From the Guidelines
The management of an active upper gastrointestinal bleed requires prompt resuscitation, medical therapy, and endoscopic intervention, with a focus on hemodynamic stabilization, proton pump inhibitor therapy, and urgent endoscopy within 24 hours. Initial management focuses on hemodynamic stabilization with intravenous fluids (normal saline or lactated Ringer's) and blood transfusion for hemoglobin levels below 7-8 g/dL 1. Proton pump inhibitors (PPIs) should be started immediately with an 80 mg IV bolus of pantoprazole or esomeprazole followed by continuous infusion at 8 mg/hour for 72 hours, or high-dose oral therapy (40 mg twice daily) 1. Octreotide (50-100 mcg IV bolus followed by 25-50 mcg/hour infusion for 3-5 days) is indicated for suspected variceal bleeding 1. Urgent endoscopy within 24 hours (within 12 hours for severe bleeding) is essential for diagnosis and therapeutic intervention, including clipping, thermal coagulation, or injection therapy for non-variceal bleeding, and band ligation or sclerotherapy for varices 1. Patients should be risk-stratified using tools like the Glasgow-Blatchford score to determine the level of care needed 1. Correction of coagulopathy with vitamin K, fresh frozen plasma, or prothrombin complex concentrate may be necessary 1. Antibiotics (ceftriaxone 1g daily) are recommended for patients with cirrhosis and GI bleeding to prevent bacterial infections that can worsen outcomes 1. Early consultation with gastroenterology and surgical teams is important for comprehensive management and to prepare for potential interventional radiology or surgical intervention if endoscopic therapy fails 1.
Some key points to consider in the management of upper GI bleeding include:
- The importance of prompt resuscitation and hemodynamic stabilization
- The use of proton pump inhibitors to reduce the risk of rebleeding
- The role of urgent endoscopy in diagnosis and therapeutic intervention
- The need for risk stratification using tools like the Glasgow-Blatchford score
- The importance of correcting coagulopathy and preventing bacterial infections in patients with cirrhosis and GI bleeding
- The need for early consultation with gastroenterology and surgical teams for comprehensive management.
Overall, the management of upper GI bleeding requires a multidisciplinary approach, with a focus on prompt resuscitation, medical therapy, and endoscopic intervention, as well as attention to risk stratification, coagulopathy correction, and prevention of bacterial infections.
From the Research
Active Upper GI Bleed Management
The management of active upper gastrointestinal (GI) bleed involves a step-wise approach, including:
- Hemodynamic status assessment and resuscitation as needed 2
- Risk stratification based on features such as hemodynamic status, comorbidities, age, and laboratory tests 2
- Pre-endoscopic erythromycin to increase diagnostic yield at first endoscopy 2
- Pre-endoscopic proton pump inhibitor (PPI) to decrease the need for endoscopic therapy, although it may not improve clinical outcomes 2, 3
Endoscopic Management
- Upper endoscopy is generally performed within 24 hours 2, 4, 5, 6
- Endoscopic features of ulcers direct further management:
- Active bleeding or non-bleeding visible vessels: receive endoscopic therapy (e.g., bipolar electrocoagulation, heater probe, sclerosant, clips) and intravenous PPI 2, 4, 6
- Adherent clot: may receive endoscopic therapy 2
- Flat spots or clean-based ulcers: do not require endoscopic therapy or intensive PPI therapy 2
Medical Management
- PPI treatment initiated before endoscopy may reduce the requirement for endoscopic haemostatic treatment at index endoscopy, but its effect on other clinical outcomes is uncertain 3
- High-dose PPI treatment is recommended for the first 72 hours post-endoscopy, as this is when rebleeding risk is highest 6
- Antithrombotic therapy should be restarted early in patients who require it, as outcomes appear to be better when these drugs are reintroduced early 4