What is the stepwise management of upper gastrointestinal (GI) bleed?

Stepwise Management of Upper Gastrointestinal Bleeding

For patients presenting with acute upper GI bleeding, immediately initiate resuscitation if hemodynamically unstable, perform risk stratification using the Glasgow Blatchford score, and proceed with endoscopy within 24 hours while administering intravenous proton pump inhibitors. 1

Step 1: Immediate Resuscitation and Stabilization

Initiate resuscitation immediately for any patient with hemodynamic instability (hypotension, tachycardia, altered mental status). 1

• Administer crystalloid fluids (normal saline or Ringer's lactate) for volume resuscitation, avoiding overly aggressive fluid administration that may exacerbate bleeding. 2
• Transfuse red blood cells at hemoglobin <80 g/L (8 g/dL) in patients without cardiovascular disease. 1
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (typically 90-100 g/L). 1, 2
• Reverse anticoagulation if present: Do not delay endoscopy in patients on anticoagulants (warfarin or DOACs), but consider reversal agents if bleeding is severe. 1

Step 2: Risk Stratification

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

• Do not use the AIMS65 score for identifying low-risk patients, as evidence does not support its use for this purpose. 1
• Consider nasogastric tube placement in selected patients for prognostic information, though this is not mandatory. 1, 2
• High-risk features include age >60 years, shock, active bleeding on endoscopy, or non-bleeding visible vessel. 2, 3

Step 3: Pre-Endoscopic Pharmacologic Management

Start intravenous proton pump inhibitor therapy immediately upon presentation, which may downstage endoscopic lesions but should not delay endoscopy. 1, 2

• Do not use promotility agents routinely before endoscopy to increase diagnostic yield. 1
• Do not use H2-receptor antagonists, as they have limited efficacy compared to PPIs. 3
• For suspected variceal bleeding in cirrhotic patients, initiate vasoactive drugs (octreotide or somatostatin) and antibiotic prophylaxis before endoscopy. 2, 4, 5

Step 4: Endoscopic Evaluation and Treatment

Perform endoscopy within 24 hours of presentation for all hospitalized patients after adequate resuscitation. 1, 2, 3

For Non-Variceal Bleeding:

• No endoscopic therapy needed for low-risk stigmata (clean-based ulcer or flat pigmented spot). 1
• Attempt clot dislodgement with targeted irrigation if adherent clot is present; consider endoscopic therapy or intensive PPI therapy alone. 1
• Provide endoscopic hemostatic therapy for high-risk stigmata (active bleeding or visible vessel). 1
• Use combination therapy (epinephrine injection plus thermal coagulation or clips) rather than epinephrine alone, as monotherapy is suboptimal. 1, 2, 3
• Thermal coagulation or sclerosant injection are strongly recommended for high-risk lesions. 1
• Through-the-scope clips are an effective alternative option. 1, 3
• TC-325 hemostatic powder may be used as temporizing therapy when conventional methods fail, but not as sole treatment. 1, 3

For Variceal Bleeding:

• Perform endoscopic band ligation for esophageal varices. 5
• Use tissue glue or thrombin injection for gastric varices. 5

Step 5: Post-Endoscopic Management

Administer high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) for 72 hours in patients with high-risk stigmata who received successful endoscopic therapy. 1, 2, 3

• Transition to oral PPI twice daily through day 14, then once daily for duration depending on the bleeding lesion. 3
• Continue antibiotics and vasoactive drugs for 2-5 days in patients with variceal bleeding. 4
• Test all patients for Helicobacter pylori and provide eradication therapy if positive (note: testing during acute bleeding may have false-negatives requiring confirmatory testing later). 2, 3
• Patients at low risk for rebleeding can be fed within 24 hours and may be discharged promptly after endoscopy. 1, 3

Step 6: Management of Recurrent Bleeding

For recurrent non-variceal bleeding, attempt repeat endoscopic therapy first. 4, 5

• If endoscopic retreatment fails, proceed to transcatheter arterial embolization by interventional radiology. 5, 6
• Surgery is the final option if embolization fails or is not feasible. 5, 6

For recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) is generally the treatment of choice. 4, 5

Step 7: Secondary Prevention and Antithrombotic Management

Restart antiplatelet therapy early (typically within 7 days) when cardiovascular risks outweigh GI bleeding risks. 2

• Prescribe PPI therapy for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy. 2, 3
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding risk. 2

Key Pitfalls to Avoid:

• Do not delay endoscopy in anticoagulated patients; the benefits of early diagnosis and treatment outweigh bleeding risks. 1
• Avoid using epinephrine injection alone for endoscopic hemostasis, as it provides suboptimal efficacy. 1
• Do not use somatostatin or octreotide for routine non-variceal bleeding management. 3
• Do not overtransfuse; restrictive transfusion strategies (Hgb <80 g/L) improve outcomes in most patients. 1