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

Management of Upper Gastrointestinal Bleeding

Immediately resuscitate with crystalloid fluids, transfuse red blood cells when hemoglobin drops below 80 g/L (70 g/L in patients without cardiovascular disease), start high-dose intravenous proton pump inhibitors, and perform endoscopy within 24 hours of presentation. 1, 2, 3

Initial Resuscitation and Hemodynamic Stabilization

Insert two large-bore intravenous cannulae and rapidly infuse 1-2 liters of normal saline or lactated Ringer solution to achieve falling pulse rate, rising blood pressure, and urine output >30 mL/hour. 2 If shock persists after 2 liters, at least 20% of blood volume has been lost and plasma expanders are needed. 2 Target central venous pressure of 5-10 cm H₂O. 2

Transfuse red blood cells at a hemoglobin threshold of <80 g/L for patients without cardiovascular disease. 1, 2, 3 Use a higher threshold for patients with underlying cardiovascular disease. 1, 2, 3 This restrictive transfusion strategy improves outcomes compared to liberal transfusion. 3

Crystalloids are preferred over colloids because colloids show no survival benefit and cost more. 1, 3

Risk Stratification

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who can be discharged home without hospitalization or urgent endoscopy. 1, 2, 3 This is the most validated tool for identifying patients safe for outpatient management. 1, 2

High-risk features requiring admission include: 1, 2, 3

• Age >60 years
• Hemodynamic instability (shock index >1)
• Hemoglobin <100 g/L
• Fresh red blood in emesis or nasogastric aspirate
• Melena
• Elevated urea, creatinine, or aminotransferase levels

Admit high-risk patients to a monitored setting for at least the first 24 hours. 1

Pre-Endoscopic Pharmacological Management

Start high-dose intravenous proton pump inhibitors immediately upon presentation, before endoscopy. 1, 2, 3 Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy. 2

For suspected variceal bleeding in cirrhotic patients, immediately initiate: 1

• Vasoactive drug therapy: Terlipressin 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours; OR somatostatin 250 μg/hour continuous infusion with initial 250 μg bolus; OR octreotide 50 μg/hour continuous infusion with initial 50 μg bolus
• Antibiotic prophylaxis: Ceftriaxone or norfloxacin

The prokinetic agent erythromycin may be administered before endoscopy to improve visualization. 4

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients. 1, 2, 3 This is the standard timing for most patients after initial resuscitation. 1, 2, 3

Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation. 1, 2 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. 1

Endoscopy must be performed by experienced endoscopists capable of therapeutic procedures. 2

Endoscopic Therapy Based on Lesion Characteristics

For high-risk stigmata (active bleeding or visible vessel), use combination endoscopic therapy—injection plus thermal coagulation—which is superior to either treatment alone. 1, 3 Through-the-scope clips are also effective. 1, 3

Do not use epinephrine injection alone. 1 It must be combined with another modality. 1

For adherent clots, attempt to dislodge them with hemostatic, pharmacologic, or combination treatment of the underlying stigmata. 1

TC-325 (hemostatic powder) can be used as temporizing therapy but not as sole treatment in actively bleeding ulcers. 1

For variceal bleeding, use endoscopic variceal band ligation for esophageal varices and tissue glue for gastric varices. 4

Post-Endoscopic Pharmacological Management

After successful endoscopic therapy for high-risk stigmata lesions, administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. 1, 2, 3 This high-dose regimen reduces rebleeding rates, mortality, and need for surgery. 1

Continue oral PPI twice daily through day 14, then once daily for duration depending on the underlying bleeding lesion. 1, 2, 3

For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days. 1

Post-Endoscopic Care and Feeding

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 1

Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly. 5, 1, 3 For high-risk ulcers (Forrest I-IIb) or variceal bleeding, wait at least 48 hours after endoscopic therapy before initiating oral or enteral feeding. 6 For low-risk ulcers (Forrest IIc and III) or gastritis, Mallory-Weiss tears, esophagitis, or angiodysplasia, patients can be fed as soon as tolerated. 6

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended. 1, 3 Routine second-look endoscopy is not recommended. 1, 3

If repeat endoscopic therapy fails, attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. 7

For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS). 1, 4

Helicobacter Pylori Testing and Eradication

Test all patients with upper GI bleeding for Helicobacter pylori and provide eradication therapy if positive. 5, 1, 2, 3 Eradication reduces ulcer recurrence and rebleeding rates in complicated ulcer disease. 5, 1, 2

Testing during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary. 5, 3 Oral eradication therapy can be initiated immediately or during follow-up—there is no rationale for urgent intravenous therapy. 5

Secondary Prophylaxis and Antiplatelet/Anticoagulant Resumption

Restart aspirin when cardiovascular risks outweigh GI risks, usually within 7 days. 1, 2, 3 Outcomes appear better when antithrombotic agents are reintroduced early. 4

Use aspirin plus PPI rather than clopidogrel alone to reduce rebleeding. 1, 2

For patients requiring NSAIDs after UGIB, use a COX-2 inhibitor plus PPI to reduce rebleeding risk. 1, 3

PPI therapy is suggested for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy. 1, 3

Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole, which inhibit CYP2C19 and reduce clopidogrel's active metabolite. 1

Common Pitfalls

Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality. 1 Do not delay endoscopy for PPI administration—start PPIs immediately but proceed with endoscopy within the recommended timeframe. 2 Avoid routine second-look endoscopy, but maintain high suspicion for rebleeding and repeat endoscopy if clinical evidence suggests it. 1, 3