGE)?
Known limitations include: Equipment availability varies by institution; Operator experience critical for outcomes; Hemospray/topical agents have variable availability; Combination therapy often preferred. Individual patient factors may require deviation from these recommendations.
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