What is the management approach for upper GI bleeding secondary to peptic ulcer disease versus bleeding esophageal varices?

Management of Upper GI Bleeding: Peptic Ulcer Disease vs. Esophageal Varices

The management of upper GI bleeding requires immediate resuscitation followed by distinct treatment pathways based on whether the bleeding source is peptic ulcer disease or esophageal varices, with combination endoscopic therapy being superior for peptic ulcer disease and vasoactive drugs plus endoscopic band ligation being recommended for variceal bleeding. 1, 2

Initial Assessment and Resuscitation (Both Conditions)

• Immediate evaluation and resuscitation are critical first steps before proceeding with diagnostic and therapeutic measures to reduce mortality and improve outcomes 1
• Fluid resuscitation with crystalloids should be initiated in patients with hemodynamic instability to restore end-organ perfusion 1
• Blood transfusion is recommended for patients with hemoglobin <80 g/L without cardiovascular disease, with higher thresholds for those with cardiovascular disease 2
• Risk stratification using Glasgow Blatchford score can identify patients at very low risk (score ≤1) who may not require hospitalization 1

IVF Management

• For peptic ulcer bleeding: Aggressive fluid resuscitation with crystalloids to maintain hemodynamic stability 1
• For variceal bleeding: Careful fluid resuscitation to restore hemodynamics while avoiding excessive volume that could increase portal pressure 3

Diet Management

• For peptic ulcer bleeding: Patients considered low risk for rebleeding after endoscopy can be fed within 24 hours 1
• For variceal bleeding: NPO initially, then advance diet after successful endoscopic therapy and hemodynamic stability 3

Labs & Diagnostics

For Both Conditions:

• Complete blood count, coagulation profile, comprehensive metabolic panel, and type and cross-match 1
• Upper endoscopy within 24 hours of presentation for most patients 2
• Contrast-enhanced CT or MRI is particularly important for evaluating patients with suspected gastric varices to identify inflow and outflow patterns 3

Specific for Variceal Bleeding:

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1
• If patient remains unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding 1

Medications

For Peptic Ulcer Bleeding:

• Start intravenous proton pump inhibitors immediately upon presentation 1
• After successful endoscopic therapy for high-risk stigmata: High-dose PPI therapy (IV loading dose followed by continuous infusion) for 3 days 1, 4
• Continue oral PPI therapy twice daily through 14 days, then once daily based on the nature of the bleeding lesion 1
• Test for H. pylori and provide eradication therapy if infection is present 1, 4

For Variceal Bleeding:

• Initiate vasoactive drug therapy as soon as bleeding is suspected 1:
  • 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
• Administer antibiotic prophylaxis in patients with cirrhosis (ceftriaxone or norfloxacin) 1
• Continue vasoactive drugs and antibiotics for 3-5 days 1

Endoscopic Management

For Peptic Ulcer Bleeding:

• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone 3, 2
• Endoscopic clips appear promising for hemostasis 3, 1
• Epinephrine injection alone is not recommended 1
• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 1

For Variceal Bleeding:

• Endoscopic band ligation is the preferred method for esophageal varices 3
• For gastric varices, endoscopic variceal obturation with cyanoacrylate injection is more effective than band ligation (94% vs 80% control of active bleeding) 3
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1

Special Orders

For Peptic Ulcer Bleeding:

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• For patients requiring NSAIDs, use a PPI with a COX-2 inhibitor to reduce rebleeding 1
• For patients requiring cardiovascular prophylaxis, restart ASA as soon as cardiovascular risks outweigh GI risks (usually within 7 days) 1, 2

For Variceal Bleeding:

• In patients with cirrhosis and severe ascites, use non-selective beta blockers with caution and avoid high doses 1
• Consider discontinuing beta blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 1

Management of Recurrent Bleeding

For Peptic Ulcer Bleeding:

• Repeat endoscopic therapy for recurrent bleeding 1
• If bleeding persists after second endoscopic treatment, consider interventional radiology or surgery 4

For Variceal Bleeding:

• For recurrent variceal bleeding despite medical and endoscopic therapy, TIPS is recommended 1
• Balloon tamponade may be attempted on a temporary basis with the Linton-Nachlas tube in cases of massive hemorrhage 3

Common Pitfalls and Caveats

• Routine second-look endoscopy is not recommended for peptic ulcer bleeding 1
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1
• For variceal bleeding, the combination of beta blockade and endoscopic variceal ligation is more effective for secondary prevention 5