What is the initial management for a patient with non-variceal upper gastrointestinal (UGI) bleed?

Initial Management of Non-Variceal Upper Gastrointestinal Bleeding

For patients with non-variceal upper GI bleeding, immediately initiate resuscitation with crystalloid fluids, transfuse blood when hemoglobin is <80 g/L (or higher threshold if cardiovascular disease present), start intravenous proton pump inhibitor therapy, and perform endoscopy within 24 hours of presentation. 1, 2

Immediate Resuscitation and Hemodynamic Stabilization

Fluid Resuscitation:

• Insert two large-bore intravenous cannulae in the anticubital fossae for hemodynamically compromised patients 1
• Infuse normal saline or Ringer's lactate (crystalloids preferred over colloids) to achieve falling pulse rate, rising blood pressure, and adequate urine output (>30 mL/hour) 1, 3
• Most patients require 1-2 liters of saline to correct volume losses; if shock persists after this, plasma expanders are needed as ≥20% of blood volume has been lost 1
• Target central venous pressure of 5-10 cm H₂O in adequately resuscitated patients 1, 4
• Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this may exacerbate bleeding 3

Blood Transfusion Thresholds:

• Without cardiovascular disease: Transfuse when hemoglobin <80 g/L 1, 2
• With cardiovascular disease: Use a higher hemoglobin threshold for transfusion 1, 2
• Transfuse immediately when bleeding is extreme (active hematemesis with shock) 1, 4

Risk Stratification

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who may not require hospitalization or inpatient endoscopy. 1, 2, 3

High-risk features include: 2, 3

• Age >60 years
• Hemodynamic instability (pulse >100 bpm, systolic BP <100 mmHg)
• Hemoglobin <100 g/L
• Significant comorbidities (cardiac disease, liver disease)
• Fresh red blood in emesis or nasogastric aspirate

Nasogastric tube placement:

• Consider in selected patients as findings have prognostic value 1, 2, 3
• Bright red blood in aspirate is an independent predictor of rebleeding 2, 4

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitor Therapy:

• Start intravenous PPI therapy immediately upon presentation 2, 3, 5
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease need for intervention but should not delay endoscopy 1, 6

Avoid routine use of:

• Promotility agents before endoscopy (not recommended routinely) 1

Endoscopic Management Timing and Approach

Perform endoscopy within 24 hours of presentation for admitted patients. 1, 2, 3

Critical timing considerations:

• Only perform endoscopy after adequate resuscitation is achieved 1, 4
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 2
• Endoscopy must be performed by experienced endoscopists capable of therapeutic procedures 4

Endoscopic therapy indications based on stigmata:

• High-risk stigmata (active bleeding or visible vessel): Endoscopic hemostatic therapy is indicated 1
• Low-risk stigmata (clean-based ulcer or flat pigmented spot): Endoscopic therapy not indicated 1
• Adherent clot: Attempt targeted irrigation to dislodge; role of endoscopic therapy is controversial, though intensive PPI alone may be sufficient 1, 2

Endoscopic treatment methods:

• Use combination therapy (injection plus thermal coagulation or clips) for high-risk stigmata 2, 3
• Never use epinephrine injection alone - it provides suboptimal efficacy and must be combined with another method 1
• Thermocoagulation, sclerosant injection, and clips are all acceptable options 2, 4

Post-Endoscopic Management

High-Dose PPI Therapy:

• For high-risk stigmata with successful endoscopic therapy: Administer 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 2
• Continue oral PPI twice daily through 14 days, then once daily for duration depending on bleeding lesion nature 2

Monitoring and Admission:

• Admit high-risk patients to monitored setting for at least 24-72 hours 2
• Hemodynamically stable patients 4-6 hours post-endoscopy can begin oral intake 4
• Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly 1

Second-look endoscopy:

• Not routinely recommended 2
• May be useful in selected high-risk patients 2
• Consider if clinical evidence of active rebleeding 4

Secondary Prevention

Helicobacter pylori management:

• Test all patients for H. pylori and provide eradication therapy if positive 2, 3
• Eradication reduces ulcer recurrence and rebleeding rates 2, 4
• Note: Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be necessary 2

Antiplatelet/anticoagulant management:

• Restart aspirin when cardiovascular risks outweigh GI risks (usually within 7 days) 2, 3
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2, 3
• Continue PPI therapy for patients requiring antiplatelet or anticoagulant therapy 2, 3
• For patients requiring NSAIDs: PPI with COX-2 inhibitor is preferred 2
• Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists, DOACs) 1

Common Pitfalls

• Performing endoscopy before adequate resuscitation increases risk 1, 4
• Using epinephrine injection alone without combination therapy results in suboptimal hemostasis 1
• Delaying endoscopy beyond 24 hours in admitted patients 1, 2
• Over-transfusing patients without cardiovascular disease (restrictive strategy at hemoglobin <80 g/L is appropriate) 1, 2
• Failing to test for H. pylori or not providing eradication therapy 2, 3