What is the initial management for a patient presenting with upper gastrointestinal (GI) bleeding?

Initial Management of Upper Gastrointestinal Bleeding

Immediately initiate resuscitation with crystalloid fluids through two large-bore IV cannulae, targeting hemodynamic stabilization before any diagnostic procedures. 1, 2

Immediate Resuscitation (First Priority)

Insert two large-bore intravenous cannulae in the anticubital fossae and begin rapid infusion of normal saline or Ringer's lactate. 2

Resuscitation Targets

• Falling pulse rate and rising blood pressure 2
• Central venous pressure of 5-10 cm H₂O 1, 2
• Urine output >30 mL/hour 1, 2
• Most patients require 1-2 liters of crystalloid; if shock persists after this volume, administer plasma expanders as ≥20% of blood volume has been lost 1, 2

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin is <80 g/L (7 g/dL) in patients without cardiovascular disease 1, 2, 3
• Use a higher hemoglobin threshold (approaching 90-100 g/L) for patients with significant cardiovascular comorbidities 1, 2, 3
• This restrictive transfusion strategy is strongly supported by high-quality evidence and reduces mortality 2, 3

Pharmacological Management (Concurrent with Resuscitation)

Start high-dose intravenous proton pump inhibitor therapy immediately upon presentation: 80 mg IV bolus followed by 8 mg/hour continuous infusion. 1, 2, 3

• This should be initiated before endoscopy but must not delay endoscopic evaluation 2, 3
• Pre-endoscopic PPI therapy downstages endoscopic lesions and decreases the need for intervention 2

For Suspected Variceal Bleeding

• If cirrhosis or portal hypertension is suspected, immediately add vasoactive drug therapy (terlipressin 2 mg IV every 4 hours, or octreotide 50 μg/hour continuous infusion with initial 50 μg bolus) 1
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in cirrhotic patients 1

Risk Stratification (Guides Disposition and Timing)

Calculate the Glasgow Blatchford Score immediately; patients with a score ≤1 are at very low risk and may be discharged without hospitalization or urgent endoscopy. 1, 2, 3

High-Risk Features Requiring Admission and Close Monitoring

• Age >60 years 1
• Hemodynamic instability (heart rate >100 bpm, systolic blood pressure <100 mmHg) 1
• Hemoglobin <100 g/L 1
• Fresh red blood in emesis or nasogastric aspirate 1
• Significant comorbidities (renal insufficiency, liver disease, ischemic heart disease, heart failure) 1

Nasogastric Tube Consideration

• Nasogastric tube placement can be considered for prognostic value; bright red blood in aspirate independently predicts rebleeding 1, 4
• However, routine nasogastric lavage is not recommended 3

Pre-Endoscopic Adjuncts

Administer intravenous erythromycin 250 mg 30-120 minutes before endoscopy in patients with clinically severe or ongoing active bleeding. 3

• This significantly improves endoscopic visualization, reduces need for second-look endoscopy, and decreases transfusion requirements 3

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation after initial hemodynamic stabilization. 1, 2, 3

Urgent Endoscopy (Within 12 Hours) Indications

• Hemodynamic instability persisting despite ongoing resuscitation 1, 2, 3
• In-hospital bloody emesis or nasogastric aspirate 3
• Contraindication to interruption of anticoagulation 3

Critical Consideration for Unstable Patients

• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before endoscopy 1
• Always consider an upper GI source in hemodynamically unstable patients presenting with bright red blood per rectum, as failure to do so leads to delayed diagnosis 1

Post-Resuscitation Monitoring

Admit high-risk patients to a monitored setting for at least the first 24 hours with continuous observation of pulse, blood pressure, and urine output. 1, 4

Common Pitfalls to Avoid

• Do not delay endoscopy for PPI therapy; start PPI immediately but proceed with endoscopy within the recommended timeframe 2, 3
• Do not use epinephrine injection alone during endoscopy; it must be combined with thermal coagulation or mechanical therapy 1, 3
• Do not perform routine second-look endoscopy; reserve repeat endoscopy only for clinical evidence of rebleeding 1, 3
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1