ESGE 2026 Guideline on Peptic Ulcer Bleeding: Key Updates for Endoscopists and GI Teams
Clinician-focused review of ESGE’s 2026 peptic ulcer bleeding guideline, covering timing, hemostasis, rescue therapy, PPIs, and follow-up.
A bleeding ulcer is rarely just an endoscopic problem
Peptic ulcer bleeding remains one of those situations in gastroenterology where several decisions arrive at once.
The patient may be hypotensive. Hemoglobin is falling. Anticoagulation may be on board. There may be ongoing hematemesis, uncertainty about airway protection, pressure to scope quickly, and—once the ulcer is found—the equally familiar question of which hemostatic tool should come out first.
For years, much of the discussion around ulcer bleeding has focused on what happens once the scope reaches the lesion: inject, clip, coagulate, repeat.
The 2026 European Society of Gastrointestinal Endoscopy update takes a broader view.
The guideline, “Endoscopic diagnosis and management of peptic ulcer bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2026,” was published online on May 13, 2026, in Endoscopy. It updates the 2021 ESGE guidance on nonvariceal upper gastrointestinal hemorrhage and focuses specifically on the pre-endoscopic, endoscopic, and postendoscopic management of peptic ulcer bleeding.
That narrower scope is worth remembering. This is guidance for peptic ulcer hemorrhage, not a universal algorithm for every cause of nonvariceal upper GI bleeding.
The methodology matters because not every recommendation carries the same weight
ESGE developed the update using structured PICO questions, formal literature searches, evidence synthesis, and the GRADE framework. The search covered English-language literature from 1946 through August 2025 across MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews.
For the practising gastroenterologist, that matters because guidelines are often read more uniformly than they were written.
Some recommendations are strong and rest on relatively mature evidence. Others are conditional, supported by lower-certainty data, or dependent on operator skill and local resources.
It is therefore better to think of this document as a decision map rather than a checklist.
That distinction becomes particularly important around newer devices, clot management, pre-endoscopy adjuncts, and rescue therapy.
Before the scope: stabilize first, then earn the right to hurry
The guideline retains the fundamentals.
Patients with acute upper gastrointestinal hemorrhage should undergo immediate hemodynamic assessment, with prompt crystalloid volume replacement when instability is present. In hemodynamically stable patients without cardiovascular disease, ESGE supports a restrictive red-cell transfusion strategy using a hemoglobin threshold below 7 g/dL and a post-transfusion target of 7–9 g/dL.
For patients with cardiovascular disease, the recommended threshold is more liberal: 8 g/dL, with a target hemoglobin of at least 10 g/dL.
These are not glamorous recommendations, but in real practice they matter more than the newest hemostatic device.
The endoscopic procedure begins, in effect, before the endoscope enters the room.
Risk stratification remains centered on the Glasgow–Blatchford Score. ESGE recommends pre-endoscopic GBS assessment and states that patients with a score of 1 or less can be managed safely as outpatients with outpatient endoscopy.
That is clinically useful for two reasons.
First, it helps identify the genuinely low-risk patient who does not need admission simply because the presenting complaint contains the words “GI bleed.”
Second, it protects resources for those who actually need monitored care, transfusion, urgent intervention, or escalation.
In a busy service, avoiding unnecessary admission is not a lesser form of good medicine.
Earlier is not always better
One of the more important 2026 messages concerns the timing of endoscopy.
ESGE does not recommend emergent endoscopy within 6 hours or urgent endoscopy within 12 hours unless the patient remains hemodynamically unstable despite adequate resuscitation.
Early endoscopy still matters. The pathway continues to support upper GI endoscopy within 24 hours after resuscitation and risk assessment.
But the sequence is important:
resuscitate first, scope early, and reserve truly urgent endoscopy for persistent instability.
This is a useful corrective to a common procedural reflex.
There is understandable pressure to equate faster endoscopy with better care. Sometimes it is. Sometimes a patient needs stabilization more than they need a scope six hours earlier.
The guideline makes that distinction explicit.
Pre-endoscopy adjuncts: useful when selected, unnecessary when routine
The update also places clear boundaries around interventions before endoscopy.
Routine video capsule endoscopy or telemetric blood-sensing capsules are not recommended for suspected upper GI hemorrhage.
For patients with clinically severe or ongoing active bleeding, intravenous erythromycin remains an option to improve gastric visualization.
A practical addition in 2026 is that intravenous metoclopramide may be used when erythromycin is unavailable in selected patients with severe or ongoing upper GI hemorrhage.
The strength of that statement matters: it is a conditional recommendation based on low-quality evidence.
That is precisely the sort of recommendation that can easily become overgeneralized once it enters a protocol.
It should not.
Pre-endoscopy high-dose intravenous proton pump inhibitor therapy may also be considered, but ESGE explicitly states that it should not delay early endoscopy.
Again, useful adjunct—not a reason to postpone definitive evaluation.
