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

Management of Upper Gastrointestinal Bleeding

For patients with acute upper GI bleeding, initiate immediate resuscitation with crystalloid fluids, transfuse at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start high-dose intravenous PPI therapy, and perform endoscopy within 24 hours with endoscopic hemostasis for high-risk stigmata lesions. 1, 2

Initial Resuscitation and Stabilization

Resuscitation is the critical first step and must be initiated before diagnostic procedures. 1, 2

• Place two large-bore IV cannulas and infuse normal saline or lactated Ringer's solution to restore hemodynamic stability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour 3, 4
• Most patients require 1-2 liters of crystalloid initially; if shock persists after this, plasma expanders are needed 3
• Crystalloids are preferred over colloids for initial resuscitation as colloids show no survival benefit and are more expensive 2

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease. 1, 2, 5

• For patients with underlying cardiovascular disease, use a higher hemoglobin threshold for transfusion 1, 2, 5
• This restrictive transfusion strategy (hemoglobin <80 g/L) is supported by moderate-quality evidence and improves outcomes 1, 2

Risk Stratification

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who can be managed as outpatients without hospitalization or urgent endoscopy. 1, 2, 5

• Do not use the AIMS65 score for risk stratification as it is not recommended 1
• Consider nasogastric tube placement for prognostic value; bright red blood in aspirate independently predicts rebleeding 1, 2, 3
• Risk factors for poor outcomes include hemodynamic instability, melena, fresh red blood in emesis, and elevated urea, creatinine, or aminotransferase levels 2, 5, 3
• High-risk patients require admission to a monitored setting for at least 24 hours (72 hours after endoscopic hemostasis) 2

Pharmacologic Management

Start high-dose intravenous PPI therapy immediately upon presentation, before endoscopy. 2, 5, 6, 4

• Pre-endoscopic PPI therapy may downstage endoscopic lesions and decrease need for intervention, but should not delay endoscopy 1
• After successful endoscopic therapy for high-risk stigmata lesions, administer PPI as 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 1, 2, 5
• Following the initial 3-day high-dose IV PPI, continue oral PPI twice daily through day 14, then once daily for duration based on the underlying cause 1, 5
• H2-receptor antagonists are NOT recommended due to limited efficacy compared to PPIs 1, 5
• Somatostatin and octreotide are NOT routinely recommended for nonvariceal upper GI bleeding 1, 5
• Consider erythromycin as a prokinetic agent before endoscopy, though routine use is not recommended 1, 6

Anticoagulation Management

Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs); endoscopy can be performed with or without reversal. 1

• Correct coagulopathy early when present 7
• The decision to reverse anticoagulation must balance bleeding risk against thrombotic risk 4, 8

Endoscopic Management

Perform endoscopy within 24 hours of presentation for all hospitalized patients. 1, 2, 5

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation 2, 6
• Endoscopy should only be performed after achieving hemodynamic stability 3, 6
• Develop institution-specific protocols with access to endoscopists trained in hemostatic techniques and support staff available urgently 1, 2

Endoscopic Therapy Based on Lesion Characteristics

No endoscopic therapy is needed for low-risk stigmata (clean-based ulcer or flat pigmented spot). 1

For adherent clots, attempt targeted irrigation to dislodge the clot and treat the underlying lesion; endoscopic therapy may be considered though intensive PPI alone may suffice. 1, 2

For high-risk stigmata (active bleeding or visible vessel), endoscopic hemostatic therapy is mandatory. 1

Specific Endoscopic Techniques

Use combination therapy (thermocoagulation or sclerosant injection) as first-line endoscopic treatment for high-risk stigmata lesions. 1, 2, 5

• Epinephrine injection alone provides suboptimal efficacy and must be combined with another method 1, 2
• Through-the-scope clips are suggested as an effective alternative 1, 2, 5
• No single thermal coaptive method is superior to another 1
• TC-325 hemostatic powder is suggested only as temporizing therapy when conventional methods are unavailable or fail, NOT as sole treatment 1, 2, 5

Management of Rebleeding

Routine second-look endoscopy is not recommended. 1, 5

• For clinical evidence of rebleeding, a second attempt at endoscopic therapy is generally recommended 1, 2
• If repeat endoscopic therapy fails, proceed to transcatheter arterial embolization, then surgery if needed 6, 4
• Consider early surgical consultation for patients at high risk for failed endoscopic retreatment 5

Post-Endoscopic Care

Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly. 1, 5

All patients must be tested for Helicobacter pylori and receive eradication therapy if positive, as this reduces ulcer recurrence and rebleeding. 2, 5

• Testing during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary 2, 5
• Monitor patients closely after endoscopy with continuous observation of vital signs and urine output 3

Secondary Prophylaxis and Antiplatelet/Anticoagulant Resumption

For patients requiring NSAIDs after UGIB, use a COX-2 inhibitor plus PPI to reduce rebleeding risk. 2

Resume aspirin as soon as cardiovascular risks outweigh GI risks, usually within 7 days. 2

• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2
• PPI therapy is suggested for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 2, 5
• Outcomes appear better when antithrombotic agents are reintroduced early 6

Common Pitfalls

• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 2
• Do not use epinephrine injection as monotherapy 1, 2
• Do not perform routine second-look endoscopy 1, 5
• Do not use H2-receptor antagonists instead of PPIs 1, 5
• Remember that H. pylori testing during acute bleeding may be falsely negative 2, 5