What is the appropriate management for a patient presenting with upper gastrointestinal (GI) bleeding?

Management of Acute Upper Gastrointestinal Bleeding

Patients with upper gastrointestinal (GI) bleeding should receive prompt risk stratification, resuscitation, IV PPI therapy, and endoscopy within 24 hours, with endoscopic hemostasis for high-risk lesions followed by 72 hours of high-dose PPI therapy. 1

Initial Assessment and Resuscitation

Hemodynamic Stabilization

• Stratify patients as unstable (shock index >1) or stable based on hemodynamic parameters 1
• For unstable patients:
  • Place two large-bore IV cannulae
  • Initiate fluid resuscitation with crystalloids (e.g., Ringer's lactate)
  • Monitor vital signs hourly and urine output in severe cases
  • Transfuse red blood cells when hemoglobin is <70 g/L (or <80 g/L in patients with cardiovascular disease) 1

Risk Stratification

• Use the Glasgow-Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization 1
• High-risk features include:
  • Hemodynamic instability
  • Advanced age
  • Comorbidities
  • Active bleeding or signs of recent hemorrhage

Medical Management

Pre-Endoscopic Care

• Administer IV PPI therapy empirically while awaiting endoscopy:
  • Pantoprazole 80 mg IV bolus followed by continuous infusion of 8 mg/hour 1
• For patients with suspected variceal bleeding:
  • Add vasoactive drugs (e.g., octreotide, terlipressin)
  • Initiate antibiotics 1, 2

Timing of Endoscopy

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

Endoscopic Management

Non-Variceal Bleeding

• Endoscopic therapy is indicated for high-risk stigmata:
  • Active bleeding
  • Visible vessel in ulcer bed
  • Adherent clot
• Recommended endoscopic treatment:
  • Combination therapy is superior to monotherapy 1, 3
  • Use epinephrine injection plus thermal method (heater probe or multipolar coagulation) 1
  • Clips or thermocoagulation, alone or with epinephrine injection 3
  • Epinephrine injection alone is not recommended 3, 1

Variceal Bleeding

• Band ligation for esophageal varices
• Tissue glue for gastric varices 1

Post-Endoscopic Care

Medical Therapy

• For high-risk lesions after successful endoscopic hemostasis:
  • Continue high-dose IV PPI (pantoprazole 80 mg bolus followed by 8 mg/hour continuous infusion) for 72 hours 1, 3
  • This decreases rebleeding and mortality in patients with high-risk stigmata 3
• After IV therapy:
  • Oral PPI 40 mg twice daily for 11 days
  • Continue once-daily oral PPI therapy to complete 6-8 weeks total 1

Hospitalization Duration

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 3
• Selected low-risk patients may be discharged promptly after endoscopy if they have:
  • Clean ulcer base or flat pigmented spot
  • Hemodynamic stability
  • No serious concurrent medical illness
  • Easy accessibility to hospital
  • Adequate social support at home 1

H. pylori Testing and Eradication

• Test all patients with bleeding peptic ulcers for H. pylori
• Provide eradication therapy if infection is present 1

Management of Antithrombotic Therapy

Anticoagulants

• Interrupt warfarin therapy at presentation
• For unstable GI hemorrhage in patients on warfarin, reverse anticoagulation with prothrombin complex concentrate and vitamin K 1
• Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1

Antiplatelet Therapy

• For patients requiring secondary cardiovascular prophylaxis:
  • Restart low-dose aspirin as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 3, 1
  • ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 3

Management of Rebleeding

• For recurrent ulcer bleeding:
  • Repeat endoscopic therapy
  • Consider interventional radiology or surgery for subsequent bleeding 2
• For recurrent variceal bleeding:
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) 2

Common Pitfalls and Caveats

• Delaying endoscopy beyond 24 hours in high-risk patients can increase mortality
• Using epinephrine injection alone is inadequate for high-risk lesions
• Failing to administer high-dose PPI therapy after successful endoscopic hemostasis
• Neglecting H. pylori testing in patients with peptic ulcer disease
• Prolonged withholding of antiplatelet therapy in patients with cardiovascular indications
• Premature discharge of high-risk patients before the 72-hour observation period

While pre-endoscopic PPI use may reduce the need for endoscopic hemostatic treatment 4, the evidence for its impact on mortality, rebleeding, and need for surgery remains insufficient. However, the current standard of care is to initiate PPI therapy upon presentation with upper GI bleeding 5, as it may downstage lesions before endoscopy 3.