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 bleeding requires immediate resuscitation, risk stratification, early endoscopy within 24 hours, combination endoscopic therapy for high-risk lesions, and high-dose proton pump inhibitor therapy following successful endoscopic intervention. 1, 2, 3

Initial Assessment and Resuscitation

• Immediate evaluation and appropriate resuscitation are critical first steps before proceeding with diagnostic and therapeutic measures 1
• Establish large-bore intravenous access for fluid resuscitation with rapid infusion of normal saline or lactated Ringer solution 1
• Transfuse packed red blood cells to maintain hemoglobin above 7 g/dL, with a higher threshold of 9 g/dL considered for patients with massive bleeding or significant cardiovascular comorbidities 1, 2
• Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets as needed 1
• Patients with ongoing bleeding, hemodynamic instability, or high risk of rebleeding should be admitted to an intensive care unit for close monitoring 1, 4

Risk Stratification

• The Glasgow Blatchford score can identify patients at very low risk (score ≤1) who may not require hospitalization 2
• Risk factors for poor outcomes include poor overall health status, melena, fresh red blood in emesis or nasogastric aspirate, and elevated urea, creatinine, or serum aminotransferase levels 2, 3
• Nasogastric tube placement should be considered as the presence of bright blood in the aspirate is an independent predictor of rebleeding and poor outcomes 3
• The presence of blood in the NG tube with bloody stool suggests a significant upper GI bleed with brisk bleeding 1

Endoscopic Management

• Endoscopy should be performed within 24 hours of presentation for most patients with upper GI bleeding 2, 5
• Earlier endoscopy should be considered after resuscitation in high-risk patients, such as those with hemodynamic instability 5
• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone for achieving hemostasis 2, 3
• Endoscopic clips are an effective option for hemostatic therapy 2
• TC-325 (hemostatic powder) can be used as a temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 2

Pharmacologic Management

• Patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy should receive high-dose proton pump inhibitor therapy (intravenous loading dose of 80 mg followed by continuous infusion of 8 mg/h) for 3 days 2, 3
• After the initial 3-day high-dose IV PPI therapy, continued oral PPI therapy is suggested twice daily through 14 days, then once daily for a duration that depends on the nature of the bleeding lesion 2
• H2-receptor antagonists are not recommended due to their limited efficacy compared to proton pump inhibitors 2
• Somatostatin and octreotide are not recommended in the routine management of nonvariceal upper GI bleeding 2

Post-Endoscopic Care

• Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 6, 2
• All patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present 6, 2, 3
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 6, 2

Management of Recurrent Bleeding

• For patients with recurrent bleeding, repeat endoscopic therapy should be attempted 2, 5
• Early surgical consultation is beneficial in patients at high risk for failed endoscopic retreatment 2
• If endoscopic retreatment fails, consider interventional radiology with transcatheter arterial embolization before proceeding to surgery 7

Common Pitfalls to Avoid

• Delaying resuscitation while pursuing diagnostic tests is a critical error; resuscitation should always take precedence 1
• Assuming lower GI bleeding based solely on rectal bleeding can lead to misdiagnosis, as up to 15% of apparent lower GI bleeds are actually from upper GI sources 1
• Routine second-look endoscopy is not recommended 2, 3
• Failing to test for H. pylori or provide eradication therapy when positive can lead to increased risk of rebleeding 6, 3