Canadian Association of Gastroenterology Clinical Practice Guideline for the Endoscopic Management of Nonvariceal Nonpeptic Ulcer Upper Gastrointestinal Bleeding

Abstract

Background & aims: Nonvariceal, nonpeptic ulcer bleeding, arising from etiologies such as malignant tumors, Mallory-Weiss tears (MWTs), Dieulafoy's lesions, and gastric antral vascular ectasia, constitutes a significant and increasing proportion of upper gastrointestinal bleeding cases. These evidence-based guidelines, developed by the Canadian Association of Gastroenterology with international collaboration, are the first to specifically address the endoscopic management of these conditions, aiming to support patients, clinicians, and others in making informed decisions.

Methods: The Canadian Association of Gastroenterology formed a guideline panel with a balanced representation to minimize potential bias from conflicts of interest. The Cochrane Gut Group supported the guideline-development process, including conducting literature searches and performing systematic reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation approach was used, including developing the Grading of Recommendations Assessment, Development and Evaluation Evidence-to-Decision frameworks, which underwent public comment.

Results: The panel formulated 19 conditional recommendations for adult patients with nonvariceal, nonpeptic ulcer bleeding due to malignant tumors, MWTs, Dieulafoy's lesions, and gastric antral vascular ectasia.

Conclusions: For patients with active bleeding from malignant tumors, the panel suggested topical hemostatic agents over conventional endoscopic hemostatic therapy; it also suggested the administration of oncologic therapy after the endoscopic intervention. In patients with active bleeding from MWTs (oozing and spurting), the panel suggested endoscopic band ligation or endoscopic through-the-scope clip over epinephrine injection alone. For nonbleeding MWTs with visible vessels, adherent clots, flat pigmented spots, or clean-based ulcers, the panel suggested against endoscopic hemostatic therapy. For Dieulafoy's lesions, the panel suggested mechanical modalities with endoscopic band ligation or through-the-scope clip, contact thermocoagulation, or injection of sclerosants over epinephrine injection alone. For patients with gastric antral vascular ectasia, the panel suggested endoscopic band ligation over argon plasma coagulation.

Guideline endorsement: This guideline has been formally endorsed by leading international endoscopy societies: the American Society for Gastrointestinal Endoscopy, the European Society of Gastrointestinal Endoscopy, the Sociedad Interamericana de Endoscopía Digestiva, and the World Endoscopy Organization, as well as by the American Gastroenterological Association.

Keywords: Dieulafoy’s Lesions; Equity; GRADE; Gastric Antral Vascular Ectasia; Gastrointestinal Hemorrhage; Gastrointestinal Neoplasms; Mallory-Weiss Syndrome; Practice Guidelines.