What is the recommended evaluation and management for upper gastrointestinal (GI) bleeding?

Management of Upper Gastrointestinal Bleeding

For patients presenting with acute upper GI bleeding, initiate resuscitation immediately if hemodynamically unstable, perform risk stratification using Glasgow Blatchford score (discharge if ≤1), transfuse at hemoglobin <7 g/dL (higher if cardiovascular disease present), administer IV erythromycin and PPI pre-endoscopy, and perform endoscopy within 24 hours with endoscopic hemostasis for high-risk stigmata (active bleeding or visible vessel). 1

Pre-Endoscopic Management

Resuscitation and Risk Assessment

• Immediate resuscitation is required for hemodynamically unstable patients 1
• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who can be safely discharged without hospitalization or inpatient endoscopy 1
• Do not use AIMS65 score for risk stratification—it lacks sufficient predictive value 1

Transfusion Strategy

• Transfuse at hemoglobin <8 g/dL (80 g/L) in patients without cardiovascular disease 1
• Use a higher threshold for patients with underlying cardiovascular disease 1
• This restrictive strategy improves outcomes compared to liberal transfusion 2, 3

Pharmacologic Pre-Treatment

• Administer IV erythromycin before endoscopy to improve visualization by promoting gastric emptying 1, 4
• If erythromycin unavailable, consider IV metoclopramide in patients with severe or ongoing active bleeding 4
• Pre-endoscopic PPI therapy may be considered to downstage lesions and reduce need for intervention, but should not delay endoscopy 1

Special Populations

• Do not delay endoscopy in patients on anticoagulants (warfarin or DOACs) 1
• For cirrhotic patients with suspected variceal bleeding, add prophylactic antibiotics and vasoactive medications 3

Endoscopic Management

Timing

• Perform endoscopy within 24 hours of presentation for all admitted patients 1, 4
• Do not perform emergent endoscopy (≤6 hours) or urgent endoscopy (≤12 hours) unless the patient remains hemodynamically unstable despite adequate resuscitation 4

Peptic Ulcer Disease - Treatment by Forrest Classification

High-Risk Stigmata (Forrest Ia, Ib, IIa):

• Endoscopic hemostatic therapy is mandatory 1

• Recommended modalities include:

  • Thermocoagulation (bipolar, heater probe) 1, 5
  • Sclerosant injection 1
  • Through-the-scope clips 1, 4
  • Over-the-scope (OTS) clips as monotherapy are suggested as first-line alternative with lower rebleeding risk 4
  • Hemostatic forceps with soft coagulation may be used as monotherapy 4

• Epinephrine injection alone is inadequate and must be combined with another method 1

Adherent Clot (Forrest IIb):

• Attempt clot removal with targeted irrigation 1
• If clot removed and high-risk stigmata revealed, treat accordingly 1
• Endoscopic therapy should be performed if the endoscopist has technical competence to safely remove clot and manage potential conversion to higher-risk lesion 4
• Intensive PPI therapy alone may be sufficient if clot not removed 1

Low-Risk Stigmata:

• No endoscopic therapy indicated for clean-based ulcers or flat pigmented spots 1

Nonvariceal Nonpeptic Ulcer Bleeding (Newer 2025 Guidance)

Malignant Tumors:

• Use topical hemostatic agents over conventional endoscopic therapy for active bleeding 6
• Administer oncologic therapy after endoscopic intervention 6

Mallory-Weiss Tears:

• For active bleeding (oozing/spurting): Use endoscopic band ligation or through-the-scope clips over epinephrine alone 6
• For nonbleeding tears with any stigmata: Do not perform endoscopic therapy 6

Dieulafoy's Lesions:

• Use mechanical modalities (band ligation or clips), contact thermocoagulation, or sclerosants over epinephrine alone 6

Gastric Antral Vascular Ectasia (GAVE):

• Endoscopic band ligation is preferred over argon plasma coagulation 6

Refractory Bleeding

• For persistent bleeding despite standard hemostasis: Consider topical hemostatic agents (TC-325 powder) or OTS clips 4
• TC-325 should be used as temporizing therapy only, not sole treatment 1
• If all endoscopic modalities fail: Transcatheter arterial embolization (TAE) is preferred over surgery 4

Post-Endoscopic Management

PPI Therapy

• For high-risk stigmata with successful hemostasis: Administer high-dose IV PPI (loading dose followed by continuous infusion) for 72 hours 1
• Continue oral PPI twice daily through 14 days, then once daily for total duration depending on lesion nature 1

Early Feeding

• Initiate early oral nutrition within 24 hours following endoscopic hemostasis in patients with durable hemostasis 4

Iron Therapy

• Initiate iron therapy prior to hospital discharge in patients with iron deficiency and/or anemia 4

Anticoagulation Management

• Resume anticoagulation as soon as clinically indicated based on thromboembolic risk 4

Management of Rebleeding

• First-line: Repeat endoscopic therapy 1, 5, 3
• Consider OTS clips for recurrent bleeding after previous successful hemostasis 4
• If second endoscopic attempt fails: TAE should be performed 4
• Surgery is indicated only when TAE unavailable or unsuccessful 4
• Prophylactic TAE may be considered in selected high-risk cases (hemodynamic instability, posterior duodenal ulcer, ulcer >2 cm, uncertain endoscopic hemostasis durability) 4

Common Pitfalls to Avoid

• Do not use epinephrine injection as monotherapy—always combine with thermal or mechanical therapy 1
• Do not use hemostatic agents as monotherapy for first-line treatment of high-risk stigmata 4
• Do not routinely use promotility agents—only erythromycin (or metoclopramide if unavailable) has evidence 1, 4
• Do not perform emergent endoscopy in stable patients—within 24 hours is appropriate 4
• Do not delay endoscopy for anticoagulation reversal in most cases 1