What are the management strategies for upper gastrointestinal bleeding (UGIB)?

Management of Upper Gastrointestinal Bleeding (UGIB)

The management of upper gastrointestinal bleeding requires immediate resuscitation, risk stratification, early endoscopy within 24 hours, and appropriate endoscopic therapy based on bleeding stigmata, followed by post-endoscopic care and prevention of rebleeding. 1, 2

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Immediate fluid resuscitation for patients with hemodynamic instability 1, 2
  • Use crystalloid fluids as first-line for volume replacement
  • Follow a restrictive fluid resuscitation strategy to avoid exacerbating bleeding

Blood Transfusion Strategy

• For patients without cardiovascular disease: transfuse when hemoglobin < 80 g/L 1, 2
• For patients with cardiovascular disease: use a higher hemoglobin threshold 1, 2
• Avoid overtransfusion which may increase rebleeding risk 2

Risk Stratification

• Use the Glasgow Blatchford Score (GBS) to identify very low-risk patients (score ≤1) who may not require hospitalization 1, 2
• Do not use the AIMS65 score for identifying low-risk patients 1, 2
• Consider nasogastric tube placement in selected patients for prognostic value 1, 2
  • Bright red blood suggests active bleeding
  • Coffee grounds or old blood suggests slower bleeding

Pre-Endoscopic Management

Pharmacological Therapy

• Administer pre-endoscopic PPI therapy to downstage endoscopic lesions 1, 2
  • Should not delay endoscopy
• Do not routinely use promotility agents before endoscopy 1, 2

Anticoagulation Management

• Do not delay endoscopy for patients on anticoagulants 1, 2
• Correction of coagulopathy may be necessary on a case-by-case basis but should not delay management 2

Endoscopic Management

Timing of Endoscopy

• Perform early endoscopy within 24 hours of presentation for all admitted patients 1, 2, 3
• Consider earlier endoscopy after resuscitation for high-risk patients (hemodynamic instability) 2, 4

Endoscopic Hemostatic Therapy

• Treatment based on stigmata of bleeding:
  • High-risk stigmata requiring endoscopic therapy: active bleeding, non-bleeding visible vessel, adherent clot 1, 2
  • Low-risk stigmata not requiring therapy: clean-based ulcer or nonprotuberant pigmented dot 1
  • For adherent clots: targeted irrigation to dislodge, then treat underlying lesion 1

Endoscopic Techniques

• Never use epinephrine injection alone; always combine with another method 1, 2, 3
• Combination therapy options:
  • Thermal coagulation methods (bipolar electrocoagulation, heater probe)
  • Mechanical methods (hemoclips) 2, 3
• For clots in ulcer beds: targeted irrigation to dislodge, then treat underlying lesion 1

Post-Endoscopic Management

Hospital Discharge

• Patients at low risk for rebleeding based on clinical and endoscopic criteria may be discharged promptly after endoscopy 1, 2

Institutional Protocols

• Develop institution-specific protocols for multidisciplinary management 1, 2
• Ensure access to an endoscopist trained in endoscopic hemostasis 1, 2
• Have support staff trained to assist in endoscopy available on an urgent basis 1, 2

Management of Recurrent Bleeding

• Recurrent non-variceal bleeding: repeat endoscopic therapy 4, 5
• Persistent or uncontrolled bleeding: interventional radiology or surgery 4, 5
• For variceal bleeding: transjugular intrahepatic portosystemic shunt (TIPS) 4, 5

Common Pitfalls and Caveats

1. Delayed resuscitation: Prioritize fluid resuscitation before diagnostic procedures in unstable patients 2

2. Overtransfusion: Excessive blood transfusion may increase rebleeding risk; follow restrictive transfusion strategy 1, 2

3. Relying on single modality therapy: Epinephrine injection alone is insufficient; always combine with another method 1, 2, 3

4. Delaying endoscopy: Perform endoscopy within 24 hours; unnecessary delays increase morbidity and mortality 1, 2, 3

5. Inappropriate risk stratification: Use validated tools (Glasgow Blatchford Score) rather than clinical impression alone 1, 2

6. Failing to address underlying causes: Identify and treat underlying conditions (H. pylori, NSAID use) to prevent recurrence 6, 4