What is the recommended treatment for upper GI bleeding?

Management of Upper GI Bleeding

The recommended treatment for upper GI bleeding includes initial resuscitation, high-dose intravenous proton pump inhibitors (80mg bolus followed by 8mg/h continuous infusion for 72 hours), and endoscopic therapy for high-risk lesions. 1

Initial Management

• Assess hemodynamic stability immediately
• Rapid infusion of normal saline or lactated Ringer solution to correct hypovolemia 2
• Blood transfusion when hemoglobin is less than 7 g/dL 2
• Risk stratification using clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) 2

Pharmacological Management

Proton Pump Inhibitors (PPIs)

• First-line pharmacological therapy:
  • Empirical high-dose PPI therapy should be started while awaiting endoscopy 1
  • After successful endoscopic therapy, administer high-dose IV PPI (80mg bolus followed by 8mg/h continuous infusion for 72 hours) 1
  • This is a class effect achievable with either IV omeprazole or pantoprazole 1
  • Continue oral PPI therapy after the initial IV treatment phase 1

H2-Receptor Antagonists

• Not recommended for management of acute upper GI bleeding due to inconsistent and marginal benefits compared to PPIs 1, 3
• Meta-analyses have found PPIs to be more effective than H2-receptor antagonists in preventing persistent or recurrent bleeding 3

Somatostatin and Octreotide

• Not recommended in routine management of nonvariceal upper GI bleeding 3, 1
• May be useful in specific scenarios:
  • Patients bleeding uncontrollably while awaiting endoscopy
  • Patients for whom surgery is contraindicated 1

Endoscopic Management

• Endoscopy should be performed within 24 hours of presentation 2
• Earlier endoscopy (after resuscitation) for high-risk patients with hemodynamic instability 4
• Endoscopic hemostasis is reserved for patients with high-risk endoscopic lesions 1
• Combination therapy (injection plus thermal coagulation) is superior to either treatment alone 1
• Hemostatic clips are a promising alternative or addition to traditional methods 1

Post-Endoscopy Care

• Continue high-dose PPI therapy for 72 hours post-endoscopy (when rebleeding risk is highest) 2
• Patients can be fed within 24 hours if considered at low risk for rebleeding 1
• Test for H. pylori infection and provide eradication therapy if positive 1
• Routine second-look endoscopy is not recommended 1

Management of Treatment Failure

• For failed endoscopic hemostasis, attempt transcatheter arterial embolization before proceeding to surgery 2
• For recurrent ulcer bleeding, use repeat endoscopic therapy 4
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 4

Special Considerations

• Antithrombotic therapy: Evidence suggests better outcomes when these drugs are reintroduced early after bleeding control 4
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be needed 1

Common Pitfalls to Avoid

• Overuse of IV PPIs before endoscopy regardless of endoscopic findings (observed in 86.2% of patients in some studies) 5
• Continuing IV PPI after endoscopy in patients with low-risk lesions 5
• Delaying endoscopy in high-risk patients 4
• Insufficient PPI dosing after endoscopic therapy for high-risk lesions 3