What is the management approach for a patient presenting with an upper gastrointestinal (GI) bleed?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal (GI) bleeding requires immediate resuscitation, risk stratification, endoscopy within 24 hours, appropriate endoscopic therapy for high-risk lesions, and high-dose proton pump inhibitor (PPI) therapy for 72 hours post-endoscopy. 1

Initial Assessment and Resuscitation

1. Immediate evaluation and resuscitation:

   • Stabilize hemodynamics with crystalloid fluids (Ringer's lactate) 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
   • Early intensive resuscitation significantly decreases mortality 3

2. Risk stratification:

   • Use Glasgow-Blatchford score to identify:
     • Very low-risk patients (score ≤1) who may not require hospitalization 1, 4
     • High-risk patients who need urgent intervention 1
   • Clinical predictors of increased risk include: age >65 years, shock, poor health status, comorbidities, low initial hemoglobin, melena, and transfusion requirement 5

Diagnostic Approach

1. Nasogastric tube placement:

   • Consider in selected patients as presence of blood has prognostic value 5
   • Detection of red blood predicts poor outcome and need for emergency endoscopy 5

2. Endoscopy:

   • Perform within 24 hours of presentation after initial stabilization 1, 2, 4
   • Consider earlier endoscopy in hemodynamically unstable patients 1, 6
   • Support staff trained in endoscopy assistance should be available for urgent procedures 5

3. Imaging:

   • If patient remains unstable after initial resuscitation, CT angiography can help localize bleeding site 1
   • No patient should proceed to emergency laparotomy without attempts to localize bleeding by radiological and/or endoscopic means 1

Therapeutic Management

1. Pharmacological therapy:

   • Pre-endoscopic:

     • Initiate PPI therapy upon presentation 6
     • Consider erythromycin infusion before endoscopy to improve visualization 4
     • For suspected variceal bleeding, administer antibiotics and vasoactive drugs 2

   • Post-endoscopic:

     • High-dose IV PPI (pantoprazole 80 mg bolus followed by 8 mg/hour continuous infusion) for 72 hours after endoscopic therapy for high-risk stigmata 1, 4
     • Continue for first 72 hours as this is when rebleeding risk is highest 6

2. Endoscopic therapy:

   • For non-variceal bleeding:

     • Indicated for high-risk stigmata: active bleeding, visible vessel, adherent clot 1
     • Use combination therapy (e.g., epinephrine injection plus thermocoagulation or clips) rather than monotherapy 1, 4
     • Clips or thermocoagulation alone are also recommended; epinephrine injection alone is not recommended 1

   • For variceal bleeding:

     • Endoscopic variceal band ligation for esophageal varices 7
     • Tissue glue for gastric varices 2
     • Continue antibiotics and vasoactive drugs after endoscopy 2

3. Management of rebleeding:

   • Recurrent ulcer bleeding: repeat endoscopic therapy 2, 4
   • Subsequent bleeding or failed endoscopic hemostasis: transcatheter arterial embolization before considering surgery 6, 4
   • Recurrent variceal bleeding: consider transjugular intrahepatic portosystemic shunt (TIPS) 2
   • Balloon tamponade can be used as a bridge in torrential variceal hemorrhage 7

Post-Acute Management

1. Hospitalization and discharge:

   • High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
   • Low-risk patients (clean ulcer base or flat pigmented spot, hemodynamically stable, no serious concurrent illness) may be discharged promptly after endoscopy 1

2. H. pylori management:

   • Test all patients with bleeding peptic ulcers for H. pylori 1
   • Provide eradication therapy if infection is present 1, 4

3. Anticoagulation and antiplatelet therapy:

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

Common Pitfalls to Avoid

• Delaying resuscitation efforts while awaiting diagnostic procedures
• Failing to risk-stratify patients appropriately
• Delaying endoscopy beyond 24 hours in high-risk patients
• Using epinephrine injection alone for endoscopic therapy
• Neglecting to test for H. pylori in peptic ulcer bleeding
• Premature discontinuation of PPI therapy
• Prolonged withholding of necessary antiplatelet therapy

By following this structured approach to upper GI bleeding management, focusing on rapid resuscitation, timely endoscopy, appropriate therapeutic interventions, and careful post-procedure management, patient outcomes can be significantly improved.