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

Theodor Bilharz Research Institute

Bibliographic Information

Authors: Barkun A.N.; Laine L.; Leontiadis G.I.; Gralnek I.M.; Carman N.; Ibrahim M.; Sey M.; Alali A.A.; Carroll M.W.; Hookey L.; Borgaonkar M.; Armstrong D.; Lau J.Y.W.; Forbes N.; Pittayanon R.; Tse F.

Journal: Gastroenterology

Publisher: W.B. Saunders

Publication Date: October 2025

Volume / Issue: Volume 169 / Issue 5

Pages: 863–891

ISSN: 165085

DOI: 10.1053/j.gastro.2025.04.041

Scopus: View on Scopus

PubMed: 40778886

Document Type: Article

Access: All Open Access; Hybrid Gold Open Access

Authors and Affiliations

Barkun A.N., Division of Gastroenterology and Hepatology, McGill University Health Centre, McGill University, Montreal, QC, Canada; Laine L., Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, Veterans Affairs Connecticut Healthcare System, West Haven, CT, United States; Leontiadis G.I., Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada; Gralnek I.M., Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel, Rappaport Family Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel; Carman N., SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children (SickKids), Toronto, ON, Canada; Ibrahim M., Department of Gastroenterology and Hepatology, Theodor Bilharz Research Institute, Cairo, Egypt; Sey M., Lawson Health Research Institute, London Health Sciences Centre, London, ON, Canada, Division of Gastroenterology, Western University, London, ON, Canada; Alali A.A., Department of Medicine, Faculty of Medicine, Kuwait University, Jabriya, Kuwait, Thunayan Alghanim Gastroenterology Center, Amiri Hospital, Sharq, Kuwait; Carroll M.W., Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada; Hookey L., Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, ON, Canada; Borgaonkar M., Department of Medicine, Memorial University, St Johns, Newfoundland, Canada; Armstrong D., Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada; Lau J.Y.W., Department of Surgery, The Chinese University of Hong Kong, New Territories, Hong Kong; Forbes N., Department of Medicine, University of Calgary, Calgary, Canada; Pittayanon R., Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tse F., Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada

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. © 2025 The Authors

Keywords

Dieulafoy's Lesions; Equity; Gastric Antral Vascular Ectasia; Gastrointestinal Hemorrhage; Gastrointestinal Neoplasms; GRADE; Mallory-Weiss Syndrome; Practice Guidelines; Canada; Endoscopy, Gastrointestinal; Evidence-Based Medicine; Gastroenterology; Hemostasis, Endoscopic; Humans; Peptic Ulcer Hemorrhage; Stomach Ulcer; Treatment Outcome; antineoplastic agent; epinephrine; hemoglobin; hemostatic agent; sclerosing agent; adult; anastomosis leakage; argon plasma coagulation; Article; artificial embolization; blood transfusion; cancer radiotherapy; cancer surgery; cancer therapy; Charlson Comorbidity Index; clinical practice guideline; clinician; Dieulafoy disease; endoscopic therapy; endoscopic variceal ligation; evidence based practice; female; Glasgow Blatchford Score; health care policy; human; Mallory Weiss syndrome; medical decision making; medical society; nonvariceal nonpeptic ulcer upper gastrointestinal bleeding; pneumonia; postoperative complication; prognosis; shared decision making; stomach antrum vascular ectasia; stomach cancer; thermocoagulation; upper gastrointestinal bleeding; adverse event; complication; endoscopic hemostasis; etiology; evidence based medicine; gastrointestinal endoscopy; peptic ulcer bleeding; practice guideline; procedures; therapy

Citation Information

Scopus Citations: 12

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