From the Guidelines
Upper GI bleeding is a medical emergency that requires immediate attention with stabilization, fluid resuscitation, and blood transfusion if necessary, followed by urgent endoscopy within 24 hours to identify and treat the bleeding source, as recommended by the most recent guidelines 1.
Initial Management
The initial management of upper GI bleeding includes:
- Stabilizing the patient with two large-bore IV lines (18-gauge or larger)
- Fluid resuscitation with crystalloids
- Blood transfusion if hemoglobin is below 7 g/dL
- Starting proton pump inhibitor therapy immediately with IV pantoprazole 80 mg bolus followed by 8 mg/hour infusion for 72 hours
Diagnostic Approach
Urgent endoscopy should be performed within 24 hours to identify and treat the bleeding source, as it is the most effective diagnostic and therapeutic approach for upper GI bleeding 1. Common causes of upper GI bleeding include peptic ulcers, gastritis, esophageal varices, and Mallory-Weiss tears.
Risk Stratification
Risk stratification using the Glasgow-Blatchford score helps determine which patients need urgent intervention versus outpatient management 1. This score takes into account various factors such as age, hemoglobin level, and presence of comorbidities to predict the risk of adverse outcomes.
Treatment
After stabilization, patients with non-variceal bleeding typically require oral PPI therapy for 4-8 weeks, while those with H. pylori-associated ulcers need eradication therapy (clarithromycin 500 mg, amoxicillin 1g, and PPI, all twice daily for 14 days) 1. It is essential to note that upper GI bleeds are serious because rapid blood loss can lead to hypovolemic shock, and the acidic environment of the stomach can worsen bleeding by preventing clot formation and impairing platelet function.
Key Considerations
- The incidence of nonvariceal upper GI bleeding is almost 5 times higher than that of variceal upper GI bleeding 1
- Peptic ulcer disease caused by Helicobacter pylori infection or nonsteroidal anti-inflammatory drug use is the most common cause of non-variceal upper GI bleeding 1
- Rare causes of nonvariceal upper GI bleeding include hemobilia, hemosuccus pancreaticus, and aortoenteric fistula 1
From the Research
Upper GI Bleed Management
- The management of upper gastrointestinal bleeding (GIB) due to peptic ulcer disease (PUD) involves the use of proton pump inhibitors (PPIs) to decrease rebleeding risk and improve ulcer healing 2.
- A study found that once-daily oral PPI dosing at hospital discharge was not associated with inferior outcomes compared to twice-daily dosing in patients hospitalized for upper GIB due to PUD 2.
- PPI treatment initiated after endoscopic diagnosis of peptic ulcer bleeding significantly reduced re-bleeding and surgery compared with placebo or H2RA 3.
- The use of PPIs before and after endoscopy, with endoscopic haemostatic therapy (EHT) for those with major stigmata of recent haemorrhage, is preferred on cost-effectiveness grounds 3.
Treatment Strategies
- A study compared the use of octreotide and a PPI versus a PPI alone in nonvariceal upper-gastrointestinal bleeding (NVUGIB) and found no difference in clinical end points, suggesting that octreotide provides no additional major clinical benefit in NVUGIB 4.
- The American College of Gastroenterology (ACG) suggests risk assessment in the emergency department to identify very-low-risk patients who may be discharged with outpatient follow-up, and recommends red blood cell transfusion at a threshold of 7 g/dL for patients hospitalized with upper gastrointestinal bleeding 5.
- Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels, and high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days after endoscopic hemostasis 5.
Proton Pump Inhibitors
- PPIs are effective in reducing the risk of rebleeding and improving outcomes in patients with upper GI bleeding 3, 5.
- A study found that standard doses of PPIs reduced the risk of NSAID-induced endoscopic gastric and duodenal ulcers, and that PPIs were superior to misoprostol in preventing recurrence of NSAID-induced endoscopic duodenal ulcers 3.
- The use of PPIs in acute upper GI bleeding is considered effective, although the optimal dosing and duration of treatment are still debated 6.