How is upper gastrointestinal bleeding managed?

Management of Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding requires immediate risk stratification, early endoscopy within 24 hours, appropriate endoscopic hemostasis for high-risk lesions, and high-dose proton pump inhibitor therapy after successful endoscopic intervention to reduce rebleeding and mortality. 1

Initial Assessment and Resuscitation

• Risk stratification: Use the Glasgow Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization 1
• Hemodynamic stabilization:
  • Intravenous fluid resuscitation
  • Blood transfusion at hemoglobin threshold <70-80 g/L (lower threshold for patients without cardiovascular disease) 1
• Pre-endoscopic pharmacotherapy:
  • Administer high-dose PPI empirically (80 mg IV bolus followed by 8 mg/h continuous infusion) 2
  • Consider erythromycin infusion before endoscopy to improve visualization 3

Endoscopic Management

• Timing: Perform endoscopy within 24 hours of presentation; consider earlier endoscopy for high-risk patients 1, 2
• Endoscopic therapy based on stigmata of bleeding:
  • High-risk stigmata (active bleeding or visible vessel): Endoscopic therapy strongly recommended 1
    • Preferred methods: Thermocoagulation or sclerosant injection (strong recommendation) 1
    • Clips are also suggested (conditional recommendation) 1
    • Combination therapy (epinephrine plus another method) is superior to epinephrine alone 1
  • Adherent clot: Consider targeted irrigation to dislodge clot with appropriate treatment of underlying lesion; either endoscopic therapy or intensive PPI therapy alone may be sufficient 1
  • Low-risk stigmata (clean-based ulcer or flat pigmented spot): Endoscopic therapy not indicated 1
• TC-325 hemostatic powder: May be used as temporizing therapy when conventional endoscopic therapies fail or are unavailable, but not recommended as sole treatment 1

Post-Endoscopic Pharmacologic Management

• For high-risk lesions after successful endoscopic therapy:
  • High-dose IV PPI (80 mg bolus followed by 8 mg/h continuous infusion) for 72 hours 1, 2
  • Then twice-daily oral PPI through 14 days, followed by once daily 1, 2
• For low-risk lesions: Standard oral PPI dosing 2
• Second-look endoscopy: Not routinely recommended, but should be considered for patients with rebleeding 1
• H. pylori testing: Test all patients with bleeding ulcers for H. pylori infection and provide eradication therapy if positive 1, 2

Special Considerations

Antiplatelet/Anticoagulant Therapy

• For patients requiring antiplatelet therapy after UGIB:
  • Resume acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh GI risks (usually within 7 days) 1
  • ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1, 2
• For patients requiring anticoagulants, do not delay endoscopy 1

Rebleeding Management

• Second attempt at endoscopic therapy generally recommended 1
• If endoscopic therapy fails, consider transcatheter embolization 3

Discharge Planning

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Low-risk patients can be discharged promptly after endoscopy 1

Common Pitfalls to Avoid

1. Delaying endoscopy beyond 24 hours in patients with acute UGIB
2. Using epinephrine injection alone for endoscopic hemostasis (suboptimal efficacy)
3. Failing to administer high-dose PPI therapy after successful endoscopic treatment of high-risk lesions
4. Neglecting H. pylori testing in patients with bleeding ulcers
5. Premature discontinuation of PPI therapy in high-risk patients
6. Prolonged withholding of antiplatelet therapy in patients requiring cardiovascular prophylaxis

By following this evidence-based approach to the management of upper gastrointestinal bleeding, clinicians can optimize patient outcomes by reducing rebleeding rates and mortality.