What is the management approach for an upper gastrointestinal (GI) bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal (GI) bleeding requires immediate fluid resuscitation with crystalloids, risk stratification using the Glasgow-Blatchford score, administration of high-dose proton pump inhibitors (PPIs), and endoscopy within 24 hours of presentation. 1, 2

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Initiate fluid resuscitation with crystalloids (such as Ringer's lactate) in patients with hemodynamic instability 1, 2
• Place two large-bore IV cannulae and insert urinary catheter to monitor hourly output in severe cases 2
• Transfuse red blood cells when hemoglobin is <70 g/L (or <80 g/L in patients with active bleeding with shock) 2, 3
• Monitor vital signs hourly (pulse, blood pressure) 2

Risk Stratification

• Use the Glasgow-Blatchford scale to identify patients at very low risk (score ≤1) who may not require hospitalization 2, 3
• Very low-risk patients can be managed as outpatients with appropriate follow-up 3

Pharmacological Management

Pre-Endoscopic Management

• Administer high-dose IV PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) 2
• Consider erythromycin infusion before endoscopy to improve visualization 3
• For patients with suspected variceal bleeding (especially those with known liver disease):
  • Administer antibiotics 4
  • Start vasoactive drugs (somatostatin analogues) 2, 4

Endoscopic Management

Timing and Approach

• Perform endoscopy within 24 hours of presentation after initial stabilization 2, 3
• Consider earlier endoscopy after resuscitation in high-risk patients (hemodynamically unstable) 5

Endoscopic Therapy

• 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) 2, 3
  • Alternative options include clips, argon plasma coagulation, or soft monopolar electrocoagulation 3
  • Hemostatic powder spray (TC-325) can be used for actively bleeding ulcers 3
• For variceal bleeding:
  • Use band ligation for esophageal varices
  • Apply tissue glue for gastric varices 5

Post-Endoscopic Management

Medication Therapy

• Continue high-dose IV PPI for 72 hours after successful endoscopic hemostasis 2, 3
• Then transition to oral PPI 40 mg twice daily for 11 days 2
• Continue once-daily oral PPI to complete a total of 6-8 weeks 2
• For variceal bleeding, continue antibiotics and vasoactive drugs 5

Management of Recurrent Bleeding

• For recurrent ulcer bleeding:
  • Perform repeat endoscopic therapy as first-line treatment 3
  • Consider over-the-scope clips for recurrent bleeding after previous successful hemostasis 3
  • If endoscopic therapy fails, proceed with transcatheter arterial embolization 3, 6
  • Surgery is reserved for cases where other interventions fail 6
• For recurrent variceal bleeding:
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) 5

Special Considerations

H. pylori Testing and Eradication

• Test all patients with bleeding peptic ulcers for H. pylori 2
• Provide eradication therapy if infection is present 2

Antithrombotic Therapy Management

• For patients on low-dose aspirin for cardiovascular prophylaxis:
  • Restart therapy as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2
• For patients requiring antithrombotic agents:
  • Early reintroduction appears to improve outcomes 5
  • Consider PPI therapy for patients receiving single or dual antiplatelet therapy to prevent recurrent bleeding 2

Common Pitfalls and Caveats

• Avoid delaying endoscopy beyond 24 hours in patients with significant upper GI bleeding 2
• Do not use epinephrine injection alone for endoscopic hemostasis; always use combination therapy 2
• Do not neglect H. pylori testing in patients with bleeding peptic ulcers 2
• Avoid premature discontinuation of PPI therapy before complete mucosal healing 2
• Do not transfuse red blood cells when hemoglobin is >70 g/L unless the patient has active bleeding with shock or significant comorbidities 2, 3
• Avoid prolonged withholding of antiplatelet therapy in patients with cardiovascular indications 2