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 IV proton pump inhibitors, and endoscopy within 24 hours of presentation after initial stabilization. 1

Initial Assessment and Resuscitation

1. Hemodynamic Stabilization

   • Initiate fluid resuscitation with crystalloids (Ringer's lactate) for hemodynamically unstable patients 1
   • Place two large-bore IV cannulae and insert urinary catheter to monitor output in severe cases 1
   • Monitor vital signs hourly (pulse, blood pressure) 1
   • Transfuse red blood cells when hemoglobin is <100 g/L or with active bleeding with shock 1
   • Aim for a hemoglobin threshold of 70-80 g/L for transfusion in most patients 2, 3

2. Risk Stratification

   • Use Glasgow-Blatchford score to identify very low-risk patients (score ≤1) who may not require hospitalization 1, 3
   • Higher scores indicate need for inpatient management and more urgent intervention 1

Medical Therapy

1. Proton Pump Inhibitor (PPI) Therapy

   • Start high-dose IV PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) immediately 1
   • Continue high-dose IV PPI for 72 hours after successful endoscopic hemostasis 1
   • Transition to oral PPI 40 mg twice daily for 11 days after IV therapy 1
   • Continue once-daily oral PPI to complete a total of 6-8 weeks for complete mucosal healing 1

2. Additional Pharmacotherapy

   • For suspected variceal bleeding (especially in patients with known liver disease):
     • Administer antibiotics 1, 4
     • Start vasoactive drugs (somatostatin analogues) 1, 4
   • Consider erythromycin infusion before endoscopy to improve visualization 3
   • Antacids can be used for immediate symptom relief while waiting for PPIs to take effect 1

Endoscopic Management

1. Timing of Endoscopy

   • Perform endoscopy within 24 hours of presentation after initial stabilization 1, 2, 3
   • Consider earlier endoscopy after resuscitation in high-risk patients (hemodynamically unstable) 1, 2

2. Endoscopic Therapy Based on Etiology

   • For peptic ulcers with high-risk stigmata (active bleeding or visible vessel):
     • Use combination therapy including epinephrine injection plus thermal method (heater probe or multipolar coagulation) 1, 3
     • Avoid using epinephrine injection alone 1
     • Consider clips, argon plasma coagulation, or hemostatic powder spray TC-325 for actively bleeding ulcers 3
   • For variceal bleeding:
     • Use band ligation for esophageal varices 1
     • Apply tissue glue for gastric varices 1, 2

Post-Endoscopy Care

1. Continued Medical Therapy

   • Continue high-dose IV PPI for 72 hours 1, 3
   • Test all patients with bleeding peptic ulcers for H. pylori 1
   • Provide eradication therapy if H. pylori infection is present 1

2. Management of Recurrent Bleeding

   • First-line: Repeat endoscopic therapy 1
   • Second-line: Consider transcatheter arterial embolization if endoscopic therapy fails 1, 3, 5
   • Last resort: Surgery for cases where other interventions fail 1

3. Antithrombotic Therapy Management

   • Restart low-dose aspirin therapy as soon as cardiovascular risks outweigh gastrointestinal risks, usually within 7 days 1
   • Consider PPI therapy for patients receiving single or dual antiplatelet therapy to prevent recurrent bleeding 1
   • Early reintroduction of antithrombotic agents appears to improve outcomes 1, 2

Special Considerations

• For NSAID-related gastritis:

  • Discontinue NSAIDs if possible 1
  • Continue PPI therapy for the duration of NSAID use if discontinuation is not possible 1

• For patients with liver disease:

  • Start antibiotics and vasoactive drugs early 4
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding 2

• Lifestyle modifications for gastritis:

  • Avoid triggers such as alcohol, spicy foods, caffeine, and smoking 1
  • Eat small, frequent meals rather than large meals 1
  • Avoid eating within 3 hours of bedtime 1

Common Pitfalls to Avoid

• Delaying endoscopy beyond 24 hours in high-risk patients 1
• Using epinephrine injection alone for endoscopic hemostasis 1
• Failing to administer high-dose PPI therapy 1
• Neglecting H. pylori testing in patients with peptic ulcers 1
• Premature discontinuation of PPI therapy 1
• Prolonged withholding of antiplatelet therapy in patients with cardiovascular indications 1
• Inadequate resuscitation before endoscopy 6
• Failure to correct coagulopathy early 6