What is the management of non-variceal upper gastrointestinal bleeding (UGIB)?

Management of Non-Variceal Upper Gastrointestinal Bleeding

For non-variceal UGIB, immediately resuscitate with crystalloids targeting hemodynamic stability (not normal blood pressure), transfuse at hemoglobin <80 g/L, start IV PPI therapy, and perform endoscopy within 24 hours with combination therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk stigmata. 1

Initial Resuscitation and Stabilization

Fluid Management:

• Use crystalloids (normal saline or Ringer lactate) for initial resuscitation rather than colloids, as colloids provide no mortality benefit and cost more 1
• Balanced crystalloids like Ringer lactate may reduce acute kidney injury compared to normal saline 1
• Critical pitfall: Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this exacerbates bleeding and disrupts coagulation 1

Transfusion Strategy:

• Transfuse red blood cells at hemoglobin <80 g/L for patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold (80-100 g/L) for patients with underlying cardiovascular disease 1, 3
• Avoid targeting hemoglobin >100 g/L as this increases rebleeding risk 3

Risk Stratification

Glasgow Blatchford Score:

• Use this score to identify very low-risk patients (score ≤1) who may not require hospitalization or inpatient endoscopy 1
• High-risk factors include age >60 years, shock, comorbidities, and active bleeding or non-bleeding visible vessel on endoscopy 1

Nasogastric Tube Placement:

• Consider placement in selected patients as findings have prognostic value 1, 3
• Important caveat: A negative nasogastric aspirate does NOT rule out UGIB (occurs in 3-16% of cases) 3

Pre-Endoscopic Management

Proton Pump Inhibitor Therapy:

• Start intravenous PPI therapy immediately, which may downstage endoscopic lesions 1, 4, 5
• Do not delay endoscopy for PPI administration—start PPI but proceed with endoscopy as planned 1

Prokinetic Agents:

• Consider giving prokinetics 30-60 minutes before endoscopy to aid in visualization and diagnosis 4

Anticoagulation Management:

• Do NOT delay endoscopy due to anticoagulation—proceed with endoscopy while correcting coagulopathy simultaneously 2, 3
• For life-threatening hemorrhage on apixaban, consider andexanet alfa as the specific reversal agent 3
• Do not routinely use prothrombin complex concentrates for DOACs prior to emergency procedures 3

Endoscopic Management

Timing:

• Perform endoscopy within 24 hours of presentation for most patients 1, 4, 5, 6
• Earlier endoscopy (after resuscitation) is indicated for high-risk patients with hemodynamic instability 3

Endoscopic Therapy Techniques:

• For high-risk stigmata (active bleeding or visible vessel), use combination therapy: epinephrine injection PLUS thermal coagulation or clips 1, 2
• Never use epinephrine injection alone—it must be combined with another method to achieve adequate hemostasis 2, 4
• Three broad categories exist: injection, thermal, and mechanical methods 4, 7

Advanced Techniques When Conventional Methods Fail:

• Over-the-scope clips, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, or EUS-guided angiotherapy 7

Post-Endoscopic Care

PPI Therapy:

• Administer high-dose IV PPI therapy for 3 days for patients with high-risk stigmata who had successful endoscopic therapy 1, 5

Helicobacter pylori Management:

• Test all patients for H. pylori (by serology in the acute setting) and provide eradication therapy if infection is present 1, 8
• H. pylori eradication prevents recurrent bleeding 5

NSAID Management:

• Withdraw non-steroidal anti-inflammatory drugs to prevent recurrent bleeding 5

Antiplatelet and Anticoagulation Resumption

Aspirin:

• Restart aspirin as soon as cardiovascular risks outweigh gastrointestinal risks, usually within 3-7 days 1, 8
• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1

Anticoagulation:

• Resume anticoagulation as soon as possible after hemostasis is secured, especially in high-risk conditions like massive PE where mortality risk without treatment outweighs rebleeding risk 2

Long-term PPI Prophylaxis:

• Continue PPI therapy for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1

Rescue Therapy When Endoscopy Fails

Alternative Interventions:

• If endoscopy cannot be performed due to massive bleeding or fails to achieve hemostasis, consider CT angiography to localize the bleeding source 3
• Visceral angiography allows simultaneous treatment by embolization if a bleeding source is identified 3
• Surgery should be considered when endoscopic and angiographic interventions fail 8

Multidisciplinary Coordination

Team Involvement:

• Involve gastroenterology, interventional radiology, and critical care simultaneously for complex cases 2
• Monitor in an intensive care setting where both cardiac parameters and bleeding can be closely observed 2