What is the management for a patient with upper GI bleeding?

Management of Upper Gastrointestinal Bleeding

For a patient presenting with upper GI bleeding, immediately initiate resuscitation with crystalloid fluids, transfuse red blood cells when hemoglobin drops below 80 g/L (or higher threshold if cardiovascular disease present), start high-dose intravenous PPI therapy before endoscopy, perform risk stratification using the Glasgow Blatchford score, and proceed with endoscopy within 24 hours (or within 12 hours if hemodynamically unstable after resuscitation). 1, 2, 3

Initial Resuscitation and Stabilization

Immediate resuscitation is the critical first step to reduce mortality and improve outcomes. 2

• Administer crystalloid fluids (normal saline or lactated Ringer solution) rapidly to restore hemodynamic stability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour. 2, 3
• Crystalloids are preferred over colloids because colloids show no survival benefit and are more expensive. 1, 2, 3
• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease; use a higher hemoglobin threshold for patients with underlying cardiovascular disease. 1, 2, 3
• This restrictive transfusion strategy (hemoglobin <80 g/L) is supported by moderate-quality evidence and improves outcomes. 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, 3

• Risk factors for poor outcomes include: hemodynamic instability, melena, fresh red blood in emesis or nasogastric aspirate, and elevated urea, creatinine, or aminotransferase levels. 2, 3
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours. 2
• Nasogastric tube placement can be considered as bright blood in the aspirate is an independent predictor of rebleeding. 2

Pharmacologic Management

Start high-dose intravenous PPI therapy immediately upon presentation, before endoscopy. 2, 3

• For patients with high-risk stigmata who undergo successful endoscopic therapy: administer pantoprazole or omeprazole as an 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. 2, 3
• This high-dose continuous infusion reduces rebleeding rates significantly compared to H2-receptor antagonists or placebo, reduces mortality rates compared to placebo, and reduces the need for surgery. 2
• After the 72-hour infusion, continue oral PPI twice daily through day 14, then once daily for a duration that depends on the nature of the bleeding lesion. 1, 2, 3
• H2-receptor antagonists are NOT recommended in the management of acute upper GI bleeding as they provide no statistically significant improvement in outcomes compared to other pharmacotherapy or endoscopic therapy. 1
• Somatostatin and octreotide are NOT recommended in routine management of nonvariceal upper GI bleeding. 1

Endoscopic Management

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

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation. 2, 3
• Endoscopic hemostasis is mandatory for high-risk stigmata (active bleeding, visible vessel, or adherent clot). 1, 2, 3

Endoscopic Therapy Based on Lesion Characteristics

Use combination therapy (thermocoagulation plus injection) as first-line endoscopic treatment for high-risk stigmata lesions, as combination therapy is superior to either treatment alone. 1, 2, 3

• Thermocoagulation and sclerosant injection are recommended. 1, 2, 3
• Through-the-scope clips are suggested as an effective alternative. 1, 2, 3
• Epinephrine injection alone is NOT recommended. 2
• TC-325 (hemostatic powder) is suggested as temporizing therapy only, not as sole treatment, in patients with actively bleeding ulcers. 1, 2
• Attempts to dislodge adherent clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata are supported by data. 2

Management of Rebleeding

Routine second-look endoscopy is NOT recommended. 1, 2, 3

• For clinical evidence of rebleeding, a second attempt at endoscopic therapy is generally recommended as it reduces the need for surgery without increasing the risk of death. 1, 2, 3
• Seek surgical consultation for patients who have failed endoscopic therapy. 1
• 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. 2

Post-Endoscopic Care

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 2

• Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly. 1, 2, 3
• All patients with upper GI bleeding must be tested for Helicobacter pylori and receive eradication therapy if infection is present, as eradication reduces the rate of ulcer recurrence and rebleeding. 1, 2, 3

Common Pitfall: H. pylori Testing During Acute Bleeding

Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary. 2, 3

Secondary Prophylaxis and Antiplatelet/Anticoagulant Resumption

Resume aspirin as soon as cardiovascular risks outweigh GI risks, usually within 7 days. 2, 3

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

Drug Interaction Consideration

Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole, which inhibit CYP2C19 and reduce clopidogrel's active metabolite. 2

Institutional Protocol Development

Hospitals should develop institution-specific protocols for multidisciplinary management, including access to an endoscopist trained in endoscopic hemostasis. 2