What is the recommended management and medication regimen for a patient with upper gastrointestinal bleeding, including specific doses and treatment duration?

Management of Upper Gastrointestinal Bleeding

The recommended management for upper gastrointestinal bleeding (UGIB) includes immediate resuscitation, early risk stratification, high-dose proton pump inhibitor therapy (80mg IV bolus followed by 8mg/hour continuous infusion for 72 hours), and endoscopy within 24 hours, with specific endoscopic interventions based on bleeding stigmata. 1, 2, 3

Initial Assessment and Resuscitation

• Use the Glasgow Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization 1
• For hemodynamically stable patients without cardiovascular disease, transfuse blood when hemoglobin is <80 g/L; use a higher threshold for those with cardiovascular disease 1
• Begin IV fluid resuscitation immediately for unstable patients 4
• Administer pre-endoscopy erythromycin to enhance gastric visualization during endoscopy 2

Pharmacological Management

Pre-Endoscopy

• Start high-dose PPI therapy as soon as possible, even before endoscopy 2, 3
• Options include:
  • Omeprazole: 80 mg IV bolus 2
  • Pantoprazole: 80 mg IV bolus 5

Post-Endoscopy (for high-risk stigmata after successful endoscopic therapy)

• Continue high-dose PPI therapy with:
  • 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 1, 2, 5, 3
• After 72 hours, transition to:
  • Oral PPI twice daily through day 14 1, 2
  • Then once daily PPI therapy for a total duration that depends on the nature of the bleeding lesion 1, 3

Endoscopic Management

• Perform endoscopy within 24 hours of presentation, earlier for high-risk patients 1
• For high-risk lesions, use one of the following endoscopic hemostasis techniques:
  • Thermocoagulation (recommended) 1
  • Sclerosant injection (recommended) 1
  • Clips (suggested) 1
  • Combination therapy with epinephrine injection plus another modality (recommended) 1
• Epinephrine injection alone is not recommended 1
• Hemostatic powder (TC-325) can be used as temporary therapy for actively bleeding ulcers, but not as sole treatment 1

Post-Procedure Management

• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis 1
• Test all patients with bleeding peptic ulcers for H. pylori infection and provide eradication therapy if positive 2, 3
• For patients requiring NSAIDs, use a PPI with a cyclooxygenase-2 inhibitor to reduce rebleeding 1
• For patients requiring cardiovascular prophylaxis, 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

Common Pitfalls to Avoid

• Do not rely solely on PPI therapy without endoscopic intervention in active bleeding 2, 5
• Do not use epinephrine injection as the only endoscopic treatment 1
• Do not discontinue PPI therapy too early (before 6-8 weeks) as this may not allow adequate time for mucosal healing 2
• Do not delay restarting antiplatelet therapy in patients requiring cardiovascular prophylaxis 1, 3

Special Considerations

• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1
• For patients with UGIB who require secondary cardiovascular prophylaxis, ASA plus PPI therapy is preferred over clopidogrel alone 1
• High-dose oral PPI may be a cost-effective alternative to IV PPI in hemodynamically stable patients 6