What is the management approach for a patient presenting with an upper gastrointestinal (GI) bleed?

Management of Upper Gastrointestinal Bleeding

Immediately initiate resuscitation with crystalloid fluids while simultaneously preparing for endoscopy within 24 hours, and start high-dose intravenous proton pump inhibitors before endoscopy. 1, 2

Initial Resuscitation and Stabilization

Resuscitation takes absolute priority over identifying the bleeding source. 1, 2

• Administer crystalloid fluids (normal saline or lactated Ringer's) rapidly to restore hemodynamic stability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour 2
• Crystalloids are preferred over colloids as colloids show no survival benefit and cost more 1, 2
• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 1, 2
• This restrictive transfusion strategy (hemoglobin <80 g/L) improves outcomes and is supported by moderate-quality evidence 2
• Correct any coagulopathy present 1
• Admit high-risk patients to a monitored setting for at least the first 24 hours 1

Early intensive resuscitation significantly decreases mortality—focus on rapid correction of hemodynamics, hematocrit, and coagulopathy. 3

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

Risk factors indicating poor outcomes and high-risk status include: 1, 2

• Hemodynamic instability (shock index >1)
• Melena
• Fresh red blood in emesis or nasogastric aspirate
• Elevated urea, creatinine, or aminotransferase levels
• Poor overall health status

Consider nasogastric tube placement in selected patients as the presence of bright blood in aspirate is an independent predictor of rebleeding. 1, 4

Pharmacologic Management

Start high-dose intravenous PPI therapy immediately upon presentation, before endoscopy. 1, 2

For Non-Variceal Bleeding:

• Administer PPI as 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy for high-risk stigmata lesions 1, 2
• Continue oral PPI twice daily through day 14, then once daily for duration based on the underlying cause 1, 2

For Suspected Variceal Bleeding:

• Initiate vasoactive drug therapy immediately when variceal bleeding is suspected: 1
  • Terlipressin: 2 mg every 4 hours for first 48 hours, then 1 mg every 4 hours thereafter
  • Somatostatin: 250 μg/hour continuous infusion with initial 250 μg bolus
  • Octreotide: 50 μg/hour continuous infusion with initial 50 μg bolus
• Administer antibiotic prophylaxis in patients with cirrhosis and suspected variceal bleeding (ceftriaxone or norfloxacin) 1
• Continue vasoactive drugs and antibiotics for 3-5 days 1

Consider erythromycin as a prokinetic agent before endoscopy to improve visualization. 5

Endoscopic Management

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

Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation. 1, 2, 4

If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy. 1

Endoscopic Therapy Based on Lesion Characteristics:

For high-risk stigmata (active bleeding or visible vessel), endoscopic hemostasis is mandatory. 1, 2

• Use combination therapy (thermocoagulation plus sclerosant injection) as first-line treatment—this is superior to monotherapy 1, 2
• Through-the-scope clips are an effective alternative 1, 2
• Epinephrine injection alone is NOT recommended 1
• TC-325 (hemostatic powder) can be used as temporizing therapy but not as sole treatment in actively bleeding ulcers 1
• Attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of underlying stigmata are supported by data 1

For Variceal Bleeding:

• Use ligation for esophageal varices 5
• Use tissue glue for gastric varices 5

Management of Rebleeding

For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended. 1, 2

Routine second-look endoscopy is NOT recommended, but may be useful in selected high-risk patients. 1, 2

• If second endoscopic therapy fails for non-variceal bleeding, attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained 6
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1, 5

Post-Endoscopic Care

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 1, 4

Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly. 1, 2

All patients with upper GI bleeding must be tested for Helicobacter pylori and receive eradication therapy if positive. 1, 2, 4

Important Caveat:

Testing for H. pylori during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary 1, 2

Eradication of H. pylori reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1

Secondary Prophylaxis and Antiplatelet/Anticoagulant Resumption

Resume aspirin as soon as cardiovascular risks outweigh GI risks, usually within 7 days. 1, 2, 4

ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding risk. 1, 2, 4

PPI therapy is recommended for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy. 1, 2, 4

For patients requiring NSAIDs after UGIB, use a COX-2 inhibitor plus PPI to reduce rebleeding risk 1, 2

Special Considerations

For Hemodialysis Patients:

Schedule endoscopic procedures on non-dialysis days to minimize bleeding risk from residual anticoagulation effects 4

For Cirrhotic Patients:

• Use non-selective beta-blockers with caution in patients with severe ascites and avoid high doses 1
• Discontinue non-selective beta-blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 1

Common Pitfalls

Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality—proper management and follow-up are critical 1

Inadequate early resuscitation is a major factor in persistently high mortality rates in upper GI bleeding 3