• gastrointestinal haemorrhage
• non-variceal haemorrhage

I enjoyed reading the guidelines on non-variceal upper gastrointestinal haemorrhage (Gut 2002;51(suppl 4):V1–6) and would like to congratulate the British Society of Gastroenterology (BSG) on their production, and hope they will form the basis for continued improvements in the management of this condition. However, several areas of the guidelines require further comment and exploration before they can be accepted as a national “gold standard” by which the management of non-variceal haemorrhage should be judged.

The guidelines give a grade A recommendation for the use of endoscopic therapy to treat adherent clots. This is despite failure of individual randomised controlled trials of endoscopic versus no endoscopic therapy to demonstrate a benefit in this subgroup.^1–4 The guidelines indicate the rationale for recommending endoscopic therapy is a meta-analysis of trials⁵; this is an incorrect interpretation of those results. The quoted meta-analysis showed that endoscopic therapy was of significant benefit in patients with active bleeding or a visible vessel but not in patients with adherent clots or flat spots.⁵ If this analysis is the …