What is the management of upper gastrointestinal (UGI) bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal bleeding (UGIB) requires immediate resuscitation with crystalloid fluids, restrictive blood transfusion (hemoglobin threshold of 70 g/L), risk stratification using the Glasgow Blatchford Score, administration of proton pump inhibitors, and endoscopy within 24 hours of presentation. 1

Initial Assessment and Resuscitation

Fluid Resuscitation

• Use balanced crystalloid fluids (such as Ringer's lactate) as first-line for volume replacement 2, 1
• Balanced crystalloids are preferred over normal saline due to reduced risk of acute kidney injury 1
• Ensure adequate IV access for rapid fluid administration 1
• Current evidence does not support the routine use of colloids over crystalloids for resuscitation 2

Blood Transfusion Strategy

• Implement a restrictive transfusion approach:
  • Transfuse when hemoglobin is less than 70 g/L in patients without cardiovascular disease 2, 1
  • Consider higher threshold for patients with cardiovascular disease 2, 1
• Avoid overtransfusion as it may increase rebleeding risk 1
• Transfusion is rarely indicated when hemoglobin level is greater than 100 g/L 2

Coagulopathy Correction

• Correction of coagulopathy is recommended for patients on anticoagulants but should not delay endoscopy 2
• Consider case-by-case correction based on severity of bleeding and coagulopathy 1

Risk Stratification

Prognostic Scoring

• Use the Glasgow Blatchford Score (GBS) to identify very low-risk patients (score ≤1) who may not require hospitalization 2, 1
• Caution: The AIMS65 score is not recommended for identifying low-risk patients 2
• Risk assessment should guide timing of endoscopy and level of care 1

Pharmacological Management

Proton Pump Inhibitors (PPIs)

• Administer pre-endoscopic PPI therapy to downstage endoscopic lesions 1
• After endoscopy, provide high-dose PPIs for patients with high-risk stigmata 1

Special Considerations for Variceal Bleeding

• For suspected variceal bleeding (especially in patients with cirrhosis):
  • Administer antibiotics promptly 1, 3
  • Start vasoactive drugs (e.g., octreotide) 1, 3

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy within 24 hours of presentation for all admitted patients 1, 4
• Consider earlier endoscopy after initial resuscitation in high-risk patients with hemodynamic instability 1, 4

Endoscopic Treatment

• Treatment strategy based on bleeding stigmata:
  • High-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot): Require endoscopic therapy 1
  • Low-risk stigmata (clean-based ulcer, flat pigmented spot): Do not require endoscopic therapy 1
• Use combination therapy rather than epinephrine injection alone:
  • Combine injection with thermal coagulation or mechanical methods (clips) 1
• For adherent clots: Perform targeted irrigation to dislodge, then treat underlying lesion 1
• For variceal bleeding:
  • Esophageal varices: Perform endoscopic band ligation 4, 3
  • Gastric varices: Use tissue glue or thrombin injection 4, 3

Management of Rebleeding

• For recurrent non-variceal bleeding:
  • First attempt: Repeat endoscopic therapy 4, 3
  • If unsuccessful: Consider interventional radiology embolization or surgery 4, 3
• For recurrent variceal bleeding:
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) 4, 3

Post-Endoscopy Care and Monitoring

• Monitor for signs of rebleeding, especially in patients with elevated BUN levels 1
• Consider repeat BUN measurements at 24 hours to identify patients at risk for poor outcomes 1
• Remove NG tube after endoscopy unless ongoing decompression is needed 1
• Patients at low risk for rebleeding may be discharged promptly after endoscopy 1

Common Pitfalls to Avoid

1. Delaying resuscitation for diagnostic procedures in unstable patients 1
2. Overtransfusion of blood products, which may increase rebleeding risk 1
3. Inappropriate risk stratification using clinical impression alone instead of validated tools 1
4. Delaying endoscopy in high-risk patients 1, 4
5. Using epinephrine injection alone instead of combination endoscopic therapy 1
6. Failing to recognize variceal bleeding, which requires specific management with antibiotics and vasoactive drugs 1, 3

By following this structured approach to UGIB management, clinicians can optimize outcomes and reduce mortality in this potentially life-threatening condition.