What is the initial management for a patient with an upper gastrointestinal (UGI) bleed in the emergency setting?

Initial Management of Upper Gastrointestinal Bleeding in the Emergency Setting

The initial management of a patient with upper gastrointestinal bleeding (UGIB) in the emergency setting should prioritize immediate hemodynamic resuscitation with crystalloid fluids while simultaneously preparing for early endoscopy within 24 hours of presentation.1, 2

Initial Resuscitation and Assessment

Hemodynamic Stabilization

• Immediate fluid resuscitation with crystalloids (1-2 liters of normal saline initially) through two large-bore IV cannulae (16-18G) placed in the antecubital fossae 1, 2
• Balanced crystalloids (such as Ringer's lactate) may be preferred over normal saline as they may reduce acute kidney injury 2
• Target parameters: mean arterial pressure >65 mmHg, urine output >30 mL/hour 2
• Avoid colloids as evidence does not show survival benefit compared to crystalloids 1, 2

Blood Transfusion

• Implement a restrictive transfusion strategy with a target hemoglobin of 7-9 g/dL 2, 3
• Transfuse red blood cells when hemoglobin falls below 7 g/dL 2
• Consider higher transfusion thresholds for patients with significant cardiovascular comorbidities 3

Risk Assessment

• Use the Glasgow Blatchford Score (GBS) for pre-endoscopy risk stratification 1, 3
• Patients with GBS ≤1 may be considered for outpatient management 1, 3
• Avoid using AIMS65 score to identify low-risk patients 1

Pharmacological Management

Proton Pump Inhibitors (PPIs)

• Initiate high-dose IV PPI immediately: 80 mg IV bolus followed by 8 mg/hour continuous infusion 2, 3
• Continue PPI infusion for 72 hours post-endoscopy if endoscopic therapy is performed 3

Prokinetic Agents

• Consider IV erythromycin (single dose, 250 mg) 30-120 minutes before endoscopy in patients with severe or ongoing active UGIB 3
• Improves endoscopic visualization and reduces need for second-look endoscopy 3

Antibiotics

• Consider antibiotic prophylaxis in patients with cirrhosis and suspected variceal bleeding 2
• Options include ceftriaxone IV 1g/day or norfloxacin oral 400 mg every 12 hours for 7 days 2

Timing of Endoscopy

• Perform upper endoscopy within 24 hours of presentation after initial hemodynamic stabilization 1, 3, 4
• Consider very early endoscopy (<12 hours) for high-risk patients with:
  • Persistent hemodynamic instability despite volume resuscitation
  • In-hospital bloody emesis/nasogastric aspirate
  • Contraindication to interruption of anticoagulation 3

Endoscopic Management

For Non-variceal Bleeding

• Provide endoscopic hemostasis for:
  • Actively bleeding ulcers (Forrest Ia and Ib)
  • Ulcers with non-bleeding visible vessels (Forrest IIa)
  • Consider clot removal and treatment for ulcers with adherent clots (Forrest IIb) 3
• Use combination therapy rather than epinephrine injection alone 3

For Variceal Bleeding

• Endoscopic variceal ligation for esophageal varices 2
• Tissue adhesive (cyanoacrylate) for gastric varices 4

Post-Endoscopic Care

• Continue high-dose PPI therapy for 72 hours after successful endoscopic hemostasis 3
• Monitor for signs of rebleeding: fresh melena or hematemesis, fall in blood pressure, rise in pulse rate 2
• Allow oral intake 4-6 hours after endoscopy if hemodynamically stable 2

Management of Rebleeding

• For recurrent bleeding after initial endoscopic therapy, perform repeat endoscopy with hemostasis 3
• If second endoscopic attempt fails, consider:
  • Transcatheter angiographic embolization
  • Surgery 3

Special Considerations

• Nasogastric tube placement is not routinely recommended as it does not reliably aid diagnosis, does not affect outcomes, and may cause complications 1, 3
• Consider ICU admission for patients with massive bleeding or persistent hemodynamic instability 2
• Early intensive resuscitation significantly decreases mortality in UGIB patients 5

Pitfalls to Avoid

• Delaying endoscopy for PPI infusion 3
• Using epinephrine injection as monotherapy 3
• Excessive fluid resuscitation which may increase portal pressure in patients with cirrhosis 2
• Routine second-look endoscopy is not recommended 3
• Overlooking an upper GI source in patients presenting with lower GI bleeding symptoms 1

By following this algorithmic approach to UGIB management, focusing on early resuscitation and timely endoscopic intervention, patient outcomes can be significantly improved with reduced morbidity and mortality.