Airway protection still requires judgement, not a standing order
Another area where the guideline favors selectivity is prophylactic intubation.
Routine prophylactic endotracheal intubation before upper GI endoscopy is not recommended.
Instead, intubation should be reserved for selected patients, including those with ongoing active hematemesis, agitation, encephalopathy, or inability to adequately protect the airway.
This is sensible.
A patient with brisk hematemesis and altered consciousness is quite different from a stable patient with melena and preserved airway reflexes.
Both technically have upper GI bleeding.
Only one may clearly benefit from prophylactic airway protection.
Guidelines are most useful when they preserve those distinctions.
Forrest classification still earns its place
Despite all the newer technology, the Forrest classification remains central to treatment decisions.
Active bleeding lesions—Forrest Ia and Ib—require endoscopic hemostasis.
A nonbleeding visible vessel, Forrest IIa, is also treated as a high-risk lesion.
Low-risk stigmata such as a flat pigmented spot or clean ulcer base do not require endoscopic therapy and can move toward medical management and, where appropriate, earlier discharge.
The more interesting territory remains Forrest IIb: the adherent clot.
ESGE suggests attempting clot removal and then treating any underlying high-risk stigma, provided the endoscopist has the technical competence to remove the clot safely and manage the bleeding that may be uncovered.
That final clause matters enormously.
Removing a clot is not simply a diagnostic manoeuvre.
One may turn a quiet-looking ulcer into an actively bleeding lesion within seconds.
The recommendation therefore belongs to operators who are prepared not only to expose the vessel, but also to control it.
Sometimes the clot is less cooperative after you introduce yourself.
OTS clips are moving from rescue toward selected first-line use
One of the clearest device-related shifts in the 2026 update is the expanded role of over-the-scope clips.
For Forrest Ia and Ib lesions, ESGE suggests that an OTS clip may be used as monotherapy as an alternative to combination therapy, based on evidence suggesting a lower risk of further bleeding compared with standard endoscopic hemostatic approaches.
For Forrest IIa lesions, the guideline continues to support thermal therapy, mechanical therapy with through-the-scope or over-the-scope clips, or sclerosing injection, either alone or combined with epinephrine.
OTS clips may also be used as alternative monotherapy in this setting.
The practical shift is significant.
OTS clips are no longer confined to the mental category of “what we reach for after standard therapy fails.”
They may now move earlier in selected high-risk lesions.
But “may be used” should not quietly become “should be used everywhere.”
An OTS clip is only as useful as the operator’s ability to reach the lesion, position the cap, capture the correct tissue, and deploy the device safely. Device availability, anatomy, fibrotic ulcer bases, lesion orientation, and local experience all matter.
The guideline supports earlier consideration, not indiscriminate deployment.
Hemostatic forceps also gain room in the toolbox
ESGE also states that hemostatic forceps with soft coagulation may be used as monotherapy for high-risk stigmata including Forrest Ia, Ib, and IIa lesions.
For experienced therapeutic endoscopists, this is a useful acknowledgement of what many already recognize at the bedside: a precisely targeted vessel may sometimes be more effectively treated with controlled soft coagulation than with repeated attempts at mechanically awkward clipping.
Again, device choice is inseparable from operator familiarity and lesion geometry.
No guideline can make a posterior duodenal bulb ulcer more polite.
Hemostatic powder: valuable rescue, poor excuse for weak first-line therapy
Topical hemostatic agents have become increasingly attractive because they are quick to deploy and can be useful when active bleeding obscures the field.
ESGE nevertheless draws a clear boundary.
Topical hemostatic agents should not be used as first-line monotherapy for high-risk peptic ulcer bleeding stigmata.
Their role is primarily in refractory bleeding.
If standard endoscopic hemostasis fails, ESGE suggests considering a topical hemostatic agent or an OTS clip.
That distinction is clinically important.
Ease of application should not be confused with durability of hemostasis.
A powder may control an unpleasant bleeding field and buy time. It should not automatically replace the mechanical or thermal treatment of an identifiable high-risk lesion when definitive therapy is feasible.
When the endoscope has done enough
Some ulcers will continue to bleed despite well-performed endoscopic therapy.
The 2026 pathway is relatively clear about what comes next.
When persistent bleeding remains refractory to all available endoscopic modalities—including topical hemostatic agents and OTS clips—transcatheter angiographic embolization should be considered.
Surgery becomes appropriate when TAE is unavailable locally or when embolization fails.
For recurrent bleeding after initial hemostasis, ESGE recommends another endoscopic attempt and consideration of an OTS clip. If that attempt fails, the pathway again moves toward TAE, with surgery reserved for cases where embolization cannot be performed or is unsuccessful.
This escalation sequence matters because recurrent bleeding is one of the situations in which teams can lose time repeating increasingly unproductive procedures.
Knowing when to stop endoscoping is part of good endoscopy.
