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2017 ACG Guidelines for first-line treatment strategies of peptic ulcer disease for providers in North America

Strong recommendation

1.Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and a nitroimidazole for 10–14 days is a recommended fi rst-line treatment option. Bismuth quadruple therapy is particularly attractive in patients with any previous macrolide exposure or who are allergic to penicillin

2.Concomitant therapy consisting of a PPI, clarithromycin, amoxicillin and a nitroimidazole for 10–14 days is a recommended first-line treatment option

Conditional recommendation

1.Patients should be asked about any previous antibiotic exposure(s) and this information should be taken into consideration when choosing an H. pylori treatment regimen .

2.Clarithromycin triple therapy consisting of a PPI, clarithromycin, and amoxicillin or metronidazole for 14 days remains a recommended treatment in regions where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure for any reason.

3.Sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, clarithromycin, and a nitroimidazole for 5–7 days is a suggested first line treatment option.

4.Hybrid therapy consisting of a PPI and amoxicillin for 7 days followed by a PPI, amoxicillin, clarithromycin and a nitroimidazole for 7 days is a suggested first-line treatment option.

5.Levofloxacin triple therapy consisting of a PPI, levofloxacin, and amoxicillin for 10–14 days is a suggested first-line treatment option.

6.Fluoroquinolone sequential therapy consisting of a PPI and amoxicillin for 5–7 days followed by a PPI, fluoroquinolone, and nitroimidazole for 5–7 days is a suggested first-line treatment option.

 Initial assessment and risk stratification 

Strong recommendation

1. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed.

Conditional recommendation

1.Blood transfusions should target hemoglobin  ≥ 7   g / dl, with higher hemoglobins targeted in patients with clinical evidence of intravascular volume depletion or comorbidities, such as coronary artery disease. 2. Risk assessment should be performed to stratify patients into higher and lower risk categories and may assist in initial decisions such as the timing of endoscopy, time of discharge, and level of care.  3. Discharge from the emergency department without inpatient endoscopy may be considered in patients with urea nitrogen < 18.2   mg / dl; hemoglobin ≥  13.0   g / dl for men (12.0   g / dl for women), systolic blood pressure  ≥  110   mm   Hg; pulse   100 beats / min; and absence of melena, syncope, cardiac failure, and liver disease, as they have  <1 %  chance of requiring intervention.

Pre-endoscopic medical therapy

Conditional recommendation

1. Intravenous infusion of erythromycin (250 mg ~ 30 min before endoscopy) should be considered to improve diagnostic yield and decrease the need for repeat endoscopy. However, erythromycin has not consistently been shown to improve clinical outcomes

2. Pre-endoscopic intravenous PPI (e.g., 80 mg bolus followed by 8 mg / h infusion) may be considered to decrease the proportion of patients who have higher risk stigmata of hemorrhage at endoscopy and who receive endoscopic therapy. However, PPIs do not improve clinical outcomes such as further bleeding, surgery, or death

3. If endoscopy will be delayed or cannot be performed, intravenous PPI is recommended to reduce further bleeding.

Gastric lavage

Conditional recommendation

1. Nasogastric or orogastric lavage is not required in patients with UGIB for diagnosis, prognosis, visualization, or therapeutic effect

Timing of endoscopy

Conditional recommendation

Timing of endoscopy 1. Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems.

2. In patients who are hemodynamically stable and without serious comorbidities endoscopy should be performed as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic fi ndings who can be safely discharged.

3. In patients with higher risk clinical features (e.g., tachycardia, hypotension, bloody emesis or nasogastric aspirate in hospital) endoscopy within 12 h may be considered to potentially improve clinical outcomes.

Endoscopic diagnosis

Strong recommendation

1. Stigmata of recent hemorrhage should be recorded as they predict risk of further bleeding and guide management decisions. The stigmata, in descending risk of further bleeding, are active spurting, non-bleeding visible vessel, active oozing, adherent clot, fl at pigmented spot, and clean base .

Endoscopic therapy

Strong recommendation

1. Endoscopic therapy should be provided to patients with active spurting or oozing bleeding or a non-bleeding visible vessel.

2. Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a fl at pigmented spot .

3. Epinephrine therapy should not be used alone. If used, it should be combined with a second modality.

4. Thermal therapy with bipolar electrocoagulation or heater probe and injection of sclerosant (e.g., absolute alcohol) are recommended because they reduce further bleeding, need for surgery, and mortality.

