Management of Upper Gastrointestinal Bleeding
The management of upper gastrointestinal bleeding requires immediate evaluation, appropriate resuscitation, risk stratification, and timely endoscopic intervention to reduce mortality and improve patient outcomes. 1
Initial Management and Resuscitation
- Immediate evaluation and appropriate resuscitation are critical first steps before proceeding with diagnostic and therapeutic measures 1
- Resuscitation should focus on:
- Early intensive resuscitation significantly decreases mortality in patients with upper GI bleeding 3
- Patients with hemodynamic instability should receive prompt fluid resuscitation and blood transfusion with a hemoglobin threshold of 70-80 g/L 4
- High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1
Risk Stratification
- Clinical stratification of patients into low and high-risk categories for rebleeding and mortality is essential for proper management 1
- Risk factors for rebleeding include:
- Age >65 years
- Shock
- Poor overall health status
- Comorbid illnesses
- Low initial hemoglobin level
- Melena
- Transfusion requirement
- Fresh red blood in emesis or nasogastric aspirate 1
- Risk factors for mortality include:
- Age >60 years
- Shock
- Poor overall health status
- Comorbid illnesses
- Continued bleeding or rebleeding
- Fresh red blood in emesis or nasogastric aspirate
- Elevated urea, creatinine, or serum aminotransferase levels 1
- Nasogastric tube placement can be considered as the findings may have prognostic value:
Endoscopic Management
- Endoscopy should be performed within 24 hours of presentation, with earlier endoscopy considered after resuscitation in high-risk patients 4
- Endoscopic therapy is indicated for:
- Variceal bleeding (ligation for esophageal varices, tissue glue for gastric varices)
- Non-variceal bleeding with high-risk features (active bleeding or non-bleeding visible vessel) 4
- Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone 1
- Endoscopic clips appear promising for hemostasis 1
- Hospitals should develop institution-specific protocols for multidisciplinary management, including access to an endoscopist trained in endoscopic hemostasis 1
Pharmacological Management
- High-dose intravenous proton pump inhibitors (PPIs) are recommended in patients who have undergone successful endoscopic therapy 1
- Prokinetic agents like erythromycin may be administered before endoscopy to improve visualization 4
- In patients with cirrhosis and suspected variceal bleeding, antibiotics and vasoactive drugs should be administered 4
Post-Endoscopic Care
- Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 1
- All patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present 1
- Eradication of H. pylori reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1
- Recurrent ulcer bleeding should be treated with repeat endoscopic therapy, with subsequent bleeding managed by interventional radiology or surgery 4
- Recurrent variceal bleeding is generally treated with transjugular intrahepatic portosystemic shunt 4
Management of Antithrombotic Agents
- In patients who require antithrombotic agents, outcomes appear to be better when these drugs are reintroduced early after bleeding is controlled 4
Common Pitfalls and Caveats
- Delaying resuscitation while waiting for endoscopy can increase mortality 3
- Routine second-look endoscopy is not recommended 1
- Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1
- Proton pump inhibitor infusion is not a replacement for urgent endoscopy and hemostasis 1
- Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1