What is the stepwise approach if a patient comes to the ICU with an acute upper gastrointestinal bleed?

Stepwise Approach for Acute Upper GI Bleed in the ICU

Severely ill patients with acute upper GI bleeding require immediate resuscitation with two large-bore IV cannulae, aggressive fluid replacement targeting hemodynamic stability, red cell transfusion when hemoglobin falls below 100 g/L in acute bleeding, and urgent endoscopy once resuscitation is achieved—ideally within 24 hours but emergently if actively bleeding with shock. 1, 2

Step 1: Immediate Resuscitation and Vascular Access

• Establish two large-bore venous cannulae (14-16 gauge) in the antecubital fossae immediately upon ICU arrival 1, 2
• Begin normal saline infusion rapidly to restore blood pressure, reduce pulse rate, and achieve adequate urine output (>30 ml/h) 1, 2
• Administer 1-2 liters of saline initially in most patients; if shock persists after this volume, the patient has lost at least 20% of blood volume and requires plasma expanders 1, 2
• Insert a urinary catheter to monitor hourly urine output as a marker of adequate perfusion 2
• Establish continuous automated monitoring of pulse and blood pressure 2
• Consider central venous pressure monitoring in patients with significant cardiac disease, targeting CVP of 5-10 cm H₂O 1, 2

Step 2: Blood Product Transfusion

Transfuse red cell concentrate when: 1, 2

• Active bleeding with hemodynamic instability (shock with pulse >100 bpm, systolic BP <100 mmHg) 1
• Hemoglobin concentration <100 g/L in acute bleeding (changes in cardiac output occur at this threshold and mortality relates to anemia severity in critically ill patients) 1

Critical pitfall: Avoid over-transfusion; target hemoglobin of 70-90 g/L post-transfusion using a restrictive strategy, as more liberal strategies do not improve outcomes and may increase risks 3, 4, 5

Step 3: Risk Stratification

Classify severity based on: 2

• Age (elderly at higher risk)
• Vital signs (pulse >100, systolic BP <100 indicates shock) 1
• Hemoglobin level (<100 g/L indicates significant blood loss) 1
• Presence of comorbidities (cardiac, renal, hepatic disease)
• Clinical presentation (hematemesis with melaena indicates more severe bleeding than melaena alone) 1

Step 4: Pharmacologic Intervention

• Initiate proton pump inhibitors as the main pharmacologic intervention for non-variceal UGIB 6, 5
• If cirrhosis is suspected, immediately start antibiotics and vasoactive drugs before endoscopy 5
• Consider erythromycin as a prokinetic agent to improve endoscopic visualization 5

Step 5: Timing and Preparation for Endoscopy

Endoscopy should only be performed after adequate resuscitation is achieved 1, 2

Timing Guidelines:

• Most patients: Endoscopy within 24 hours of presentation (ideally morning after admission) 1, 2, 5
• High-risk patients with active bleeding and shock: Emergency "out of hours" endoscopy once hemodynamically stabilized 1
• Very low-risk young patients with minor bleeding and no hemodynamic compromise may be discharged without endoscopy 2

Pre-Endoscopy Preparation:

• Keep patient fasted until hemodynamically stable 2
• For severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1, 2
• Ensure endoscopy is performed by experienced endoscopists capable of therapeutic interventions in a fully equipped endoscopy unit or operating theater with anesthetic support 1, 2
• Have equipment available for cardiorespiratory monitoring during and after the procedure 1

Step 6: Endoscopic Evaluation and Therapy

Endoscopy serves three critical purposes: 1

Diagnostic:

• Identify the bleeding source (peptic ulcer 35-50%, gastroduodenal erosions 8-15%, varices 5-10%, esophagitis 5-15%, Mallory-Weiss tear 15%) 1
• Use catheters to wash bleeding points and remove adherent clot to expose accurate targets 1

Prognostic:

• Assess stigmata of recent hemorrhage to determine rebleeding risk 1

Therapeutic:

Endoscopic therapy is indicated for: 1

• Esophageal varices: Banding or injection sclerotherapy 1
• Ulcers with major stigmata: Active spurting or oozing hemorrhage, non-bleeding visible vessel, or adherent blood clot 1
• Use at least two hemostatic modalities (injection, thermal probes, or clips) for high-risk non-variceal lesions 5, 7

Do NOT treat endoscopically: Clean ulcer base or black/red spots (low rebleeding risk) 1

Step 7: Post-Endoscopy Management

• High-dose PPI therapy after endoscopic hemostasis for ulcer bleeding to reduce rebleeding and mortality 5, 7
• Continue antibiotics and vasoactive drugs for variceal bleeding 5
• Patients who are hemodynamically stable 4-6 hours after endoscopy can start drinking and eating a light diet 2
• Monitor continuously for rebleeding: fresh hematemesis/melaena with shock, CVP fall >5 mmHg, or hemoglobin drop >20 g/L over 24 hours 1

Step 8: Management of Rebleeding

Rebleeding must always be confirmed by endoscopy 1

• Recurrent ulcer bleeding: Repeat endoscopic therapy first-line 5
• Subsequent bleeding after failed repeat endoscopy: Interventional radiology or surgery 5
• Recurrent variceal bleeding: Transjugular intrahepatic portosystemic shunt (TIPS) 5
• Torrential variceal hemorrhage: Balloon tamponade as bridge to further endoscopy or TIPS 7

Critical Pitfalls to Avoid

• Never perform endoscopy before adequate resuscitation—blood pressure and CVP should be stable first 1, 2
• Avoid excessive crystalloid administration that can exacerbate portal pressure, impair clot formation, and increase rebleeding risk 3
• Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized 3
• In patients with renal failure, exercise extreme caution with fluid volumes to prevent pulmonary edema 4
• Identify liver disease early as these patients require specific protocols (antibiotics, vasoactive drugs, different transfusion thresholds) 2, 5

Special Considerations for ICU Patients

• Severely ill patients are best managed in HDU or ICU with experienced nursing staff at ratios compatible with high-dependency care 1
• Care should be under medical or surgical gastroenterologist with 24-hour observation capability 1
• Emergency endoscopy in ICU patients may be more safely performed in operating theater with anesthetic support available 1