What is the recommended treatment for an upper gastrointestinal (GI) bleed?

Treatment of Upper GI Bleeding

The recommended treatment for upper gastrointestinal bleeding includes endoscopic therapy with thermocoagulation or sclerosant injection for actively bleeding ulcers, followed by high-dose proton pump inhibitor therapy via intravenous loading dose and continuous infusion for 72 hours. 1, 2

Initial Assessment and Management

• Assess hemodynamic stability and resuscitate with intravenous fluids; transfuse blood when hemoglobin is less than 7 g/dL in patients without cardiovascular disease 2, 3
• Risk stratification using the Glasgow Blatchford score can identify patients at very low risk who may not require hospitalization 2
• Endoscopy should be performed within 24 hours of presentation for most patients with upper GI bleeding 2, 3

Endoscopic Management

• For patients with actively bleeding ulcers with high-risk stigmata, endoscopic therapy with thermocoagulation or sclerosant injection is strongly recommended 1
• Through-the-scope clips are also suggested as an effective option for hemostatic therapy 1, 2
• Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method 1
• TC-325 (hemostatic powder) can be used as a temporizing therapy when conventional endoscopic therapies are not available or fail, but not as a single therapeutic strategy 1, 2
• Routine second-look endoscopy is not recommended, but a second attempt at endoscopic therapy is generally recommended in cases of rebleeding 1

Pharmacologic Management

• For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy, high-dose PPI therapy is recommended via intravenous loading dose (80 mg) followed by continuous infusion (8 mg/hour) for 72 hours 1, 2, 4
• After the initial 3-day high-dose IV PPI therapy, twice-daily oral PPIs are suggested through 14 days, followed by once daily 1, 2
• H2-receptor antagonists, somatostatin, and octreotide are not recommended for patients with acute ulcer bleeding 1, 2
• Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying cause 1

Post-Endoscopic Care

• Patients at low risk after endoscopy can be fed within 24 hours 1, 2
• Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours 1
• Seek surgical consultation for patients for whom endoscopic therapy has failed 1
• Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed 1

Management of Specific Causes

• Patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if it is present, with confirmation of eradication 1, 2
• Negative H. pylori diagnostic tests obtained in the acute setting should be repeated due to increased false-negative rates 1, 2
• In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding 1

Prevention of Recurrent Bleeding

• In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding 1
• For patients with previous ulcer bleeding receiving antiplatelet or anticoagulant therapy for cardiovascular prophylaxis, PPI therapy is suggested 1, 2

Common Pitfalls to Avoid

• Do not substitute PPI therapy for urgent endoscopy and hemostasis - it is an adjunct to, not a replacement for, endoscopic therapy 4
• Avoid delaying endoscopic intervention in patients with active bleeding 2, 3
• Recent evidence suggests that low-dose PPI therapy may be as effective as high-dose infusion in some patients, though high-dose remains the standard recommendation for high-risk patients 5, 6, 7