From the Guidelines
The immediate management for an upper gastrointestinal (GI) bleed involves rapid assessment and resuscitation, with the most recent guidelines from 2024 1 emphasizing the importance of early risk stratification and endoscopy within 24 hours.
Key Steps in Management
- Establish two large-bore IV lines (16-18 gauge) and begin fluid resuscitation with crystalloids while obtaining blood for laboratory tests including complete blood count, coagulation studies, and type and cross-match.
- Administer blood products as needed, targeting a hemoglobin of at least 7 g/dL (or 9 g/dL in patients with cardiovascular disease) as suggested by previous guidelines 1.
- Start a proton pump inhibitor (PPI) such as pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion, which is supported by the latest update 1 for reducing rebleeding risk.
- Correct any coagulopathy with fresh frozen plasma, platelets, or vitamin K as appropriate, considering the patient's specific condition and the latest recommendations 1.
- Place a nasogastric tube to assess ongoing bleeding and clear the stomach of blood before endoscopy, as part of the initial assessment and preparation for endoscopy.
- Arrange for urgent endoscopy within 24 hours (or sooner if hemodynamically unstable), which is a crucial step for both diagnosis and treatment, as emphasized in the recent guidelines 1.
- Consider terlipressin 2 mg IV every 4 hours or octreotide 50 mcg IV bolus followed by 50 mcg/hour infusion if variceal bleeding is suspected, based on the clinical presentation and risk factors.
- Monitor vital signs closely, maintain oxygen saturation above 92%, and consider ICU admission for unstable patients, as these measures are critical for preventing complications and improving outcomes 1.
Rationale
The approach to managing upper GI bleed prioritizes stabilization of the patient, identification of the bleeding source, and timely intervention to control the bleed and prevent rebleeding. The use of PPIs, such as pantoprazole, is supported by evidence for its role in reducing gastric acidity, which helps in stabilizing clots and decreasing the risk of rebleeding 1. Early endoscopy is recommended for its diagnostic and therapeutic benefits, allowing for the direct visualization of the bleeding site and the application of appropriate therapeutic measures to achieve hemostasis 1. The management strategy should be tailored to the individual patient's risk factors, clinical presentation, and response to initial treatment, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the Research
Immediate Management of Upper GI Bleed
The immediate management of an upper gastrointestinal (GI) bleed involves several key steps:
- Resuscitation with intravenous fluids and blood transfusions as needed to maintain blood pressure and hemoglobin levels 2, 3
- Administration of proton pump inhibitors (PPIs) to reduce gastric acid production 4, 5, 2, 3
- Endoscopy within 24 hours of presentation to diagnose and treat the cause of the bleed 2, 3
- Use of clinical prediction guides, such as the Glasgow-Blatchford bleeding score, to stratify risk and determine therapy 3
Pharmacologic Intervention
Pharmacologic intervention for upper GI bleed includes:
- Proton pump inhibitors (PPIs) as the main pharmacologic intervention 4
- Use of PPIs prior to endoscopy to reduce the need for endoscopic haemostatic treatment 6
- Administration of antibiotics and vasoactive drugs in patients with cirrhosis 2
Endoscopic Intervention
Endoscopic intervention for upper GI bleed includes:
- Endoscopy within 24 hours of presentation to diagnose and treat the cause of the bleed 2, 3
- Use of endoscopic therapy, such as ligation, thermal probes, or clips, to treat variceal and non-variceal bleeding 2
- Early endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability 2
Multidisciplinary Collaboration
The management of severe upper GI bleed requires multidisciplinary collaboration, including: