What is the management plan for a patient presenting with an upper gastrointestinal (UGI) bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal bleeding requires immediate resuscitation, risk assessment, early endoscopy within 24 hours, and appropriate endoscopic hemostasis based on bleeding stigmata. 1

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Immediate fluid resuscitation should be initiated for patients with hemodynamic instability 1
• Use crystalloid fluids (e.g., normal saline, Ringer's lactate) as first-line for volume replacement 1
• Establish adequate IV access for fluid and blood product administration 2

Blood Transfusion Strategy

• For patients without cardiovascular disease: transfuse when hemoglobin is <80 g/L 1
• For patients with cardiovascular disease: use a higher hemoglobin threshold for transfusion 1
• Follow a restrictive transfusion strategy to avoid complications of overtransfusion 1

Risk Assessment

• Use the Glasgow Blatchford Score (GBS) to identify patients at very low risk (score ≤1) who may not require hospitalization or inpatient endoscopy 1
• Do not use the AIMS65 score to identify low-risk patients 1

Pre-Endoscopic Management

Nasogastric Tube Placement

• Consider nasogastric tube placement in selected patients for prognostic value 1, 2
• Use 8-12 French tube for adequate drainage of blood and clots 2
• Apply low intermittent suction (60-80 mmHg) rather than continuous suction 2

Medication Management

• Administer pre-endoscopic proton pump inhibitor (PPI) therapy to downstage endoscopic lesions, but do not delay endoscopy 1
• Do not routinely use promotility agents before endoscopy 1
• For patients on anticoagulants (vitamin K antagonists, DOACs), do not delay endoscopy 1

Endoscopic Management

Timing of Endoscopy

• Perform early endoscopy (within 24 hours of presentation) for all admitted patients with acute UGIB 1, 3
• Consider very early endoscopy (<12 hours) for patients with hemodynamic instability despite resuscitation 4

Endoscopic Hemostasis Based on Stigmata

• High-risk stigmata requiring endoscopic therapy:

  • Active bleeding (spurting or oozing) - Forrest Ia and Ib 1, 4
  • Non-bleeding visible vessel - Forrest IIa 1, 4
  • Adherent clot - Forrest IIb (consider clot removal and treat underlying lesion) 4

• Low-risk stigmata not requiring endoscopic therapy:

  • Flat pigmented spot - Forrest IIc 4
  • Clean-based ulcer - Forrest III 4

Endoscopic Hemostasis Techniques

• Do not use epinephrine injection alone; always combine with another method 1, 4
• Options for combination therapy include:
  • Thermal coagulation methods (no single method is superior) 1
  • Mechanical methods (clips) 5
  • Combination of injection plus thermal or mechanical methods 6

Post-Endoscopic Management

Pharmacological Therapy

• For patients who received endoscopic hemostasis, administer high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours) 4
• Continue PPI therapy after the initial treatment period 4

Monitoring and Follow-up

• Do not routinely perform second-look endoscopy 4
• For patients with clinical evidence of rebleeding after initial successful endoscopic hemostasis, perform repeat endoscopy 4
• If second endoscopic treatment fails, consider transcatheter angiographic embolization or surgery 4, 7

Discharge Planning

• Patients at low risk for rebleeding based on clinical and endoscopic criteria may be discharged promptly after endoscopy 1
• Test for Helicobacter pylori in the acute setting and initiate appropriate antibiotic therapy when detected 4
• For patients on low-dose aspirin for secondary cardiovascular prevention who develop peptic ulcer bleeding:
  • Resume aspirin immediately after endoscopy if rebleeding risk is low
  • For high-risk ulcers, reintroduce aspirin by day 3 after adequate hemostasis 4

Special Considerations

Coagulopathy Management

• Do not delay endoscopy for mild to moderate coagulopathy 2
• Correct severe coagulopathy on a case-by-case basis 2

Institutional Preparedness

• Develop institution-specific protocols for multidisciplinary management 1
• Ensure access to an endoscopist trained in endoscopic hemostasis 1
• Have support staff trained to assist in endoscopy available on an urgent basis 1