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

Management of Upper Gastrointestinal Bleeding

Immediately initiate resuscitation with crystalloid fluids, start high-dose IV PPI therapy before endoscopy, and arrange endoscopy within 24 hours for all hospitalized patients, with earlier intervention (within 12 hours) for hemodynamically unstable patients after initial resuscitation. 1

Initial Resuscitation and Stabilization

Establish two large-bore IV lines (18-gauge or larger) and begin aggressive fluid resuscitation with crystalloids (normal saline or lactated Ringer's) targeting hemodynamic stability: heart rate reduction, blood pressure increase, and urine output >30 mL/hour. 1, 2

• Crystalloids are superior to colloids for initial resuscitation—colloids show no survival benefit and cost more 1
• Keep the patient NPO until hemodynamically stable 2
• Monitor vital signs continuously, including pulse, blood pressure, and urine output to detect early decompensation 2

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin drops below 80 g/L (7 g/dL) in patients without cardiovascular disease. 1

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

Risk Stratification

Use the Glasgow Blatchford score to stratify risk—patients with a score ≤1 can be managed as outpatients without hospitalization or urgent endoscopy. 1

High-risk features requiring hospitalization and close monitoring include: 3, 2

• Age >65 years
• Hemodynamic instability (tachycardia >100 bpm, systolic BP <100 mmHg)
• Fresh red blood in emesis or nasogastric aspirate
• Melena
• Elevated urea, creatinine, or aminotransferase levels
• Hemoglobin <100 g/L

Consider nasogastric tube placement—bright red blood in aspirate is an independent predictor of rebleeding. 3, 2

Pharmacologic Management

Start high-dose IV PPI immediately upon presentation, before endoscopy: 80 mg IV bolus followed by 8 mg/hour continuous infusion. 1, 3

• Continue the 8 mg/hour infusion for 72 hours after successful endoscopic therapy for high-risk stigmata lesions 1, 3
• After 72 hours, transition to oral PPI twice daily through day 14, then once daily for duration based on the underlying cause 1, 3
• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole 3

For suspected variceal bleeding in cirrhotic patients, initiate vasoactive drug therapy immediately: 3

• Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours
• 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 (ceftriaxone or norfloxacin) 3

Endoscopic Management

Perform endoscopy within 24 hours of presentation for all hospitalized patients. 1, 3

For high-risk patients with hemodynamic instability after initial resuscitation, perform endoscopy within 12 hours. 1, 3

• 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 3
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 3

Endoscopic Therapy Based on Lesion Characteristics

Use combination therapy (thermocoagulation or sclerosant injection plus another modality) as first-line endoscopic treatment for high-risk stigmata lesions (active bleeding or visible vessel). 1, 3

• Through-the-scope clips are an effective alternative 1
• Epinephrine injection alone is not recommended—it must be combined with another modality 3
• TC-325 (hemostatic powder) can be used as temporizing therapy but not as sole treatment 3
• Attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of underlying stigmata are supported by data 3

For variceal bleeding: 3

• Esophageal varices: endoscopic band ligation
• Gastric varices: tissue glue injection
• Continue vasoactive drugs and antibiotics for 3-5 days post-endoscopy

Management of Rebleeding

Routine second-look endoscopy is not recommended, but a second attempt at endoscopic therapy is generally recommended for clinical evidence of rebleeding. 1, 3

• For recurrent ulcer bleeding after failed repeat endoscopy, proceed to transcatheter arterial embolization, then surgery if hemostasis is not obtained 3
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 3
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 3, 2

Post-Endoscopic Care

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 3

Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly. 1, 3

All patients must be tested for Helicobacter pylori and receive eradication therapy if positive. 1, 3

• Testing during acute bleeding has increased false-negative rates—confirmatory testing outside the acute context may be necessary 1, 3
• Eradication of H. pylori reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 3

Secondary Prophylaxis and Antiplatelet/Anticoagulant Resumption

Resume aspirin as soon as cardiovascular risks outweigh GI risks, usually within 7 days. 1, 3

• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 3
• PPI therapy is suggested for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 3
• For patients requiring NSAIDs after UGIB, use a COX-2 inhibitor plus PPI to reduce rebleeding risk 1, 3

Common Pitfalls and Caveats

• Do not use colloids for initial resuscitation—they offer no survival benefit and are more expensive 1
• Do not perform routine second-look endoscopy—it is not recommended unless there is clinical evidence of rebleeding 1, 3
• Do not use epinephrine injection alone for endoscopic hemostasis—always combine with thermal or mechanical therapy 3
• In cirrhotic patients with severe ascites, use non-selective beta-blockers with caution and avoid high doses 3
• Consider discontinuing non-selective beta-blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 3