What is the management for a patient with an upper gastrointestinal (GI) bleed who is not actively bleeding?

Management of Upper GI Bleeding in Patients Not Actively Bleeding

For patients with upper GI bleeding who are not actively bleeding, early endoscopy within 24 hours of presentation, risk stratification, and appropriate pharmacologic management are recommended to reduce morbidity and mortality. 1

Initial Assessment and Risk Stratification

• Use validated risk assessment tools to determine management approach:

  • Glasgow-Blatchford score (GBS) can identify very low-risk patients (score 0-1) who may be suitable for outpatient management 1, 2
  • Consider placement of nasogastric tube in selected patients as findings may have prognostic value 1

• Hemodynamic assessment:

  • For patients without underlying cardiovascular disease: transfuse at hemoglobin <80 g/L 1
  • For patients with cardiovascular disease: use higher hemoglobin threshold for transfusion 1

Endoscopic Management

• Early endoscopy within 24 hours of presentation is recommended even for patients not actively bleeding 1

• Endoscopic management depends on endoscopic findings:

  • Low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot): no endoscopic therapy needed 1
  • Adherent clot: targeted irrigation to dislodge, then treat underlying lesion; intensive PPI therapy alone may be sufficient 1
  • High-risk stigmata (visible vessel): endoscopic hemostatic therapy indicated 1

• For patients on anticoagulants:

  • Do not delay endoscopy for anticoagulant reversal 1
  • Correction of coagulopathy is recommended but should not delay endoscopic evaluation 1

Post-Endoscopy Management

• For patients with low-risk stigmata:

  • May be discharged promptly after endoscopy if clinically stable 1, 3
  • Can resume oral intake within 24 hours 1

• For patients with high-risk stigmata who received endoscopic therapy:

  • Hospitalize for at least 72 hours after endoscopic hemostasis 1, 3
  • 60-76% of rebleeding episodes occur within the first 72 hours 3
  • Close monitoring with frequent vital sign checks for at least 24 hours 3

Pharmacologic Management

• Pre-endoscopic PPI therapy:

  • May be considered to downstage endoscopic lesions 1
  • Should not delay endoscopy 1

• Post-endoscopic PPI therapy:

  • For high-risk stigmata after successful endoscopic therapy: IV PPI loading dose followed by continuous IV infusion 1
  • For patients at high risk of rebleeding: twice-daily oral PPIs for 14 days, then once daily 1
  • For low-risk patients: single daily-dose oral PPI as dictated by underlying cause 1

• Other pharmacologic agents:

  • Histamine-2 receptor antagonists are not recommended 1
  • Somatostatin and octreotide are not routinely recommended 1
  • Promotility agents should not be used routinely before endoscopy 1

Management of Recurrent Bleeding

• A second attempt at endoscopic therapy is generally recommended for rebleeding 1
• Routine second-look endoscopy is not recommended 1
• If endoscopic therapy fails:
  • Seek surgical consultation 1
  • Consider percutaneous embolization as an alternative to surgery where available 1, 2

Additional Considerations

• Test for Helicobacter pylori and provide eradication therapy if present 1
• Negative H. pylori tests obtained during acute bleeding should be repeated 1
• For patients on antithrombotics:
  • Restart ASA as soon as cardiovascular risk outweighs bleeding risk 1
  • Consider PPI therapy for patients on antiplatelet or anticoagulant therapy 1

Common Pitfalls to Avoid

• Delaying endoscopy beyond 24 hours, which can increase morbidity and mortality
• Discharging high-risk patients too early (before 72 hours) after endoscopic therapy
• Failing to test for H. pylori or not repeating negative tests obtained during acute bleeding
• Using epinephrine injection alone for endoscopic therapy (should be combined with another method) 1
• Neglecting to restart ASA therapy when cardiovascular risk outweighs bleeding risk