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

Initial Management of Upper Gastrointestinal Bleeding

The initial management of upper gastrointestinal (GI) bleeding should focus on immediate resuscitation, risk stratification, and early endoscopic intervention within 24 hours of presentation to reduce mortality and improve patient outcomes. 1

Immediate Resuscitation

• Assess hemodynamic stability immediately upon presentation and initiate prompt volume resuscitation with crystalloids (1-2 liters of normal saline) to restore blood pressure, increase venous pressure, and ensure adequate diuresis 2
• Place two large-bore intravenous catheters to facilitate rapid volume expansion 2
• Implement restrictive blood transfusion strategy with a hemoglobin threshold of 7 g/dL and a target range of 7-9 g/dL after transfusion (threshold may be higher at 8 g/dL with target of 10 g/dL in patients with cardiovascular disease) 3, 1
• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy 3
• Monitor vital signs closely, including heart rate, blood pressure, and urine output to assess response to resuscitation 2

Pharmacological Management

• Start intravenous proton pump inhibitors (PPIs) immediately upon presentation with upper GI bleeding 1, 4
• For suspected variceal bleeding, particularly in patients with known cirrhosis, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected 3
  • Terlipressin: 2 mg/4 hours for first 48 hours, then 1 mg/4 hours thereafter
  • Somatostatin: 250 μg/hour continuous infusion with initial 250 μg bolus
  • Octreotide: 50 μg/hour continuous infusion with initial 50 μg bolus 3
• Administer antibiotic prophylaxis in patients with cirrhosis and suspected variceal bleeding (ceftriaxone or norfloxacin) 3, 5

Risk Stratification

• Stratify patients into low and high-risk categories for rebleeding and mortality using clinical prediction tools such as the Glasgow-Blatchford bleeding score 1, 6
• High-risk features include:
  • Poor overall health status
  • Melena or fresh red blood in emesis/nasogastric aspirate
  • Elevated urea, creatinine, or serum aminotransferases
  • Hemodynamic instability 1, 6
• Consider nasogastric tube placement as findings may have prognostic value (bright blood in aspirate is an independent predictor of rebleeding) 1, 2

Endoscopic Management

• Perform upper endoscopy within 24 hours of presentation after adequate resuscitation 1, 4
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 3, 4
• If no source is identified by CT angiography in an unstable patient, perform immediate upper endoscopy 3
• Use combination endoscopic therapy (injection plus thermal coagulation or mechanical clips) for high-risk lesions 1
• If variceal bleeding is confirmed, perform band ligation for esophageal varices or use tissue glue for gastric varices 4

Post-Endoscopic Care

• Continue high-dose PPI therapy for 72 hours post-endoscopy for non-variceal bleeding, particularly when endoscopic therapy was performed 1, 4
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 3
• Monitor patients closely after endoscopy with continuous observation of vital signs 2
• Allow oral intake within 24 hours for patients at low risk of rebleeding 1
• Test for Helicobacter pylori and provide eradication therapy if positive to reduce ulcer recurrence and rebleeding 1, 2

Management of Recurrent Bleeding

• For recurrent non-variceal bleeding, perform repeat endoscopic therapy 4
• If endoscopic hemostasis fails, consider transcatheter arterial embolization before proceeding to surgery 6
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 3, 4

Common Pitfalls and Caveats

• Avoid routine second-look endoscopy as it is not recommended for most patients 1
• Be aware that H. pylori testing during acute bleeding may have increased false-negative rates; consider confirmatory testing later 1
• Do not delay endoscopy in high-risk patients, but ensure adequate resuscitation first 1, 4
• In patients with cirrhosis and severe ascites, use NSBBs with caution and avoid high doses 3
• Consider discontinuing NSBBs in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 3