What is the initial evaluation and management for a suspected upper gastrointestinal (GI) bleed?

Evaluation of Upper Gastrointestinal Bleeding

Immediate Hemodynamic Assessment and Resuscitation

Begin with immediate hemodynamic assessment using the shock index (heart rate divided by systolic blood pressure), where a shock index >1 indicates instability requiring urgent intervention. 1

• Place at least two large-bore intravenous catheters immediately to allow rapid volume expansion 1
• Initiate fluid resuscitation with crystalloids to restore hemodynamic stability 1
• Use a restrictive transfusion strategy with hemoglobin threshold of 7 g/dL and target range of 7-9 g/dL for most patients 2, 1, 3
• For patients with cardiovascular disease, use a higher transfusion threshold of 8 g/dL with target ≥10 g/dL 1

Initial Laboratory Workup

Obtain complete blood count, coagulation studies (PT/INR), blood typing and cross-matching, and blood urea nitrogen levels immediately. 1

• Hemoglobin levels are critical for risk stratification: <70 g/L carries highest risk, while ≥160 g/L carries lowest risk 1
• Elevated blood urea nitrogen suggests upper GI source 2
• Coagulation studies identify coagulopathy requiring correction 1

Risk Stratification

Apply the Glasgow Blatchford score for pre-endoscopic risk stratification and the complete Rockall score post-endoscopy to predict rebleeding and mortality. 2, 4

• The Blatchford score uses hemoglobin, blood urea, pulse, systolic blood pressure, presence of syncope or melena, and evidence of hepatic disease or cardiac failure 2
• A Blatchford score of 0 identifies very low-risk patients who can be safely managed as outpatients without early endoscopy 2
• The complete Rockall score incorporates endoscopic findings and has better discriminative ability for mortality than rebleeding 2

Pre-Endoscopic Management

Administer high-dose proton pump inhibitors (PPIs) before endoscopy, as they reduce rebleeding risk through clot stabilization. 5, 3

• Consider intravenous erythromycin as a prokinetic agent to improve endoscopic visualization 3
• For patients with cirrhosis or suspected variceal bleeding, initiate antibiotics and vasoactive drugs immediately 3, 4
• For patients on warfarin with unstable bleeding, reverse anticoagulation immediately with prothrombin complex concentrate and vitamin K 1
• Temporarily withhold direct oral anticoagulants at presentation in patients with major bleeding 6

Endoscopic Evaluation Timing

Perform upper endoscopy within 24 hours of presentation for all patients after achieving hemodynamic stability. 2, 3, 4

• For hemodynamically unstable patients (shock index >1) who remain unstable despite resuscitation, consider earlier endoscopy after initial stabilization 3
• Do not delay endoscopy beyond 24 hours in high-risk patients, as this increases mortality 1
• Endoscopy should only be performed after hemodynamic stability has been achieved 5

Alternative Diagnostic Approach for Unstable Patients

For hemodynamically unstable patients with shock index >1, perform CT angiography immediately to localize bleeding before any intervention. 1

• CT angiography can detect bleeding at rates as low as 0.5 mL/min and provides anatomic information for subsequent intervention 2
• Multiple acquisitions are required to distinguish active hemorrhage from other high-density gastric contents 2
• Following positive CT angiography, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1

Special Diagnostic Considerations

Always consider an upper GI source in patients with hemodynamic instability, even when presenting with hematochezia, as 10-15% of apparent lower GI bleeding originates from the upper tract. 7, 1

• Nasogastric tube lavage in ventilated patients remains useful if blood return is shown, but avoid in unsedated patients due to risk of aerosolization 2
• For patients with negative initial endoscopy but persistent bleeding, consider repeat endoscopy with cap-fitted technique to examine blind areas (high lesser curve, under incisura angularis, posterior duodenal bulb wall) 2
• Use side-viewing endoscope to examine the ampulla in patients with suspected pancreaticobiliary pathology 2
• Consider push enteroscopy to examine the duodenal C-loop after glucagon injection if needed 2

Common Pitfalls to Avoid

• Never fail to consider an upper GI source in hemodynamically unstable patients, as this leads to delayed diagnosis and treatment 1
• Do not use barium or iodinated oral contrast for fluoroscopy, as positive oral contrast obscures active hemorrhage and interferes with subsequent procedures 2
• Avoid delaying appropriate imaging in unstable patients while attempting bowel preparation for colonoscopy 7
• Do not rely on nasogastric tube placement to rule out upper GI bleeding in non-ventilated patients, as it is not reliable and carries aspiration risk 2, 7