What is the initial management and treatment 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 with intravenous fluids, risk stratification, and early endoscopy within 24 hours of presentation, followed by appropriate endoscopic therapy and high-dose proton pump inhibitors for high-risk lesions. 1, 2

Initial Assessment and Resuscitation

• Immediate evaluation and appropriate resuscitation are critical first steps to reduce mortality and improve patient outcomes 1
• Fluid resuscitation with crystalloids should be initiated in patients with hemodynamic instability to restore end-organ perfusion and tissue oxygenation 1
• Blood transfusion is recommended when hemoglobin is less than 80 g/L in patients without cardiovascular disease, with a higher threshold for those with cardiovascular disease 1, 2
• Patients with hemodynamic instability should be admitted to a monitored setting for at least the first 24 hours 1

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, 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 1
• Nasogastric tube placement can be considered as findings may have prognostic value, with bright blood in the aspirate being an independent predictor of rebleeding 1

Endoscopic Management

• Endoscopy should be performed within 24 hours of presentation for most patients 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 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 1
• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone for achieving hemostasis 1, 2
• Endoscopic clips are an effective option for hemostatic therapy 1, 2
• TC-325 (hemostatic powder) can be used as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1, 2

Pharmacological Management

• Start intravenous proton pump inhibitors immediately upon presentation with upper GI bleeding 1
• Patients with bleeding ulcers with high-risk stigmata who have had successful endoscopic therapy should receive high-dose PPI therapy (intravenous loading dose of 80 mg followed by continuous infusion of 8 mg/h) for 3 days 1, 2
• H2-receptor antagonists are not recommended due to their limited efficacy compared to proton pump inhibitors 2
• For suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as bleeding is suspected 1
• Administer antibiotic prophylaxis in patients with cirrhosis and suspected variceal bleeding (ceftriaxone or norfloxacin) 1

Post-Endoscopic Care

• After the initial 3-day high-dose IV PPI therapy, continue oral PPI therapy twice daily through 14 days, then once daily for a duration that depends on the nature of the bleeding lesion 1, 2
• Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 1, 2
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• All patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present 1, 2
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1, 2

Management of Recurrent Bleeding

• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1
• For recurrent bleeding after initial endoscopic therapy, perform repeat endoscopic therapy 3
• If endoscopic retreatment fails, consider interventional radiology (transcatheter arterial embolization) or surgery 1, 4
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1

Secondary Prophylaxis

• For patients who require NSAIDs, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 1
• Patients requiring secondary cardiovascular prophylaxis should restart acetylsalicylic acid (ASA) 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 recommended for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 1, 2

Common Pitfalls and Caveats

• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1
• In patients with cirrhosis and severe ascites, use non-selective beta blockers with caution and avoid high doses 1
• Consider discontinuing non-selective beta blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 1