What is the treatment for upper gastrointestinal (GI) bleeding?

Treatment of Upper GI Bleeding

The management of upper gastrointestinal bleeding requires immediate resuscitation, early endoscopy within 24 hours, appropriate endoscopic therapy based on bleeding stigmata, and high-dose proton pump inhibitor therapy for 72 hours following successful endoscopic hemostasis. 1

Initial Assessment and Resuscitation

• Perform immediate hemodynamic resuscitation in unstable patients
• Use restrictive blood transfusion strategy:
  • Transfuse at hemoglobin <70-80 g/L in patients without cardiovascular disease
  • Consider higher threshold for patients with cardiovascular disease 1, 2
• Perform risk stratification using Glasgow Blatchford scale:
  • Patients with score ≤1 may be managed as outpatients
  • Higher risk patients require hospitalization 1
• High-risk features include:
  • Age >65 years
  • Shock
  • Comorbidities
  • Low initial hemoglobin
  • Melena
  • Fresh red blood in emesis or rectal exam 1

Endoscopic Management

Timing and Preparation

• Perform endoscopy within 24 hours of presentation
• Consider earlier endoscopy for high-risk patients after resuscitation 1, 3
• Administer IV erythromycin before endoscopy to improve visualization 1, 3
• Consider high-dose PPI prior to endoscopy to reduce stigmata of recent bleeding 1

Endoscopic Therapy

1. For peptic ulcers with high-risk stigmata (active bleeding or visible vessel):

   • Use combination therapy: epinephrine injection plus thermal method (heater probe or multipolar coagulation) 4, 1
   • Alternative: through-the-scope clips or hemostatic powder (TC-325) for temporary control when conventional methods fail 1, 3
   • For ulcers with adherent clots, attempt targeted irrigation to dislodge clot and treat underlying lesion 1

2. For esophageal varices:

   • Use band ligation as first-line therapy 4, 1
   • For gastric varices, tissue glue is recommended 2

3. For Mallory-Weiss tears:

   • Most stop bleeding spontaneously
   • If needed, use endoscopic injection with adrenaline or thermal methods 4

4. For vascular malformations:

   • Apply heat using Argon Plasma Coagulator or heater probe
   • Multiple sessions may be required 4

5. For Dieulafoy lesions:

   • Options include band ligation, injection, or thermal methods 4

Post-Endoscopic Management

Medication Management

• After successful endoscopic hemostasis for high-risk stigmata:
  • Administer high-dose IV PPI: 80 mg bolus followed by continuous infusion (8 mg/h) for 72 hours 4, 1, 3
  • Follow with oral PPI twice daily for 14 days, then once daily 1
  • Continue PPI therapy for 6-8 weeks to allow mucosal healing 1

H. pylori Management

• Test all patients with bleeding peptic ulcers for H. pylori
• Provide eradication therapy if infection is present
• Repeat testing if initial results are negative during acute bleeding (may be false negative) 1

Antithrombotic Therapy

• For patients on low-dose aspirin:
  • Restart therapy within 7 days when cardiovascular risk outweighs bleeding risk
  • Consider aspirin plus PPI therapy 1
• For patients requiring NSAIDs with history of bleeding:
  • Discontinue NSAIDs if possible
  • If NSAIDs must be continued, use combination of PPI and COX-2 inhibitor 1

Management of Rebleeding

• Monitor patients closely for signs of rebleeding (fresh melena, hematemesis, hemodynamic instability)
• Patients with high-risk stigmata should remain hospitalized for at least 72 hours 1
• For rebleeding:
  1. Perform repeat endoscopy and attempt endoscopic therapy again 4, 1, 3
  2. If second endoscopic attempt fails:
     • Consider transcatheter angioembolization where available 1, 3
     • Surgical consultation for persistent or recurrent bleeding 1

Special Considerations

• For variceal bleeding:

  • Administer antibiotics and vasoactive drugs
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent bleeding 2

• For patients with uncontrolled hemorrhage:

  • Urgent surgical intervention may be required
  • Surgical approach depends on bleeding source and patient factors 4

• Low-risk patients:

  • Can be fed within 24 hours
  • May be discharged quickly after endoscopy 1

Pitfalls to Avoid

• Delaying endoscopy beyond 24 hours in high-risk patients
• Using epinephrine injection alone (inferior to combination therapy)
• Failing to administer high-dose PPI therapy after successful endoscopic hemostasis
• Neglecting H. pylori testing in patients with peptic ulcer bleeding
• Premature discontinuation of PPI therapy
• Prolonged withholding of antiplatelet therapy in patients with cardiovascular risk 1