What is the management for a suspected upper gastrointestinal (GI) bleed?

Management of Suspected Upper Gastrointestinal Bleeding

The management of suspected upper gastrointestinal (GI) bleeding requires immediate resuscitation with crystalloid fluids to achieve hemodynamic stability, followed by endoscopy within 24 hours of presentation after initial stabilization. 1

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Initiate fluid resuscitation with crystalloids (e.g., Ringer's lactate) for hemodynamic instability 1
• Place two large-bore IV cannulae for fluid administration 1
• Monitor vital signs hourly (pulse, blood pressure) 1
• Insert urinary catheter in severe cases to monitor hourly output 1

Blood Transfusion

• Transfuse red blood cells when hemoglobin is <70 g/L (or <80 g/L in patients with cardiovascular disease) 2, 1
• Use restrictive RBC thresholds (Hb target 70-90 g/L after transfusion) 2

Risk Stratification

• Use the Glasgow-Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization 1
• Stratify patients as unstable (shock index >1) or stable based on hemodynamic parameters 2
• Patients with a minor self-terminating bleed can be discharged for urgent outpatient investigation 2

Medical Therapy

• Administer high-dose IV PPI therapy immediately (80 mg IV bolus followed by 8 mg/hour continuous infusion) 1
• Continue high-dose IV PPI for 72 hours after successful endoscopic hemostasis 1
• Consider promotility agents (erythromycin) before endoscopy in patients suspected to have substantial amounts of blood in the stomach to improve visualization 2, 3
• For patients with suspected variceal bleeding (especially those with known liver disease), administer antibiotics and vasoactive drugs (somatostatin analogues) 1

Endoscopy

Timing

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

Endoscopic Management

• For non-variceal bleeding with high-risk stigmata (active bleeding or visible vessel):
  • Use combination endoscopic therapy (epinephrine injection plus thermal method or clips) 2, 1
  • Avoid using epinephrine injection alone 1
• For variceal bleeding:
  • Use band ligation for esophageal varices 1
  • Use tissue glue for gastric varices 1

Post-Endoscopy Care

• Continue high-dose IV PPI for 72 hours after successful endoscopic hemostasis 1
• Transition to oral PPI 40 mg twice daily for 11 days 1
• Continue once-daily oral PPI to complete a total of 6-8 weeks 1
• Test all patients with bleeding peptic ulcers for H. pylori 1
• Provide eradication therapy if H. pylori infection is present 1
• Negative H. pylori tests obtained in the acute setting should be repeated 2

Management of Recurrent Bleeding

• Repeat endoscopic therapy is recommended as first-line treatment for recurrent bleeding 1
• If endoscopic therapy fails, consider:
  • Catheter angiography with embolization (should be performed within 60 minutes for hemodynamically unstable patients) 2, 1
  • Surgery as a last resort when other interventions fail 1
• No patient should proceed to emergency laparotomy unless every effort has been made to localize bleeding by radiological and/or endoscopic modalities 2

Antithrombotic Therapy Management

• For patients on warfarin:
  • Interrupt warfarin therapy at presentation 2
  • In cases of unstable GI hemorrhage, reverse anticoagulation with prothrombin complex concentrate and vitamin K 2
  • For patients with low thrombotic risk, restart warfarin at 7 days after hemorrhage 2
• For patients on antiplatelet therapy:
  • Restart low-dose aspirin as soon as cardiovascular risks outweigh GI risks (usually within 7 days) 1
  • Consider PPI therapy for patients receiving single or dual antiplatelet therapy to prevent recurrent bleeding 1

Special Considerations

CT Angiography

• If a patient is hemodynamically unstable (shock index >1) after initial resuscitation and/or active bleeding is suspected, CT angiography provides the fastest means to localize the site of blood loss 2
• If no source is identified by initial CT angiography, upper endoscopy should be performed immediately 2

Low-Risk Patients

• Selected patients with acute ulcer bleeding who are at low risk for rebleeding based on clinical and endoscopic criteria may be discharged promptly after endoscopy 2
• Criteria for early discharge include a clean ulcer base or flat pigmented spot, hemodynamic stability, no serious concurrent medical illness, easy accessibility to hospital, and adequate social support at home 2

By following this structured approach to the management of suspected upper GI bleeding, clinicians can optimize patient outcomes and reduce morbidity and mortality associated with this common medical emergency.