What are the management strategies for an upper gastrointestinal (GI) bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal (GI) bleeding requires prompt resuscitation, risk stratification, early endoscopy within 24 hours, appropriate endoscopic therapy for high-risk lesions, and high-dose proton pump inhibitor therapy to reduce rebleeding and mortality. 1

Initial Assessment and Stabilization

1. Risk Stratification:

   • Use the Glasgow-Blatchford score to identify very low-risk patients (score ≤1) who may be managed as outpatients 1
   • Stratify patients as unstable (shock index >1) or stable based on hemodynamic parameters 1

2. Resuscitation:

   • Initiate fluid resuscitation with crystalloids (e.g., Ringer's lactate) in hemodynamically unstable patients 1
   • Monitor vital signs hourly (pulse, blood pressure) 1
   • Transfuse red blood cells when hemoglobin is <70 g/L (or <80 g/L in patients with cardiovascular disease) 1, 2

3. Medical Therapy:

   • Administer high-dose IV PPI (pantoprazole 80 mg bolus followed by 8 mg/hour continuous infusion) 1
   • Consider erythromycin infusion before endoscopy to improve visualization 3

Endoscopic Management

Timing:

• Perform endoscopy within 24 hours of presentation after initial stabilization 1
• Consider earlier endoscopy in high-risk patients who are hemodynamically unstable 1, 2

Endoscopic Therapy:

• Indicated for high-risk stigmata: active bleeding, visible vessel in ulcer bed, and adherent clot 1
• Use combination therapy (epinephrine injection plus thermocoagulation or sclerosant) rather than monotherapy 1
• Clips or thermocoagulation, alone or with epinephrine injection, are recommended 1, 3
• Epinephrine injection alone is not recommended 1
• For variceal bleeding, use ligation for esophageal varices and tissue glue for gastric varices 2
• Consider hemostatic powder spray TC-325 for actively bleeding ulcers and over-the-scope clips for recurrent bleeding 3

Post-Endoscopic Management

1. Pharmacological Therapy:

   • Continue high-dose IV PPI for 72 hours after endoscopic hemostasis for high-risk stigmata 1
   • After 72 hours, transition to twice-daily oral PPI for the first 2 weeks 3
   • For patients with gastritis, avoid triggers (alcohol, spicy foods, caffeine, smoking) 1

2. Hospitalization and Monitoring:

   • High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
   • Low-risk patients with clean ulcer base or flat pigmented spot, hemodynamic stability, no serious concurrent illness, easy hospital accessibility, and adequate social support may be discharged early 1

3. Management of Recurrent Bleeding:

   • Perform repeat endoscopy for recurrent bleeding 3
   • If endoscopic therapy fails, use transcatheter arterial embolization 3, 4
   • Consider surgery as a last resort if other interventions fail 2, 4

Special Considerations

1. H. pylori Management:

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

2. Anticoagulation and Antiplatelet Therapy:

   • Interrupt warfarin therapy at presentation 1
   • Reverse anticoagulation with prothrombin complex concentrate and vitamin K in patients with unstable GI hemorrhage 1
   • Restart warfarin at 7 days after hemorrhage in patients with low thrombotic risk 1
   • Restart low-dose aspirin therapy within 7 days when cardiovascular risks outweigh GI risks 1
   • For patients requiring secondary cardiovascular prophylaxis, ASA plus PPI therapy is preferred over clopidogrel alone 1

3. Diagnostic Imaging:

   • If a patient remains hemodynamically unstable after initial resuscitation, perform CT angiography to localize bleeding 1
   • If no source is identified by CT angiography, proceed to immediate upper endoscopy 1

Common Pitfalls to Avoid

• Delaying endoscopy beyond 24 hours in high-risk patients 1
• Using epinephrine injection alone for endoscopic therapy 1
• Failing to administer high-dose PPI therapy after endoscopic hemostasis 1
• Neglecting H. pylori testing in patients with peptic ulcer bleeding 1
• Premature discontinuation of PPI therapy 1
• Prolonged withholding of antiplatelet therapy in patients with cardiovascular indications 1
• Proceeding to emergency laparotomy without attempting radiological and/or endoscopic localization of bleeding 1