What are the latest guidelines for managing upper Gastrointestinal (GI) bleeding?

Latest Guidelines for Managing Upper GI Bleeding

The latest guidelines recommend immediate risk stratification using the Glasgow Blatchford score, endoscopy within 24 hours of presentation, combination endoscopic therapy for high-risk stigmata, and high-dose PPI therapy for 3 days following successful endoscopic treatment of high-risk lesions. 1, 2

Initial Assessment and Resuscitation

• Immediate fluid resuscitation with crystalloids should be initiated in patients with hemodynamic instability to restore end-organ perfusion and tissue oxygenation 2
• Blood transfusion is recommended for patients with hemoglobin <80 g/L in those without cardiovascular disease, with a higher threshold for those with cardiovascular disease 1, 2
• The Glasgow Blatchford score of 1 or less can identify patients at very low risk for rebleeding who may not require hospitalization 1, 2
• Nasogastric tube placement may be considered as findings have prognostic value, with bright blood in the aspirate being an independent predictor of rebleeding 2

Pre-Endoscopic Management

• Intravenous PPI therapy should be started immediately upon presentation with upper GI bleeding, which may downstage endoscopic lesions but should not delay endoscopy 3
• For suspected variceal bleeding in patients with cirrhosis, vasoactive drug therapy (terlipressin, somatostatin, or octreotide) should be initiated as soon as bleeding is suspected 2
• Antibiotic prophylaxis is recommended in patients with cirrhosis and suspected variceal bleeding 2

Endoscopic Management

• Endoscopy should be performed within 24 hours of presentation for most patients with upper GI bleeding 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 2
• For high-risk stigmata, combination endoscopic therapy is recommended: 1, 2
  • Thermocoagulation and sclerosant injection are recommended 1
  • Clips are suggested as an effective option 1
  • Epinephrine injection alone is not recommended 2
• TC-325 (hemostatic powder) is suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1, 2
• Attempts to dislodge clots with subsequent hemostatic treatment of underlying stigmata are supported by evidence 2

Pharmacologic Management

• For patients with bleeding ulcers with high-risk stigmata who have undergone successful endoscopic therapy: 1
  • High-dose PPI therapy via intravenous loading dose followed by continuous intravenous infusion for 3 days is strongly recommended 1, 2
  • Recent evidence suggests that intermittent PPI dosing may be comparable to continuous infusion, potentially reducing costs and resource use 4
• For high-risk patients after the initial 3 days of treatment: 1
  • Oral PPI therapy is suggested twice daily through 14 days 1
  • Then once daily for a duration that depends on the nature of the bleeding lesion 1
• H2-receptor antagonists are not recommended for patients with acute ulcer bleeding 1
• Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding (non-variceal bleeding) 1

Post-Endoscopic Care

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1, 2
• Patients at low risk after endoscopy can be fed within 24 hours 1, 2
• Routine second-look endoscopy is not recommended 1, 2
• A second attempt at endoscopic therapy is generally recommended in cases of rebleeding 1, 2
• If endoscopic therapy fails, surgical consultation should be sought 1
• Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed 1

Testing and Treatment for H. pylori

• All patients with bleeding peptic ulcers should be tested for Helicobacter pylori 1, 2
• Eradication therapy should be provided if H. pylori infection is present, with confirmation of eradication 1, 2
• Negative H. pylori diagnostic tests obtained in the acute setting should be repeated due to increased false-negative rates during acute bleeding 1, 2

Secondary Prophylaxis

• For patients with previous ulcer bleeding who require NSAIDs: 1
  • Treatment with a traditional NSAID plus a PPI or COX-2 inhibitor alone still carries a clinically important risk for recurrent ulcer bleeding 1
  • The combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding 1, 2
• For patients on antiplatelet therapy: 1, 2
  • In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complications outweighs the risk for bleeding (usually within 7 days) 1, 2
  • PPI therapy is suggested for patients with previous ulcer bleeding receiving single or dual antiplatelet therapy 1, 2
• For patients on anticoagulants: 1
  • PPI therapy is suggested for patients with previous ulcer bleeding requiring continued cardiovascular prophylaxis with anticoagulant therapy (vitamin K antagonists, DOACs) 1, 2

Management of Recurrent Bleeding

• For recurrent peptic ulcer bleeding, repeat endoscopic therapy is recommended 2, 5
• For recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) is recommended 2, 5
• If repeat endoscopic therapy fails, interventional radiology or surgery should be considered 6