GI Bleed Endoscopic Hemostasis (ACG/ASGE)

Algorithm Steps

1. ▶

   Start

   Endoscopy for GI Bleeding

   Active bleeding or high-risk stigmata identified

   1. ●

      Action

      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)
      1. ◆

         Decision

         Endoscopic Therapy Indicated?

         Based on stigmata and clinical context

         1. ●

            Action

            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
            1. ◆

               Decision

               Endoscopic Modality Selection

               Choose based on lesion and availability

               1. ●

                  Action

                  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
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ✓

                           Outcome

                           Hemostasis Achieved

                           Continue PPI, address etiology, H. pylori testing

                        2. ⚠

                           Warning

                           ⚠️ 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)
                           1. ✓

                              Outcome

                              IR Embolization/Surgery

                              For refractory bleeding after failed endoscopy

               2. ●

                  Action

                  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
               3. ●

                  Action

                  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
               4. ●

                  Action

                  Topical Hemostatic Agents

                  Hemospray/TC-325

                  • Nanopowder spray
                  • Good for diffuse bleeding, malignancy
                  • Rescue therapy if other modalities fail
                  • Temporary - may need repeat intervention
         2. ●

            Action

            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
         3. ●

            Action

            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%)