This update of the 2010 International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding (UGIB) refines previous important statements and presents new clinically relevant recommendations. Methods: An international multidisciplinary group of experts developed the recommendations. Data sources included evidence summarized in previous recommendations, as well as systematic reviews and trials identified from a series of literature searches of several electronic bibliographic databases from inception to April 2018. Using an iterative process, group members formulated key questions. Two methodologists prepared evidence profiles and assessed quality (certainty) of evidence relevant to the key questions according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Group members reviewed the evidence profiles and, using a consensus process, voted on recommendations and determined the strength of recommendations as strong or conditional. Recommendations: Preendoscopic management: The group suggests using a Glasgow Blatchford score of 1 or less to identify patients at very low risk for rebleeding, who may not require hospitalization. In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease. Endoscopic management: The group suggests that patients with acute UGIB undergo endoscopy within 24 hours of presentation. Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata. Use of TC-325 (hemostatic powder) was suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers. Pharmacologic management: The group recommends that patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy receive high-dose proton-pump inhibitor (PPI) therapy (intravenous loading dose followed by continuous infusion) for 3 days. For these high-risk patients, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a total duration that depends on the nature of the bleeding lesion. Secondary prophylaxis: The group suggests PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis.# 
meeting included up to 20 voting participants for each statement (numbers varied, mainly because of travel difficulties), 2 nonvoting GRADE methodologists, and a nonvoting moderator (J.K.M).
The cochairs, other steering committee members, and methodologists generated a list of new and old statements that were presented to the group through an anonymous, Web-based consensus platform (ECD Solutions). Via teleconference, the steering committee members reached consensus on which statements warranted inclusion in the guideline by focusing on priority areas. Using a modified Delphi process (14), all voting participants modified and finalized the new statements. After reviewing the evidence profiles, the participants anonymously voted on their degree of agreement or disagreement with each statement and submitted comments. Votes were nonbinding and designed to gauge the extent of agreement and the pattern of evidence uncertainty to guide the allotment of time for discussion during the meeting. The Canadian Association of Gastroenterology (CAG) office tabulated the votes and comments and presented the results to the group. Although initially discussed in the form of declarative statements, these were edited into specific PICO questions by the methodologists before the consensus meeting.
At a 2-day consensus meeting in May 2018, the group applied the GRADE Evidence to Decision framework to move from evidence to recommendations by assessing 7 key criteria: the balance between desirable and undesirable effects, quality (certainty) of the evidence, variability in patients' values and preferences, resource requirements, cost-effectiveness, acceptability, and feasibility (Supplement Appendix 2) (15)(16)(17). Participants voted on the direction of the PICO question (for or against) as yes, uncertain, or no. Consensus for or against a specific strategy was reached if at least 75% of the participants voted yes or no, respectively. For PICO questions on which agreement was reached, the group then discussed the strength of the recommendation (strong vs. conditional) by considering the factors in the Evidence to Decision framework (18). In cases of low or very low QoE, unless at least 1 of the other 3 factors was overwhelmingly strong, the strength of the recommendation would default (without a vote) to "conditional" by using the phrase "we suggest." If the statement warranted a vote and at least 75% of the participants voted "strong," then the recommendation would be designated as strong with the phrase "we recommend."
Consensus was not reached on 4 PICO questions (no recommendation A to D), because fewer than 75% of the participants voted either yes or no. No corresponding statements were developed for these questions, but the pertinent evidence and discussions are summarized briefly in the text.

# Oversight and Review
The guideline process was overseen by the CAG clinical affairs committee to ensure methodological quality and a transparent, nonbiased, evidence-based

# CLINICAL GUIDELINE
Management of Upper Gastrointestinal Bleeding decision-making process. Recommendations are based on evidence from the literature and consensus discussion and may not fully reflect the product labeling for a given country.
The manuscript was initially drafted by the cochairs (A.N.B. and M.B.) and the GRADE experts (F.T. and G.I.L.). It was reviewed and revised by the steering committee members (E.J.K., J.S., L.L., and M.A.) before dissemination to the full consensus group for feedback. Finally, the manuscript was posted on the CAG Web site, and members were invited via e-mail to submit comments over a 2-week period.
In accordance with CAG policy, written conflict-ofinterest disclosures for the 24 months preceding the consensus meeting were provided by all participants and made available to the group.

# Role of the Funding Source