What is the management of upper gastrointestinal bleeding (UGIB)?

From the Guidelines

The management of upper gastrointestinal bleeding (UGIB) should prioritize prompt assessment and intervention, focusing on hemodynamic stabilization, early endoscopy, and targeted treatment to reduce morbidity, mortality, and improve quality of life. Initial management focuses on hemodynamic stabilization with intravenous fluid resuscitation using crystalloids and blood transfusion for hemoglobin levels below 7 g/dL (or 8 g/dL in patients with cardiovascular disease) 1. Proton pump inhibitors (PPIs) should be administered immediately, such as pantoprazole or esomeprazole 80 mg IV bolus followed by 8 mg/hour infusion for 72 hours. Early endoscopy within 24 hours is crucial for diagnosis and treatment, with options including epinephrine injection (1:10,000 dilution), thermal coagulation, or mechanical clips for active bleeding. For variceal bleeding, vasoactive medications like octreotide (50 mcg IV bolus followed by 50 mcg/hour for 3-5 days) should be started, and antibiotic prophylaxis with ceftriaxone 1g IV daily for 7 days is recommended. Patients with peptic ulcer disease should receive oral PPI therapy (e.g., omeprazole 20 mg twice daily) for 4-8 weeks after the acute phase, along with H. pylori testing and eradication if positive. Antithrombotic medications should be temporarily discontinued but restarted based on thrombotic risk assessment. Risk stratification using scoring systems like Glasgow-Blatchford helps determine the need for intervention and hospitalization. This comprehensive approach addresses both immediate bleeding control and prevention of recurrence by targeting underlying causes, as supported by recent guidelines and expert statements 1.

Some key points to consider in the management of UGIB include:

• Early risk stratification using validated prognostic scales
• Early endoscopy (within 24 hours) for diagnosis and treatment
• Endoscopic hemostasis for high-risk lesions
• Use of PPIs and other medications to reduce rebleeding and mortality
• Hospitalization for at least 72 hours after endoscopic hemostasis for high-risk patients
• Consideration of cardiovascular risks and benefits when restarting antithrombotic medications.

Overall, the management of UGIB requires a multidisciplinary approach, taking into account the latest evidence and guidelines to optimize patient outcomes and reduce morbidity and mortality 1.

From the Research

Diagnosis and Initial Management

• Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department, with numerous causes, including peptic ulcer disease and variceal bleeding 2.
• Nasogastric tube lavage for diagnosis is not recommended based on current evidence 2.
• A hemoglobin transfusion threshold of 7 g/dL is recommended, with 8 g/dL in those with myocardial ischemia 2.
• Patients with severe bleeding and hemodynamic instability require emergent transfusion regardless of their hemoglobin level 2.

Medications and Therapies

• Medications that may be used in UGIB include proton pump inhibitors, prokinetic agents, and vasoactive medications 2.
• Antibiotics are recommended for those with cirrhosis and suspected variceal bleeding 2, 3.
• Proton pump inhibitors should be initiated upon presentation with upper GI bleeding, with high-dose treatment recommended for the first 72 hours post-endoscopy 4.

Endoscopy and Interventional Procedures

• Endoscopy is the diagnostic and therapeutic modality of choice and should be performed within 24 hours of presentation in non-variceal bleeding after resuscitation 2, 3.
• Patients with variceal bleeding may require endoscopy within 12 hours 2.
• Endoscopic treatment is used for variceal bleeding and high-risk non-variceal bleeding 3.
• Transcatheter arterial embolization or surgical intervention may be necessary in cases of failed endoscopic hemostasis 3, 4.

Risk Stratification and Patient Management

• Clinical prediction guides, such as the Glasgow-Blatchford bleeding score, are necessary for upper GI bleeding risk stratification and to determine therapy 2, 4.
• Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation 4.
• Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult due to a lack of sufficient data 4.