What is the first-line treatment for upper gastrointestinal (GI) bleed?

From the Guidelines

The first-line treatment for upper gastrointestinal (GI) bleeding is a combination of hemodynamic stabilization, proton pump inhibitor (PPI) therapy, and endoscopic intervention. Initially, patients should be resuscitated with intravenous fluids and blood products as needed to maintain hemodynamic stability. High-dose intravenous PPI therapy should be started immediately, typically with pantoprazole or esomeprazole 80mg IV bolus followed by 8mg/hour continuous infusion for 72 hours 1. Urgent endoscopy should be performed within 24 hours of presentation, ideally within 12 hours for patients with high-risk features. During endoscopy, therapeutic interventions such as epinephrine injection, thermal coagulation, or mechanical clips may be applied to actively bleeding lesions. Some key points to consider in the management of upper GI bleeding include:

• The importance of early endoscopy in diagnosing and treating the cause of bleeding 1
• The use of PPIs in reducing rebleeding rates and mortality 1
• The role of vasoactive drugs, such as terlipressin, somatostatin, or octreotide, in the management of variceal hemorrhage 1
• The need for antibiotic prophylaxis in patients with cirrhosis and upper GI bleeding 1 It is essential to note that the management of upper GI bleeding should be individualized based on the patient's underlying condition, the severity of bleeding, and the presence of any comorbidities. The combination of pharmacological acid suppression and endoscopic therapy significantly reduces rebleeding rates, need for surgery, and mortality compared to either approach alone.

From the Research

First-Line Treatment for Upper GI Bleed

The first-line treatment for upper gastrointestinal (GI) bleed involves a combination of medical therapy, endoscopy, and supportive care.

• The use of proton pump inhibitors (PPIs) is a key component of medical therapy, with studies suggesting that high-dose PPI infusion may not be superior to low-dose PPI therapy in preventing rebleeding 2, 3.
• Endoscopy should be undertaken within 24 hours, with earlier endoscopy considered after resuscitation in patients at high risk, such as those with hemodynamic instability 4.
• Supportive care includes intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L 4.
• The prokinetic agent erythromycin may be administered, with antibiotics and vasoactive drugs recommended in patients who have cirrhosis 4.

Proton Pump Inhibitor (PPI) Therapy

PPI therapy is an attractive adjuvant to endoscopic treatment in upper GI bleed, but the method and dose of PPI therapy remains controversial.

• Studies have compared the treatment effects of continuous infusion and low-dose PPI therapies, with no significant difference observed in rebleeding rates, need for surgery, and mortality rate 2, 3.
• Intermittent bolus dosing of intravenous PPIs may be as effective as continuous infusion dosing, with lower costs and easier administration 5.
• The choice of PPI therapy should be individualized based on patient risk factors and clinical presentation, with high-dose PPI infusion considered for patients at high risk of rebleeding 4.

Endoscopic Treatment

Endoscopic treatment is used for variceal bleeding and high-risk non-variceal bleeding.

• Endoscopic therapy, such as ligation for esophageal varices and tissue glue for gastric varices, is effective in controlling variceal bleeding 4.
• For non-variceal bleeding, endoscopic therapy, such as injection, thermal probes, or clips, is used for lesions with active bleeding or non-bleeding visible vessel 4.
• Patients who require endoscopic therapy for ulcer bleeding should receive high-dose PPIs after endoscopy, whereas those who have variceal bleeding should continue taking antibiotics and vasoactive drugs 4.