What is the approach to a patient with suspected upper gastrointestinal bleed (UGIB) presenting with vomiting but no frank red blood?

Management of Suspected Upper Gastrointestinal Bleeding Without Frank Red Blood

For a patient with vomiting and suspected UGIB but no frank red blood, immediate risk stratification followed by early endoscopy within 24 hours is the recommended approach. 1

Initial Assessment and Stabilization

1. Risk Stratification:

   • Use Glasgow Blatchford score to assess bleeding severity and risk 1
   • Score of 1 or less identifies patients at very low risk who may not require hospitalization 1
   • Higher scores indicate need for inpatient management

2. Hemodynamic Assessment:

   • Check vital signs including heart rate, blood pressure, and calculate shock index (heart rate/systolic BP)
   • If shock index >1 after initial resuscitation, consider active bleeding requiring urgent intervention 1

3. Resuscitation:

   • Establish IV access with two large-bore IVs
   • Fluid resuscitation with crystalloids for hemodynamic instability
   • Blood transfusion threshold:
     • <80 g/L for patients without cardiovascular disease
     • Higher threshold for those with cardiovascular disease 1

Diagnostic Approach

1. Nasogastric Tube Placement:

   • Consider placement to assess for blood in gastric contents
   • Note: May be negative in 3-16% of patients with UGIB 1
   • Not routinely recommended as it does not reliably aid diagnosis and may cause complications 1

2. Laboratory Testing:

   • Complete blood count, coagulation profile, comprehensive metabolic panel
   • Type and cross-match if significant bleeding suspected

3. Imaging:

   • If patient is hemodynamically unstable (shock index >1) or active bleeding is suspected, CT angiography is recommended as the fastest means to localize bleeding before planning intervention 1

4. Endoscopy:

   • Early endoscopy (within 24 hours) is recommended for all patients with suspected UGIB 1
   • Consider more urgent endoscopy (<12 hours) for patients with:
     • Hemodynamic instability despite resuscitation
     • Active bleeding
     • High-risk features (e.g., hematemesis, elevated BUN/creatinine ratio) 1

Pre-Endoscopic Management

1. Pharmacologic Therapy:

   • Administer high-dose proton pump inhibitor (PPI) therapy
     • May downstage the bleeding lesion and reduce need for endoscopic therapy 1
   • Consider erythromycin before endoscopy to improve visualization 2
   • For patients with cirrhosis, add antibiotics and vasoactive drugs 2, 3

2. Medication Management:

   • Discontinue NSAIDs 4
   • For patients on antithrombotic therapy:
     • Do not routinely stop dual antiplatelet therapy in patients with coronary stents 4
     • For those on aspirin for secondary prevention, continue or restart as soon as hemostasis is achieved 4
     • Direct oral anticoagulants should be interrupted, with consideration of reversal agents for life-threatening hemorrhage 4

Endoscopic Management

1. Endoscopic Therapy for high-risk lesions:

   • Recommended for active bleeding, visible vessel, or adherent clot 1
   • Effective methods include:
     • Clips or thermocoagulation, alone or with epinephrine injection 1
     • Epinephrine injection alone is not recommended 1
     • Consider TC-325 (hemostatic powder) as temporizing therapy for actively bleeding ulcers 1

2. Post-Endoscopic Management:

   • For high-risk stigmata with successful endoscopic therapy:
     • Continue high-dose PPI therapy (IV loading dose followed by continuous infusion) for 3 days 1
     • Then oral PPI twice daily through 14 days, then once daily 1
   • High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1

Management of Rebleeding

1. Second-look endoscopy:

   • May be useful in selected high-risk patients but not routinely recommended 1
   • Consider for patients with recurrent bleeding

2. If endoscopic therapy fails:

   • Consider interventional radiology (transcatheter arterial embolization) 5
   • Surgery as last resort for persistent bleeding despite other interventions 5

Pitfalls and Caveats

• Don't assume coffee-ground emesis or non-bloody vomit excludes significant UGIB - up to 16% of patients with UGIB may have a negative nasogastric aspirate 1
• Don't delay endoscopy beyond 24 hours - early endoscopy reduces resource utilization, decreases transfusion requirements, and shortens hospital stays 1
• Don't forget to consider non-peptic ulcer causes of UGIB, including Mallory-Weiss tears, esophagitis, gastritis, and vascular malformations 1
• Don't use epinephrine injection as sole therapy for high-risk lesions - combination therapy is more effective 1
• Don't forget to restart antithrombotic agents when appropriate - outcomes appear better when these drugs are reintroduced early 2