Management of Upper Gastrointestinal Bleeding
For patients with acute upper GI bleeding, perform endoscopy within 24 hours after initial resuscitation, use combination endoscopic therapy (thermocoagulation or sclerosant injection plus clips) for high-risk stigmata, and administer high-dose IV PPI therapy (80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours) after successful endoscopic hemostasis. 1, 2
Initial Resuscitation and Stabilization
Initiate immediate fluid resuscitation with crystalloids in hemodynamically unstable patients to restore end-organ perfusion and tissue oxygenation 1, 3, 4
Transfuse red blood cells at hemoglobin <80 g/L in patients without cardiovascular disease 1
Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (though the specific threshold is not rigidly defined, clinical judgment favoring earlier transfusion is appropriate) 1
Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs); proceed with endoscopy and hemostatic therapy as needed 1
Risk Stratification
Use the Glasgow Blatchford score to identify very low-risk patients (score ≤1) who may not require hospitalization or inpatient endoscopy 1, 4, 2
Avoid using the AIMS65 score for risk stratification as it is not recommended for identifying low-risk patients 1
Consider nasogastric tube placement in selected patients, as findings (particularly bright red blood) have prognostic value for rebleeding risk 1, 2
Pre-Endoscopic Pharmacologic Management
Start IV PPI therapy immediately upon presentation, before endoscopy, to downstage endoscopic lesions and decrease the need for intervention 1, 3, 2
Do not use H2-receptor antagonists as they are not recommended for acute ulcer bleeding 1
Do not routinely use somatostatin or octreotide for nonvariceal upper GI bleeding 1
Promotility agents should not be used routinely before endoscopy, though erythromycin may be considered in selected cases to improve visualization 1
Endoscopic Management Timing and Approach
Perform endoscopy within 24 hours of presentation after initial stabilization 1, 4
Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability or ongoing bleeding 2
Endoscopic Therapy Based on Stigmata
No endoscopic therapy needed for low-risk stigmata (clean-based ulcer or flat pigmented spot) 1
Attempt targeted irrigation for clots in ulcer beds to dislodge them and treat the underlying lesion 1
Endoscopic therapy may be considered for adherent clots, though intensive PPI therapy alone may be sufficient (this remains controversial) 1
Endoscopic hemostatic therapy is mandatory for high-risk stigmata (active bleeding or visible vessel in ulcer bed) 1, 4
Specific Endoscopic Techniques
Use combination therapy with thermocoagulation or sclerosant injection for high-risk stigmata (strong recommendation) 1, 4
Through-the-scope clips are suggested as part of combination therapy 1
Never use epinephrine injection alone as it provides suboptimal efficacy and must be combined with another method 1
TC-325 hemostatic powder may be used as temporizing therapy when conventional therapies are unavailable or fail, but should not be used as sole treatment 1
No single thermal coaptive method is superior to another (contact thermal probes, heater probe, or multipolar electrocoagulation are equivalent) 1
Post-Endoscopic Pharmacologic Management
For High-Risk Stigmata After Successful Endoscopic Therapy
Administer IV PPI as 80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours (strong recommendation, moderate-quality evidence) 1, 2
After 3 days of IV therapy, transition to oral PPI twice daily for 14 days, then once daily thereafter 1
All patients should be discharged with daily oral PPI for duration dictated by the underlying cause 1
Post-Endoscopic Care and Monitoring
Hospitalize patients with high-risk stigmata for at least 72 hours after endoscopic hemostasis 1, 4
Low-risk patients can be fed within 24 hours after endoscopy 1
Selected low-risk patients may be discharged promptly after endoscopy based on clinical and endoscopic criteria 1
Do not perform routine second-look endoscopy as it is not recommended 1
Management of Rebleeding
Attempt repeat endoscopic therapy as the first approach for rebleeding 1
Obtain surgical consultation for patients in whom endoscopic therapy has failed 1
Consider percutaneous embolization as an alternative to surgery where available 1
Helicobacter pylori Management
Test all patients with bleeding peptic ulcers for H. pylori and provide eradication therapy if present 1, 4
Confirm eradication after treatment 1
Repeat negative H. pylori tests obtained during acute bleeding, as false-negative rates are increased in this setting 1
Secondary Prevention and Antiplatelet/Anticoagulant Management
For Patients Requiring NSAIDs After Ulcer Bleeding
Recognize that traditional NSAID plus PPI OR COX-2 inhibitor alone still carries clinically important rebleeding risk 1, 3
Use combination of PPI plus COX-2 inhibitor to reduce recurrent bleeding risk beyond COX-2 inhibitor alone 1, 3
For Patients on Aspirin
- Resume aspirin as soon as cardiovascular risk outweighs bleeding risk (typically within 7 days, though often earlier) 1, 2
For Patients on Antiplatelet or Anticoagulant Therapy
Use PPI therapy in patients with previous ulcer bleeding receiving single or dual antiplatelet therapy 1
Use PPI therapy in patients requiring continued anticoagulation (warfarin or DOACs) 1
Common Pitfalls to Avoid
Do not use AIMS65 score for risk stratification—it is specifically not recommended 1
Do not delay endoscopy for anticoagulation reversal in stable patients 1
Do not use epinephrine injection as monotherapy—always combine with thermal or mechanical methods 1
Do not perform routine second-look endoscopy—it adds no benefit 1
Do not rely on initial negative H. pylori testing—repeat testing is necessary as acute bleeding increases false-negative rates 1