What is the recommended management bundle for upper gastrointestinal (UGI) bleeding?

Recommended Management Bundle for Upper Gastrointestinal Bleeding

The management of upper gastrointestinal bleeding requires a structured approach including immediate resuscitation, risk stratification, timely endoscopy, appropriate endoscopic therapy, and post-endoscopic care to reduce mortality and improve patient outcomes. 1, 2

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 for fluid resuscitation using crystalloids (preferred over colloids) 3, 4
• For patients without cardiovascular disease, blood transfusion is recommended when hemoglobin is <80 g/L 1, 2
• For patients with underlying cardiovascular disease, use a higher hemoglobin threshold for transfusion 1, 2
• Consider nasogastric tube placement in selected patients as findings may have prognostic value 1, 2
• Correct coagulopathy (INR >1.5) or thrombocytopenia (<50,000/μL) with fresh frozen plasma or platelets as needed 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
• Do not use the AIMS65 score to identify very low-risk patients 1
• High-risk factors include age >60 years, shock, comorbidities, active bleeding or non-bleeding visible vessel on endoscopy 2
• Patients with high-risk features should be admitted to a monitored setting for at least the first 24 hours 4

Pre-Endoscopic Management

• Start intravenous proton pump inhibitor (PPI) therapy, which may downstage endoscopic lesions but should not delay endoscopy 1, 2
• Do not routinely use promotility agents before endoscopy to increase diagnostic yield 1
• For patients receiving anticoagulants (vitamin K antagonists, DOACs), do not delay endoscopy 1
• For suspected variceal bleeding in patients with cirrhosis, initiate vasoactive drugs (terlipressin, somatostatin, or octreotide) and administer antibiotic prophylaxis 2, 4

Endoscopic Management

• Perform early 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 4
• Develop institution-specific protocols for multidisciplinary management, including access to an endoscopist trained in endoscopic hemostasis 1
• Have support staff trained to assist in endoscopy available on an urgent basis 1
• For high-risk stigmata (active bleeding or visible vessel in ulcer bed), endoscopic hemostatic therapy is indicated 1, 2
• Use combination endoscopic therapy rather than monotherapy - epinephrine injection alone provides suboptimal efficacy and should be used with another method 1, 2
• For ulcers with adherent clots, attempt targeted irrigation for dislodgement with appropriate treatment of the underlying lesion 1
• Endoscopic therapy is not indicated for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot) 1

Post-Endoscopic Care

• Administer high-dose PPI therapy (IV loading dose followed by continuous infusion) for 3 days for patients with high-risk stigmata who have had successful endoscopic therapy 2, 4
• For high-risk patients, continue oral PPI therapy twice daily through 14 days, then once daily depending on the nature of the bleeding lesion 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 4
• Selected patients with acute ulcer bleeding who are at low risk for rebleeding based on clinical and endoscopic criteria may be discharged promptly after endoscopy 1

Management of Recurrent Bleeding

• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 4
• If second attempt at endoscopic hemostasis fails, consider transcatheter angiographic embolization or surgery 4, 5

Secondary Prophylaxis

• 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
• For patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy, PPI therapy is recommended 2, 4

Common Pitfalls to Avoid

• Delaying resuscitation while pursuing diagnostic tests - resuscitation should always take precedence 3
• Assuming lower GI bleeding based solely on rectal bleeding - up to 15% of apparent lower GI bleeds are actually from upper GI sources 3
• Using epinephrine injection as monotherapy - always combine with another endoscopic method 1, 2
• Delaying endoscopy in patients receiving anticoagulants 1
• Routine second-look endoscopy is not recommended 4, 5