What is the management of upper gastrointestinal (GI) bleeding?

Management of Upper Gastrointestinal Bleeding

The management of upper gastrointestinal bleeding requires immediate resuscitation, risk stratification, early endoscopy within 24 hours, appropriate endoscopic therapy for high-risk lesions, and post-endoscopic pharmacological treatment with high-dose proton pump inhibitors. 1, 2

Initial Assessment and Resuscitation

• Immediate evaluation of hemodynamic status and appropriate resuscitation are critical first steps to reduce mortality and improve patient outcomes 2
• Fluid resuscitation should be initiated in patients with UGIB and hemodynamic instability to restore end-organ perfusion and tissue oxygenation 1
• Crystalloids are recommended over colloids for initial fluid resuscitation, as current evidence does not show survival benefit with colloids, and they are more expensive 1
• In patients without cardiovascular disease, the suggested hemoglobin threshold for blood transfusion is less than 80 g/L, with a higher threshold for those with cardiovascular disease 1
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 2

Risk Stratification

• The Glasgow Blatchford score of 1 or less can identify patients at very low risk for rebleeding who may not require hospitalization 1
• Risk factors for rebleeding and mortality include poor overall health status, melena, fresh red blood in emesis or nasogastric aspirate, and elevated urea, creatinine, or serum aminotransferase levels 2
• Nasogastric tube placement can be considered as the findings may have prognostic value, with bright blood in the aspirate being an independent predictor of rebleeding 2, 3

Endoscopic Management

• Patients with acute UGIB should undergo endoscopy within 24 hours of presentation 1
• Earlier endoscopy (within 12 hours) should be considered for high-risk patients with hemodynamic instability 2
• For high-risk stigmata lesions, endoscopic hemostasis is indicated 1
• Thermocoagulation and sclerosant injection are recommended, and clips are suggested, for endoscopic therapy in patients with high-risk stigmata 1
• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone 2, 4
• Epinephrine injection alone is not recommended 1
• TC-325 (hemostatic powder) is suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1
• Attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata are supported by data 1

Pharmacological Management

• Pre-endoscopy proton pump inhibitor (PPI) therapy may downstage the lesion but does not improve clinical outcomes 1, 4
• Patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy should receive high-dose PPI therapy (intravenous loading dose followed by continuous infusion) for 3 days 1
• For high-risk patients, 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 1
• Pre-endoscopic erythromycin may be considered to increase diagnostic yield at first endoscopy 4, 3

Post-Endoscopic Care

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1
• Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 2, 4
• All patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present 2, 4
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 2

Management of Recurrent Bleeding

• Recurrent bleeding after endoscopic therapy is treated with a second endoscopic treatment 4, 3
• If bleeding persists or recurs after second endoscopic treatment, intervention with surgery or interventional radiology should be undertaken 4, 3

Secondary Prophylaxis

• For patients with UGIB who require a nonsteroidal anti-inflammatory drug (NSAID), a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 1
• Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid (ASA) again as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 1
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1
• PPI therapy is suggested for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 1

Common Pitfalls and Caveats

• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 2
• Routine second-look endoscopy is not recommended 2
• 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 2
• In patients with cirrhosis and suspected variceal bleeding, initiate vasoactive drug therapy and antibiotic prophylaxis as soon as bleeding is suspected 2