Conditional recommendation

1. Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation. Benefi t may be greater in patients with clinical features potentially associated with a higher risk of rebleeding (e.g., older age, concurrent illness, inpatient at time bleeding began).

2. Clips are recommended because they appear to decrease further bleeding and need for surgery. However, comparisons of clips vs. other therapies yield variable results and currently used clips have not been well studied .

3. For the subset of patients with actively bleeding ulcers, thermal therapy or epinephrine plus a second modality may be preferred over clips or sclerosant alone to achieve initial hemostasis .

Medical therapy after endoscopy

Strong recommendation

1. After successful endoscopic hemostasis, intravenous PPI therapy with 80 mg bolus followed by 8 mg/h continuous infusion for 72 h should be given to patients who have an ulcer with active bleeding, a non-bleeding visible vessel, or an adherent clot.

2. Patients with ulcers that have fl at pigmented spots or clean bases can receive standard PPI therapy (e.g., oral PPI once daily).

Repeat endoscopy

Conditional recommendation

1. Routine second-look endoscopy, in which repeat endoscopy is performed 24 h after initial endoscopic hemostatic therapy, is not recommended.

2.If further bleeding occurs after a second endoscopic therapeutic session, surgery or interventional radiology with transcathether arterial embolization is generally employed

Hospitalization

Conditional recommendation

1.Patients with high-risk stigmata (active bleeding, visible vessels, clots) should generally be hospitalized for 3 days assuming no rebleeding and no other reason for hospitalization. They may be fed clear liquids soon after endoscopy.

Strong recommendation

1.Patients with clean-based ulcers may receive a regular diet and be discharged after endoscopy assuming they are hemodynamically stable, their hemoglobin is stable, they have no other medical problems, and they have a residence where they can be observed by a responsible adult.

Long-term prevention of recurrent bleeding ulcers

Strong recommendation

1.Patients with H. pylori -associated bleeding ulcers should receive H. pylori therapy. After documentation of eradication, maintenance antisecretory therapy is not needed unless the patient also requires NSAIDs or antithrombotics.

2. In patients with NSAID-associated bleeding ulcers, the need for NSAIDs should be carefully assessed and NSAIDs should not be resumed if possible. In patients who must resume NSAIDs, a COX-2 selective NSAID at the lowest effective dose plus daily PPI is recommended.

Conditional recommendation

1.In patients with low-dose aspirin-associated bleeding ulcers, the need for aspirin should be assessed. If given for secondary prevention (i.e., established cardiovascular disease) then aspirin should be resumed as soon as possible after bleeding ceases in most patients: ideally within 1 – 3 days and certainly within 7 days. Long-term daily PPI therapy should also be provided. If given for primary prevention (i.e., no established cardiovascular disease), anti-platelet therapy likely should not be resumed in most patients.

2. In patients with idiopathic (non- H. pylori , non-NSAID) ulcers, long-term antiulcer therapy (e.g., daily PPI) is recommended.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2], Sargun Singh Walia M.B.B.S.[3]

2017 ACG Guidelines for first-line treatment strategies of peptic ulcer disease for providers in North America

Strong recommendation

In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.

The following regimens can be considered for use as salvage treatment: 1.Bismuth quadruple therapy for 14 days is a recommended salvage regimen. 2.Levofloxacin triple regimen for 14 days is a recommended salvage regimen.

Conditional recommendation

Bismuth quadruple therapy or levofloxacin salvage regimens are the preferred treatment options if a patient received a first-line treatment containing clarithromycin. Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics.

Clarithromycin or levofloxacin-containing salvage regimens are the preferred treatment options, if a patient received first-line bismuth quadruple therapy. Selection of best salvage regimen should be directed by local antimicrobial resistance data and the patient’s previous exposure to antibiotics.

The following regimens can be considered for use as salvage treatment: 1.Concomitant therapy for 10–14 days is a suggested salvage regimen. 2.Clarithromycin triple therapy should be avoided as a salvage regimen. 3.Rifabutin triple regimen consisting of a PPI, amoxicillin, and rifabutin for 10 days is a suggested salvage regimen. 4.High-dose dual therapy consisting of a PPI and amoxicillin for 14 days is a suggested salvage regimen.