What is the definition, diagnosis, and management of an upper gastrointestinal (GI) bleed?

Upper Gastrointestinal Bleeding: Definition, Diagnosis, and Management

Definition

Upper gastrointestinal bleeding (UGIB) is bleeding from a source proximal to the ligament of Treitz, typically presenting with hematemesis (vomiting blood), melena (black tarry stools), or hematochezia (bright red blood per rectum) when bleeding is brisk. 1

• UGIB accounts for significant morbidity with reported mortality of 2-10%, though death is generally related to comorbidity rather than exsanguination 2, 1
• Common causes include peptic ulcer disease (most frequent), variceal bleeding in cirrhosis, and erosive gastritis 3, 2

Initial Assessment and Resuscitation

Immediate hemodynamic assessment using shock index (heart rate divided by systolic blood pressure) is the critical first step, with a shock index >1 defining instability and mandating urgent intervention. 1

Resuscitation Protocol

• Place at least two large-bore intravenous catheters immediately to allow rapid volume expansion 1
• Initiate fluid resuscitation with crystalloids (preferred over colloids) to restore hemodynamic stability 1, 4
• Use restrictive transfusion strategy with hemoglobin threshold of 7 g/dL (target range 7-9 g/dL) for most patients 1, 4
• For patients with cardiovascular disease or myocardial ischemia, use higher threshold of 8 g/dL with target ≥10 g/dL 1, 3
• Correct coagulopathy immediately: transfuse fresh frozen plasma for INR >1.5 and platelets for platelets <50,000/µL 5

Risk Stratification

• Clinical predictors of poor outcome include: age >65 years, shock, comorbid illness, low hemoglobin, melena, fresh red blood in emesis/nasogastric aspirate or on rectal exam 1
• Glasgow Blatchford score of 1 or less identifies patients at very low risk who may not require hospitalization 4, 3
• Nasogastric tube placement is NOT routinely recommended—it does not reliably aid diagnosis, does not affect outcomes, and is complicated in up to one-third of patients 6, 3

Diagnostic Approach

For Hemodynamically Stable Patients (Shock Index ≤1)

• Perform upper endoscopy within 24 hours of presentation after adequate resuscitation 1, 4, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with suspected variceal bleeding or those with hemodynamic instability that stabilizes after resuscitation 4, 3
• Endoscopy serves both diagnostic and therapeutic purposes 2

For Hemodynamically Unstable Patients (Shock Index >1)

• Perform CT angiography (CTA) immediately to localize bleeding before any intervention—this is the fastest and least invasive means to identify the bleeding source 1, 5
• CTA has sensitivity of 79-95% and specificity of 95-100%, requiring bleeding velocity of 0.3-1.0 mL/min 6
• Following positive CTA, proceed to catheter angiography with embolization within 60 minutes in centers with 24/7 interventional radiology 1, 5
• If no source is identified by CTA in an unstable patient, perform immediate upper endoscopy as hemodynamic instability may indicate an upper GI source 6, 4

Critical Pitfall to Avoid

• Always consider an upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum—failure to do so leads to delayed diagnosis and treatment 6, 1, 5
• Findings suggestive of upper GI source include: brisk rectal bleeding with hemodynamic compromise, history of peptic ulcer disease, portal hypertension, elevated blood urea/creatinine ratio, and use of antiplatelet drugs 6

Pharmacological Management

Proton Pump Inhibitors (PPIs)

• Start intravenous PPIs immediately upon presentation with UGIB 4
• For patients with high-risk stigmata who undergo successful endoscopic therapy: administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 4
• After 72 hours, continue oral PPI therapy twice daily through 14 days, then once daily 4
• This regimen significantly reduces rebleeding rates, mortality, and need for surgery 4

For Suspected Variceal Bleeding

• Initiate vasoactive drug therapy immediately when variceal bleeding is suspected, before endoscopy 4
  • Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours
  • Somatostatin: 250 μg/hour continuous infusion with initial 250 μg bolus
  • Octreotide: 50 μg/hour continuous infusion with initial 50 μg bolus 4, 7
• Administer antibiotic prophylaxis in all patients with cirrhosis and suspected variceal bleeding (ceftriaxone or norfloxacin) 4, 3
• Continue vasoactive drugs and antibiotics for 3-5 days 4

Prokinetic Agents

• Erythromycin may be administered before endoscopy to improve visualization 2

Endoscopic Management

Indications for Endoscopic Therapy

• Endoscopic hemostasis is indicated for high-risk stigmata lesions: active bleeding, non-bleeding visible vessel, or adherent clot 4

Endoscopic Techniques

• Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone 4
• Thermocoagulation and sclerosant injection are recommended; clips are also suggested 4
• Epinephrine injection alone is NOT recommended 4
• For variceal bleeding: ligation for esophageal varices, tissue glue for gastric varices 2
• TC-325 (hemostatic powder) is suggested as temporizing therapy only, not as sole treatment 4

Management of Recurrent Bleeding

• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 4
• If repeat endoscopy fails, proceed to interventional radiology (angiographic embolization) or surgery 2
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 4, 2

Post-Endoscopic Care and Disposition

Admission Criteria

• High-risk patients should be admitted to a monitored setting for at least 72 hours after endoscopic hemostasis 4
• ICU admission indicated for: orthostatic hypotension, hematocrit decrease ≥6%, transfusion requirement >2 units, continuous active bleeding, or persistent hemodynamic instability 5

Early Feeding and Testing

• Patients at low risk for rebleeding after endoscopy can be fed within 24 hours 4
• All patients with UGIB should be tested for Helicobacter pylori and receive eradication therapy if positive—this reduces ulcer recurrence and rebleeding 4
• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be necessary 4

Management of Antithrombotic Therapy

Anticoagulation

• For patients on warfarin with unstable GI hemorrhage: interrupt warfarin immediately and reverse with prothrombin complex concentrate and vitamin K 1, 5
• For patients with low thrombotic risk, restart warfarin 7 days after hemorrhage 1, 5

Antiplatelet Therapy

• Aspirin for primary prophylaxis should be permanently discontinued 5
• Aspirin for secondary cardiovascular prevention should not be routinely stopped; if stopped, restart as soon as hemostasis is achieved (usually within 7 days) 5, 4
• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 4
• For patients requiring NSAIDs: use PPI with cyclooxygenase-2 inhibitor to reduce rebleeding 4

Key Pitfalls and Caveats

• Routine second-look endoscopy is NOT recommended 4
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 4
• Mortality in UGIB is generally related to comorbidity rather than exsanguination, with overall mortality 2-10% but rising to 20% in patients requiring ≥4 units of red cells 5, 2
• Avoid intubation if possible in patients with UGIB; if necessary, ensure adequate resuscitation prior to induction, utilize preoxygenation and appropriate suction, and administer a prokinetic agent 3
• In patients with cirrhosis and severe ascites, use non-selective beta-blockers with caution; discontinue in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 4