What is the recommended management of an active gastric ulcer bleed?

Management of Active Gastric Ulcer Bleeding

For patients with active gastric ulcer bleeding, prompt endoscopic therapy with combination methods (epinephrine injection plus either thermocoagulation, sclerosant injection, or clips) followed by high-dose intravenous PPI therapy (80 mg bolus followed by 8 mg/h continuous infusion for 72 hours) is strongly recommended as the first-line management approach. 1, 2

Initial Assessment and Resuscitation

• Prioritize hemodynamic stabilization with crystalloids and blood products
• Blood transfusion recommended at hemoglobin threshold <70-80 g/L (lower threshold for patients without cardiovascular disease) 2
• Risk stratification based on:
  • Age >65 years
  • Presence of shock
  • Comorbidities
  • Low initial hemoglobin
  • Fresh blood in emesis or melena
  • Need for transfusion 2

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy within 24 hours of presentation 1, 2
• Consider earlier endoscopy for high-risk patients 2

Endoscopic Therapy

• Endoscopic therapy is indicated for high-risk stigmata (active bleeding or visible vessel in ulcer bed) 1
• For ulcers with adherent clots, targeted irrigation should be attempted to dislodge the clot and treat the underlying lesion 1
• Combination therapy approaches:
  • Epinephrine injection should not be used alone but combined with another method 1, 2
  • Thermocoagulation or sclerosant injection (strong recommendation) 1
  • Through-the-scope clips (conditional recommendation) 1
  • TC-325 (hemostatic powder) may be used as temporizing therapy when conventional methods fail 1

Pitfall to Avoid

• Using epinephrine injection as monotherapy is suboptimal and should be avoided 1, 2

Pharmacologic Management

Pre-Endoscopic PPI Therapy

• Consider administering high-dose PPI prior to endoscopy to reduce stigmata of recent bleeding 1
• This may reduce requirement for endoscopic therapy but does not replace urgent endoscopy 1, 2

Post-Endoscopic PPI Therapy

• After successful endoscopic hemostasis for high-risk stigmata:
  • Administer IV PPI bolus (80 mg) followed by continuous infusion (8 mg/h) for 72 hours 1, 2, 3
  • This regimen significantly reduces rebleeding rates (5.9% vs 10.3%) 1, 3
• After 72 hours of IV therapy, transition to twice-daily oral PPI for 14 days, then once daily 1
• For long-term therapy, patients should be discharged with a prescription for a single daily-dose oral PPI 1

Post-Endoscopic Care

Hospitalization Duration

• Patients who have undergone endoscopic hemostasis for high-risk stigmata should remain hospitalized for at least 72 hours 1, 2
• Low-risk patients can be fed within 24 hours and discharged quickly after endoscopy 1, 2

Management of Rebleeding

• A second attempt at endoscopic therapy is generally recommended in cases of rebleeding 1
• If endoscopic therapy fails:
  • Seek surgical consultation 1, 2
  • Consider transcatheter angioembolization as an alternative where resources are available 1, 2

Additional Important Measures

H. pylori Testing and Eradication

• Test all patients with bleeding peptic ulcers for H. pylori 1, 2
• Provide eradication therapy if infection is present 1, 2
• Negative tests during acute bleeding may be false-negative and should be repeated later 1, 2

Antiplatelet and NSAID Management

• For patients on low-dose aspirin, restart therapy as soon as cardiovascular risk outweighs bleeding risk (usually within 7 days) 1, 2
• For patients requiring NSAIDs with history of bleeding:
  • Discontinue NSAIDs if possible 2
  • If NSAIDs must be continued, use combination of PPI and COX-2 inhibitor 1, 2

Follow-up Care

• Patients should receive PPI therapy for 6-8 weeks following endoscopic treatment to allow mucosal healing 1
• Once H. pylori eradication is confirmed, long-term acid suppression is generally not needed unless there are other indications 1, 2

The management approach outlined above is based on strong evidence showing that prompt endoscopic intervention combined with high-dose PPI therapy significantly reduces rebleeding rates, need for surgery, and mortality in patients with active gastric ulcer bleeding.