What happens after hemostasis matters almost as much
The postendoscopy section is one of the most practical parts of the guideline.
High-dose PPI therapy should be given after successful endoscopic hemostasis and also to patients with an adherent clot who do not undergo endoscopic therapy.
The guideline allows several approaches, including intravenous bolus followed by continuous infusion, at least twice-daily intravenous bolus therapy for 72 hours, or oral therapy.
The management of Helicobacter pylori remains equally important.
Testing should be performed at index endoscopy, with treatment when positive.
If initial testing is negative, clinicians should verify that the result is truly negative. Repeat testing is recommended, with PPIs withheld for at least two weeks beforehand.
This is not a minor follow-up detail.
Acute bleeding and acid suppression can produce false-negative results, and missing H. pylori means leaving a preventable cause of recurrent ulcer disease untreated.
Stopping the bleeding while forgetting the cause is an incomplete victory.
Anticoagulation, anemia, and nutrition belong in the same pathway
For patients who still require anticoagulation, ESGE recommends resuming therapy as soon as clinically indicated according to thromboembolic risk.
There is deliberately no universal restart day.
The balance depends on the competing risks of recurrent bleeding and thrombosis.
Two additional recommendations are particularly practical.
ESGE suggests initiating iron therapy before discharge in patients with iron deficiency and/or anemia following peptic ulcer bleeding.
It also suggests early oral nutrition within 24 hours after successful hemostasis when durable control has been achieved.
These may appear less dramatic than an OTS clip or embolization.
They are also the sort of details that determine whether the patient leaves hospital still depleted, weak, and halfway through recovery.
What the 2026 update changes—and what it does not
Several conclusions are well supported by the guideline.
Resuscitation and risk stratification remain foundational.
GBS still helps identify very-low-risk patients.
Early endoscopy within 24 hours remains the default for appropriate patients, while emergent or urgent endoscopy is discouraged in those who have stabilized.
Forrest classification continues to drive endoscopic treatment.
OTS clips now have an expanded role in selected high-risk and recurrent bleeding scenarios.
Hemostatic forceps are acknowledged as an additional option in experienced hands.
Topical agents remain primarily rescue tools rather than preferred definitive first-line monotherapy.
And when endoscopic therapy has failed, escalation to TAE should not be indefinitely postponed.
There are equally important things clinicians should not conclude.
Not every patient needs the fastest possible endoscopy.
Not every adherent clot should be removed by every operator.
OTS clips do not eliminate the need for anatomical judgement or technical expertise.
Hemostatic powders should not become a shortcut around durable first-line treatment.
And these recommendations should not be casually generalized to every cause of nonvariceal upper GI hemorrhage, because the 2026 update is specifically focused on peptic ulcer bleeding.
Clinical Takeaway
The ESGE 2026 guideline does not reinvent peptic ulcer bleeding management.
It refines it.
The central message is to move through the episode in a disciplined sequence:
stabilize first; stratify risk; perform early rather than reflexively emergent endoscopy; classify the ulcer accurately; choose durable hemostasis according to the stigma and operator capability; escalate decisively when endoscopy fails; and complete the job with acid suppression, H. pylori management, anticoagulation planning, iron replacement, and nutrition.
For the endoscopist, the most noticeable technical change is probably the earlier role assigned to OTS clips.
For the wider GI team, the more important change may be conceptual: good ulcer bleeding care is not defined by how quickly one can deploy a device.
It is defined by making the right decision at each stage of the pathway.
The guideline also reminds us that new tools do not abolish old principles.
Resuscitation still matters.
Risk stratification still matters.
Forrest classification still matters.
Knowing when endoscopy has failed still matters.
And perhaps most importantly, the patient still needs care after the vessel has stopped bleeding.
Five points worth carrying into practice
This is a formal ESGE guideline update. It was developed using PICO questions, systematic literature searching, evidence synthesis, and GRADE methodology.
Do not confuse speed with quality. Emergent or urgent endoscopy is not recommended unless hemodynamic instability persists despite adequate resuscitation.
Forrest classification remains the treatment backbone. Active bleeding and visible vessels require therapy; adherent clots require selective management by operators capable of treating what lies beneath.
OTS clips now have an earlier role. They may be used as alternative monotherapy in selected high-risk lesions and should be considered in recurrent bleeding, but technical expertise and lesion suitability remain important.
Have a rescue pathway before you need one. Refractory bleeding should progress from endoscopic rescue modalities to transcatheter angiographic embolization, with surgery when TAE is unavailable or unsuccessful.
Source
Gralnek IM, Morris J, Laursen SB, Camus M, Tziatzios G, Debels LK, Nigam GB, Erőss B, Goetz M, Forbes N, Cúrdia Gonçalves T, Kurek K, Bretthauer M, Tham TC. Endoscopic diagnosis and management of peptic ulcer bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2026. Endoscopy. 2026;58:899–924. Published online May 13, 2026. DOI: 10.1055/a-2863-8314.
References
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