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

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal (GI) bleeding requires immediate risk stratification, resuscitation, pharmacological intervention with high-dose proton pump inhibitors, and endoscopy within 24 hours of presentation, followed by appropriate post-endoscopic care based on findings. 1

Initial Assessment and Risk Stratification

1. Risk Assessment:

   • Use the Glasgow-Blatchford score to identify very low-risk patients (score ≤1) who may not require hospitalization 1
   • High-risk factors include: age >65 years, shock, poor health status, comorbidities, low initial hemoglobin, melena, and transfusion requirement 1
   • Check nasogastric tube aspirate for blood, which has prognostic value 1

2. Hemodynamic Assessment:

   • Stratify patients as unstable (shock index >1) or stable based on hemodynamic parameters 1
   • Patients with hemodynamic instability require more urgent intervention 2

Resuscitation and Initial Management

1. Fluid Resuscitation:

   • Rapidly infuse intravenous fluids to correct hypovolemia and maintain blood pressure 3

2. Blood Transfusion:

   • Transfuse red blood cells when hemoglobin is <70 g/L (or <80 g/L in patients with cardiovascular disease) 1, 4

3. Laboratory Testing:

   • Order complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and crossmatch 3

4. Anticoagulation Management:

   • Interrupt warfarin therapy at presentation 1
   • Reverse anticoagulation with prothrombin complex concentrate and vitamin K in patients with unstable GI hemorrhage 1

Pharmacological Management

1. Proton Pump Inhibitors (PPIs):

   • Administer high-dose IV PPI (pantoprazole 80 mg bolus followed by 8 mg/hour continuous infusion) for 72 hours in patients with high-risk stigmata 1
   • Continue high-dose PPI therapy for 3 days after endoscopic hemostasis, followed by twice-daily oral PPI for 2 weeks 5

2. Prokinetic Agents:

   • Consider erythromycin infusion before endoscopy to improve visualization 4, 5

3. For Patients with Cirrhosis:

   • Add antibiotics and vasoactive drugs 4

Endoscopic Management

1. Timing of Endoscopy:

   • Perform endoscopy within 24 hours of presentation after initial stabilization 1, 4, 5
   • Consider earlier endoscopy in high-risk patients who are hemodynamically unstable 1, 4

2. Endoscopic Therapy for Non-variceal Bleeding:

   • Indicated for high-risk stigmata: active bleeding, visible vessel in ulcer bed, and adherent clot 1
   • Use combination therapy (epinephrine injection combined with thermocoagulation or sclerosant injection) rather than monotherapy 1
   • Clips or thermocoagulation, alone or with epinephrine injection, are recommended; epinephrine injection alone is not recommended 1, 5
   • Consider hemostatic powder spray TC-325 for actively bleeding ulcers 5

3. Endoscopic Therapy for Variceal Bleeding:

   • Use ligation for esophageal varices and tissue glue for gastric varices 4

Post-Endoscopic Management

1. Hospitalization Duration:

   • High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
   • Low-risk patients may be discharged earlier based on clinical and endoscopic criteria 1

2. Management of Recurrent Bleeding:

   • Treat recurrent ulcer bleeding with repeat endoscopic therapy 4
   • Consider over-the-scope clips for recurrent ulcer bleeding 5
   • If endoscopic therapy fails, use transcatheter arterial embolization before proceeding to surgery 1, 3, 5
   • For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt 4

3. H. pylori Management:

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

4. Antiplatelet/Anticoagulant Resumption:

   • 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 gastrointestinal risks 1
   • For patients requiring secondary cardiovascular prophylaxis, ASA plus PPI therapy is preferred over clopidogrel alone 1

Special Considerations

1. Imaging:

   • If a patient remains hemodynamically unstable after initial resuscitation, CT angiography can help localize the bleeding site 1

2. Surgical Intervention:

   • Surgery should be considered only after exhausting radiological and endoscopic modalities 1

3. Discharge Criteria for Low-Risk Patients:

   • Clean ulcer base or flat pigmented spot
   • Hemodynamic stability
   • No serious concurrent medical illness
   • Easy accessibility to hospital
   • Adequate social support at home 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 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 risk 1
• Proceeding to emergency laparotomy without first attempting localization by radiological and/or endoscopic modalities 1