What is the management approach for upper gastrointestinal (GI) bleeding?

Management of Upper Gastrointestinal Bleeding

Immediately resuscitate with crystalloid fluids targeting hemodynamic stability, perform risk stratification using the Glasgow Blatchford score, start high-dose IV PPI therapy before endoscopy, and proceed with endoscopy within 24 hours (or within 12 hours if hemodynamically unstable). 1, 2

Initial Resuscitation and Stabilization

Fluid resuscitation is the critical first step before any diagnostic or therapeutic intervention. 1, 2

• Administer crystalloid fluids (preferred over colloids) with goals of heart rate reduction, blood pressure increase, central venous pressure 5-10 cm H₂O, and urine output >30 mL/hour 1, 2
• Most patients require 1-2 liters of saline; if shock persists after this volume, plasma expanders are needed as ≥20% of blood volume has been lost 1
• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease; use a higher threshold for patients with underlying cardiovascular disease 1, 2, 3

Special Considerations for Variceal Bleeding

If variceal bleeding is suspected (cirrhosis, portal hypertension):

• Start vasoactive drug therapy immediately: 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 1
• Administer antibiotic prophylaxis with ceftriaxone or norfloxacin 1

Risk Stratification

Use the Glasgow Blatchford score to identify patients who can be managed as outpatients. 2, 3

• Glasgow Blatchford score ≤1 identifies very low-risk patients who may not require hospitalization or urgent endoscopy 1, 2, 3
• High-risk features include: age >60 years, shock (heart rate >100 bpm and systolic BP <100 mmHg), hemoglobin <100 g/L, significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure), melena, fresh red blood in emesis or nasogastric aspirate, and elevated urea, creatinine, or aminotransferase levels 1, 2, 3
• Nasogastric tube placement can provide prognostic value, with bright blood in aspirate being an independent predictor of rebleeding 1
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1

Critical Pitfall to Avoid

Always consider an upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum, as failure to do so leads to delayed diagnosis and treatment 1

Pharmacological Management

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

Pre-Endoscopy PPI Administration

• Administer pantoprazole or omeprazole 80 mg IV bolus immediately to improve endoscopic stigmata appearance 3
• This is recommended even before endoscopy, though evidence shows potential cost-effectiveness rather than definitive mortality benefit in unselected patients 3

Post-Endoscopy High-Dose PPI Protocol (for High-Risk Stigmata)

After successful endoscopic therapy for high-risk stigmata lesions (active bleeding, visible vessel, adherent clot), administer 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. 1, 2, 3

• This regimen significantly reduces rebleeding rates, mortality, and need for surgery compared to H2-receptor antagonists or placebo 1, 3
• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily for duration based on the underlying cause 1, 2, 3
• This is a class effect applicable to both omeprazole and pantoprazole 3

Drugs NOT Recommended

• H2-receptor antagonists are not recommended due to limited efficacy compared to PPIs 3
• Somatostatin and octreotide are not recommended in routine management of nonvariceal upper GI bleeding 3
• Epinephrine injection alone is not recommended; it must always be combined with another method 1

Endoscopic Management

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

Timing of Endoscopy

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation 1, 2, 3
• 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

Endoscopic Therapy Based on Lesion Characteristics

Combination endoscopic therapy (injection plus thermal coagulation) is superior to either treatment alone. 1, 3

• For high-risk stigmata (active bleeding, visible vessel, adherent clot): Use combination therapy with thermocoagulation or sclerosant injection as first-line treatment 1, 2, 3
• Through-the-scope clips are suggested as an effective alternative 2, 3
• For adherent clots: Attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata are supported 1
• TC-325 (hemostatic powder) is suggested as temporizing therapy only, not as sole treatment, in patients with actively bleeding ulcers 1, 3

Variceal Bleeding Endoscopic Management

• Endoscopic ligation for esophageal varices 4
• Tissue glue for gastric varices 4
• Continue vasoactive drugs and antibiotics for 3-5 days post-endoscopy 1

Post-Endoscopic Care

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 1, 2, 3
• All patients with upper GI bleeding must be tested for Helicobacter pylori and receive eradication therapy if positive, as this reduces ulcer recurrence and rebleeding rates 1, 2, 3

Important Caveat

Testing for H. pylori during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary 1, 2, 3

Management of Recurrent Bleeding

Routine second-look endoscopy is not recommended. 1, 2

For Nonvariceal Bleeding

• A second attempt at endoscopic therapy is generally recommended for clinical evidence of rebleeding 2
• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1
• Early surgical consultation may be particularly beneficial in patients at high risk for failed endoscopic retreatment 3

For Variceal Bleeding

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

Secondary Prophylaxis and Resumption of Antithrombotic Therapy

Resume aspirin as soon as cardiovascular risks outweigh gastrointestinal risks, usually within 7 days. 1, 2

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

Drug Interaction Consideration

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
• Mortality is rare in patients <40 years but reaches 30% in those >90 years 1
• In patients with cirrhosis and severe ascites, use non-selective beta-blockers with caution and avoid high doses 1
• Consider discontinuing non-selective beta-blockers in patients with progressive hypotension (systolic BP <90 mmHg) or acute conditions like bleeding, sepsis, or acute kidney injury 1