What is the evaluation approach for an upper gastrointestinal (GI) bleed?

Evaluation of Upper Gastrointestinal Bleeding

Endoscopy is the first-line diagnostic and therapeutic procedure for upper GI bleeding and should be performed within 24 hours of presentation in most patients, with urgent endoscopy (within 6 hours) reserved for hemodynamically unstable patients. 1, 2, 3

Initial Clinical Assessment and Risk Stratification

Use the Glasgow-Blatchford score immediately upon presentation to stratify bleeding risk. 4, 3

• Patients with Glasgow-Blatchford score of 0-1 can be safely discharged with outpatient follow-up without inpatient endoscopy. 3, 5
• Patients with scores ≥12 indicate high risk for further bleeding or death and require hospitalization. 6
• Document any observed bleeding by photographing emesis basins, bedsheets, or toilet bowls to confirm symptoms. 2

Laboratory Evaluation

Obtain the following tests immediately: 4

• Complete blood count
• Basic metabolic panel
• Coagulation panel
• Liver function tests
• Type and crossmatch

Resuscitation Protocol

Transfuse packed red blood cells at a hemoglobin threshold of 7 g/dL (or 9 g/dL in patients with massive bleeding or significant cardiovascular comorbidities). 2, 4, 7

• Rapidly infuse normal saline or lactated Ringer solution to correct hypovolemia and maintain blood pressure. 4
• Initiate proton pump inhibitor therapy immediately upon presentation. 4, 7, 3
• Consider erythromycin infusion before endoscopy to improve visualization. 3

Endoscopic Evaluation

Perform esophagogastroduodenoscopy (EGD) within 24 hours for most hospitalized patients. 1, 2, 6, 3

• For hemodynamically unstable patients, perform urgent endoscopy within 6 hours after resuscitation. 2, 7
• However, note that a high-quality 2020 randomized trial found no mortality benefit from endoscopy within 6 hours versus 6-24 hours in high-risk patients (30-day mortality 8.9% vs 6.6%, difference not significant). 6
• Endoscopy provides both diagnostic capability and therapeutic intervention for bleeding lesions. 2, 4

Common lesions to identify during endoscopy include: 1, 2

• Cameron's erosions in large hiatal hernias
• Fundic varices
• Peptic ulcer disease
• Angioectasias
• Dieulafoy's lesion
• Gastric antral vascular ectasia

When Endoscopy is Negative or Contraindicated

If initial endoscopy is negative but bleeding persists (obscure bleeding), proceed with the following algorithm: 1

For Active Ongoing Bleeding:

CT angiography (CTA) is the preferred next step when endoscopy fails to identify a source. 1

• CTA can detect bleeding rates as slow as 0.3 mL/min with sensitivity of 79% and specificity of 95%. 1
• Multiphase CT protocol is essential: noncontrast, late arterial, and venous phases. 1
• Critical caveat: Avoid oral contrast as it obscures active hemorrhage and interferes with subsequent procedures. 1
• In high-risk patients (requiring ≥500 mL transfusion), CTA sensitivity is 81%, dropping to 50% in slower bleeds. 1

Visceral arteriography is an alternative that allows simultaneous therapeutic embolization. 1

• Can detect bleeding rates as low as 0.5 mL/min. 1
• Angiography identified bleeding in 72-80% of patients with overt nonvariceal UGIB. 1
• Early angiography (within first 5 hours) significantly improves visualization of extravasation. 1
• Limitation: Cannot detect venous bleeding and may miss intermittent bleeding. 1

For Postsurgical or Traumatic Bleeding When Endoscopy is Contraindicated:

Primary angiographic evaluation should be preferred over endoscopy. 1

• This applies to patients with new anastomotic sites (bariatric surgery, tumor resection), vascular postsurgical edema, or concern for perforation. 1

Modalities to AVOID:

Fluoroscopy with barium or iodinated oral contrast has NO role in acute UGIB evaluation. 1

• Positive oral contrast obscures active hemorrhage and interferes with subsequent endoscopy, angiography, or CT. 1

Tc-99m-labeled RBC scanning has limited utility in UGIB. 1

• High false-positive and false-negative rates specifically for upper GI sources. 1
• Errors in localization frequently occur with gastric or duodenal bleeding. 1
• Can detect bleeding as slow as 0.05-0.1 mL/min but diagnostic efficacy is widely variable. 1

Management After Failed Endoscopic Hemostasis

If endoscopic therapy fails, attempt transcatheter arterial embolization before proceeding to surgery. 4, 3

• For recurrent bleeding, repeat endoscopy is suggested first. 3
• If second endoscopic attempt fails, transcatheter embolization is the next step. 3

Post-Endoscopy Management

After successful endoscopic hemostasis, administer high-dose proton pump inhibitor therapy continuously or intermittently for 72 hours, then twice-daily oral PPI for the first 2 weeks. 4, 3

• This timing is critical as rebleeding risk is highest in the first 72 hours post-endoscopy. 4