What is the algorithm for upper Gastrointestinal (GI) bleeding management?

Algorithm for Upper Gastrointestinal Bleeding Management

The management of upper gastrointestinal bleeding requires a systematic approach focusing on initial resuscitation, risk stratification, endoscopic intervention, and post-endoscopic care to reduce mortality and improve patient outcomes.

Initial Assessment and Resuscitation

• Immediate resuscitation should be initiated for patients with acute UGIB and hemodynamic instability to restore end-organ perfusion and tissue oxygenation 1, 2
• Establish large-bore intravenous access (two lines) and initiate crystalloid fluid resuscitation 2, 3
• Monitor vital signs frequently, including heart rate, blood pressure, and urine output 1, 2
• Blood transfusion is recommended for patients with a hemoglobin level <80 g/L in those without cardiovascular disease 1, 2
• For patients with underlying cardiovascular disease, use a higher hemoglobin threshold for transfusion 1, 2
• Consider placement of a nasogastric tube in selected patients as findings may have prognostic value 1
• For patients with severe bleeding, consider cardiac monitoring and supplemental oxygen 1, 3

Risk Stratification

• Use the Glasgow Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization or inpatient endoscopy 1, 2
• High-risk factors include:
  • Age >60 years 1
  • Shock (pulse >100 beats/min, systolic BP <100 mm Hg) 1
  • Comorbidities (cardiac failure, liver disease, renal failure, malignancy) 1
  • Active bleeding or non-bleeding visible vessel on endoscopy 1
• The AIMS65 score is not recommended to identify low-risk patients 1
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 2, 3

Pre-Endoscopic Management

• Start intravenous proton pump inhibitor therapy (may downstage endoscopic lesions but should not delay endoscopy) 1, 4
• For suspected variceal bleeding in patients with cirrhosis:
  • Initiate vasoactive drugs (terlipressin, somatostatin, or octreotide) 2, 5
  • Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) 2, 5
• Do not routinely use promotility agents before endoscopy 1
• For patients on anticoagulants, do not delay endoscopy 1
• If patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography 2, 3

Endoscopic Management

• Perform endoscopy within 24 hours of presentation for most patients with UGIB 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 2, 5
• Develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis 1
• Endoscopic treatment based on findings:
  • For high-risk stigmata (active bleeding, non-bleeding visible vessel), use combination endoscopic therapy (injection plus thermal coagulation or clips) 1, 4
  • Epinephrine injection alone is not recommended 2, 4
  • For clots in ulcer beds, attempt targeted irrigation for dislodgement with appropriate treatment of underlying lesion 1
  • For low-risk stigmata (clean-based ulcer or non-protuberant pigmented dot), endoscopic therapy is not indicated 1, 4
  • For variceal bleeding, use band ligation for esophageal varices and tissue glue for gastric varices 6, 5
  • TC-325 (hemostatic powder) may be used as temporizing therapy but not as sole treatment 2, 4

Post-Endoscopic Care

• For patients with high-risk stigmata who have had successful endoscopic therapy, administer high-dose PPI therapy (IV loading dose of 80 mg followed by continuous infusion of 8 mg/h) for 3 days 2, 4
• After initial 3-day high-dose IV PPI therapy, continue oral PPI twice daily through 14 days, then once daily based on the nature of the bleeding lesion 2, 4
• Patients at low risk for rebleeding after endoscopy can be fed within 24 hours 2, 4
• Test all patients for Helicobacter pylori and provide eradication therapy if infection is present 2, 4
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 2, 4
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 2, 5

Management of Recurrent Bleeding

• For recurrent non-variceal bleeding:
  • Perform repeat endoscopic therapy 6, 5
  • If endoscopic retreatment fails, consider interventional radiology (angiographic embolization) or surgery 6, 5
• For recurrent variceal bleeding:
  • Consider transjugular intrahepatic portosystemic shunt (TIPS) 2, 5
• Early surgical consultation may benefit patients at high risk for failed endoscopic retreatment 4, 3

Secondary Prophylaxis

• For patients requiring NSAIDs, use a PPI with a cyclooxygenase-2 inhibitor to reduce rebleeding 2, 7
• For patients requiring cardiovascular prophylaxis, restart acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2, 4
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 2, 4
• PPI therapy is recommended for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 2, 4

Common Pitfalls and Caveats

• Routine second-look endoscopy is not recommended 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, 4
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 2, 6
• In patients with cirrhosis and severe ascites, use non-selective beta blockers with caution 2, 5
• Consider discontinuing non-selective beta blockers in patients with progressive hypotension or acute conditions like bleeding, sepsis, or acute kidney injury 2, 5