What is the management approach for a patient with upper gastrointestinal bleeding (UGIB)?

Management of Upper Gastrointestinal Bleeding

Initiate immediate hemodynamic resuscitation with crystalloid fluids, transfuse red blood cells at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start intravenous proton pump inhibitor therapy, and perform endoscopy within 24 hours with combination endoscopic therapy for high-risk lesions. 1, 2

Immediate Resuscitation

Fluid resuscitation is the absolute first priority to restore end-organ perfusion and prevent multiorgan failure and death in hemodynamically unstable patients. 1, 2

• Use crystalloids (normal saline or Ringer lactate) rather than colloids for initial resuscitation, as colloids offer no mortality benefit and are more expensive. 1
• Balanced crystalloids like Ringer lactate may reduce acute kidney injury compared to normal saline. 1
• Transfuse packed red blood cells at hemoglobin threshold <80 g/L for patients without cardiovascular disease. 2, 3
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease. 2
• Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this may exacerbate bleeding and disrupt coagulation. 1

Risk Stratification

Apply the Glasgow Blatchford score immediately to identify very low-risk patients (score ≤1) who can be managed as outpatients without urgent endoscopy. 2, 3

High-risk features requiring intensive monitoring include: 2

• Age >60 years
• Hemodynamic instability or shock
• Significant comorbidities
• Active bleeding or visible vessel on endoscopy

Pre-Endoscopic Pharmacotherapy

Start intravenous proton pump inhibitor therapy immediately upon presentation, which may downstage endoscopic lesions, but do not delay endoscopy for this. 2, 4, 3

• Administer erythromycin 30-60 minutes before endoscopy as a prokinetic agent to improve visualization. 4, 3
• For suspected variceal bleeding in cirrhotic patients, initiate vasoactive drugs (octreotide) and antibiotic prophylaxis before endoscopy. 2, 5

Endoscopic Management Timing and Technique

Perform endoscopy within 24 hours of presentation for most patients after initial stabilization. 2, 4, 3

• Consider earlier endoscopy (after resuscitation) in high-risk patients with hemodynamic instability. 3
• Do not delay endoscopy for coagulopathy correction in anticoagulated patients—proceed with endoscopy while simultaneously correcting coagulopathy. 6

Endoscopic Therapy for High-Risk Lesions

Use combination endoscopic therapy for high-risk stigmata (active bleeding, non-bleeding visible vessel, adherent clot): 2, 4

• Epinephrine injection PLUS thermal coagulation or mechanical clips—never use epinephrine injection alone, as monotherapy has inferior outcomes. 6, 2
• Injection, thermal, and mechanical methods can be combined for optimal hemostasis. 4

Post-Endoscopic Management

Administer high-dose intravenous PPI therapy for 72 hours following successful endoscopic therapy in patients with high-risk stigmata. 2

• Test all patients for Helicobacter pylori and provide eradication therapy if positive. 2
• Monitor closely for rebleeding, particularly in the first 72 hours. 3

Management of Rebleeding

Attempt repeat endoscopic therapy for recurrent ulcer bleeding. 3

• If second endoscopic attempt fails, proceed to interventional radiology (angiographic embolization) or surgery. 3, 7
• Recurrent variceal bleeding is generally managed with transjugular intrahepatic portosystemic shunt (TIPS). 3

Resumption of Antithrombotic Therapy

Restart antiplatelet agents (aspirin) within 7 days once hemostasis is secured, as cardiovascular risks typically outweigh rebleeding risks. 2, 3

• Aspirin plus PPI is superior to clopidogrel alone for reducing rebleeding in patients requiring cardiovascular prophylaxis. 2
• Continue PPI therapy long-term in patients requiring antiplatelet or anticoagulant therapy. 2
• In patients with massive pulmonary embolism and concurrent UGIB, resume anticoagulation as soon as hemostasis is achieved, as PE-related mortality risk exceeds rebleeding risk. 6

Critical Pitfalls to Avoid

• Never use epinephrine injection monotherapy—always combine with thermal or mechanical modality. 6, 2
• Do not use systemic thrombolytic therapy in patients with active bleeding. 6
• Do not delay endoscopy waiting for coagulopathy correction in anticoagulated patients. 6
• Do not withhold blood transfusion until hemoglobin drops below 70 g/L in patients with cardiovascular disease—use higher threshold. 2