Management of Upper Gastrointestinal Bleeding
Initiate immediate resuscitation for any patient with acute UGIB and hemodynamic instability, perform endoscopy within 24 hours after stabilization, and use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk stigmata. 1, 2
Initial Resuscitation and Hemodynamic Stabilization
Restore end-organ perfusion immediately using crystalloid fluids as first-line volume replacement. 2 Balanced crystalloids like Ringer's lactate are preferred over normal saline because they reduce acute kidney injury risk. 3, 2 Avoid colloids—they offer no mortality benefit and cost more. 2 Do not aggressively target normal blood pressure during resuscitation, as this may exacerbate bleeding and disrupt coagulation. 2
Blood Transfusion Thresholds
- Transfuse at hemoglobin <80 g/L for patients without cardiovascular disease 1, 3, 2
- Use a higher hemoglobin threshold for patients with underlying cardiovascular disease 1, 3, 2
This restrictive transfusion strategy is based on evidence showing improved outcomes compared to liberal transfusion protocols. 4
Risk Stratification
Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who may be safely managed as outpatients without hospitalization or inpatient endoscopy. 1, 3, 2 However, apply this cautiously in patients with chronic kidney disease given their inherently higher mortality risk. 3
Do not use the AIMS65 score for risk stratification—it is not recommended for identifying low-risk patients. 1, 3
Consider nasogastric tube placement in selected patients, as findings may have prognostic value. 1, 2
Pre-Endoscopic Pharmacologic Management
Start intravenous proton pump inhibitor (PPI) therapy immediately upon presentation. 3, 2, 5 This may downstage endoscopic lesions and decrease the need for endoscopic intervention, but should never delay endoscopy. 1, 3, 2
Prokinetic agents (such as erythromycin) can be given 30-60 minutes before endoscopy to improve visualization, but should not be used routinely. 1, 5, 4
For suspected variceal bleeding in cirrhotic patients, initiate vasoactive drugs (octreotide) and antibiotic prophylaxis immediately. 2, 4, 6
Endoscopic Management Timing and Technique
Perform endoscopy within 24 hours of presentation for all admitted patients after initial stabilization. 1, 3, 2, 5 Earlier endoscopy (after resuscitation) should be considered for high-risk patients with hemodynamic instability. 4, 7
Critical Point on Anticoagulation
Do not delay endoscopy for correction of coagulopathy in patients receiving anticoagulants (vitamin K antagonists or DOACs). 1, 3, 8 Proceed with endoscopy while simultaneously correcting coagulopathy. 8, 7
Endoscopic Therapy for High-Risk Stigmata
Use combination endoscopic therapy—never epinephrine injection alone. 3, 2, 8, 9 The recommended approach is:
- Epinephrine injection PLUS thermal coagulation (multipolar or heater probe) OR clips 2, 8, 5, 9
- Epinephrine alone has unacceptably high rebleeding rates 8, 9
High-risk stigmata requiring endoscopic therapy include: active arterial bleeding, non-bleeding visible vessel, and adherent clot. 9 Patients with minor stigmata or clean-based ulcers do not benefit from endoscopic therapy and can be triaged to less intensive care. 9
Post-Endoscopic Care
Administer high-dose PPI therapy for 72 hours after successful endoscopic therapy for high-risk stigmata. 3, 2 Continue oral PPI twice daily through 14 days, then once daily. 3
Test all patients for Helicobacter pylori and provide eradication therapy if infection is present. 2
Management of Rebleeding
For recurrent ulcer bleeding, attempt repeat endoscopic therapy first. 4 If bleeding persists after second endoscopic attempt, proceed to interventional radiology (angiography with embolization) or surgery. 4, 7
For recurrent variceal bleeding, transjugular intrahepatic portosystemic shunt (TIPS) is generally the treatment of choice. 4
Resumption of Antithrombotic Therapy
Restart aspirin as soon as cardiovascular risks outweigh gastrointestinal risks—typically within 7 days for patients requiring cardiovascular prophylaxis. 2, 4 Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding. 3, 2
For patients with massive pulmonary embolism and concurrent UGIB, resume anticoagulation as soon as hemostasis is secured, as PE-related mortality risk outweighs rebleeding risk. 8
Institutional Protocols
Develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis and support staff available on an urgent basis. 1, 7 For complex cases (such as massive PE with concurrent UGIB), involve gastroenterology, interventional cardiology/pulmonology, interventional radiology, and critical care simultaneously. 8