What is the management of upper gastrointestinal bleeding (UGIB) from vomiting?

Management of Upper Gastrointestinal Bleeding from Vomiting

Initial management of upper gastrointestinal bleeding (UGIB) from vomiting should focus on prompt resuscitation, risk stratification, and early endoscopy within 24 hours, followed by appropriate endoscopic therapy based on identified lesions. 1, 2

Initial Assessment and Resuscitation

• Immediate priorities:

  • Ensure adequate IV access for volume resuscitation with crystalloid fluids (Ringer's lactate preferred over normal saline) 2
  • Assess hemodynamic stability (blood pressure, heart rate, orthostatic changes)
  • Perform risk stratification using Glasgow Blatchford Score (GBS) 2
  • Monitor for signs of active bleeding (hematemesis, melena, hematochezia)

• Laboratory evaluation:

  • Complete blood count, coagulation profile, comprehensive metabolic panel
  • Type and cross-match for potential blood transfusion
  • Monitor BUN levels (elevated or rising BUN indicates increased risk of poor outcomes) 2

Transfusion Strategy

• Implement restrictive transfusion approach:
  • Transfuse when hemoglobin <70-80 g/L for patients without cardiovascular disease
  • Consider higher threshold for patients with cardiovascular disease
  • Avoid overtransfusion as it may increase rebleeding risk 2

Pharmacologic Management

• Pre-endoscopic therapy:
  • Administer high-dose proton pump inhibitors (PPIs) to downstage lesions 1, 2
  • Consider erythromycin (prokinetic agent) to improve endoscopic visualization 3

Endoscopic Evaluation and Treatment

• Timing of endoscopy:

  • Perform endoscopy within 24 hours of presentation for all admitted patients
  • Consider earlier endoscopy after initial resuscitation in high-risk patients with hemodynamic instability 1, 2

• Endoscopic findings and treatment in vomiting-induced UGIB:

  • Mallory-Weiss tears (most common vomiting-related cause):

    • Usually self-limiting and require no specific intervention
    • For active bleeding: endoscopic hemostasis with clips or thermal coagulation

  • Other potential findings:

    • Esophagitis with erosions or ulcerations
    • Gastroduodenal erosions
    • Dieulafoy's lesion (rare)

• Endoscopic treatment based on stigmata:

  • High-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot):

    • Use combination therapy with injection plus thermal or mechanical methods
    • Epinephrine injection alone is not recommended 1, 2

  • Low-risk stigmata (clean-based ulcer, flat pigmented spot):

    • No endoscopic therapy required 2

Post-Endoscopic Management

• Medication:

  • Continue high-dose PPI therapy after successful endoscopic hemostasis 1
  • Adjust medication dosages according to renal function 2

• Monitoring:

  • High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
  • Monitor for signs of rebleeding (recurrent hematemesis, melena, hemodynamic instability, dropping hemoglobin)
  • Consider repeat BUN measurements at 24 hours 2

• Discharge planning:

  • Low-risk patients may be discharged promptly after endoscopy 1, 2
  • Provide clear instructions on warning signs requiring return to hospital

Activity Recommendations After Discharge

• For high-risk lesions:

  • Avoid moderate to vigorous exercise for 1-2 weeks
  • Gradually reintroduce light walking when hemodynamically stable with normalized hemoglobin 2

• For low-risk lesions:

  • Begin with short walks (5-10 minutes) several times daily
  • Gradually increase activity over 1-2 weeks 2

Prevention of Recurrence

• Identify and address underlying causes:
  • Avoid triggers for vomiting (alcohol, certain medications)
  • Treat underlying conditions (gastroesophageal reflux, bulimia)
  • Consider PPI therapy if erosive disease is present

Special Considerations

• For patients on antithrombotic agents:

  • More conservative exercise progression is warranted
  • Resume antithrombotic agents as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days)
  • ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1, 2

• For patients with renal impairment:

  • Monitor fluid balance carefully to avoid volume overload
  • Consider nephrology consultation for significantly impaired renal function 2