What is the NICE guidance for managing upper gastrointestinal (GI) bleeding?

Management of Upper Gastrointestinal Bleeding

Initial Resuscitation and Stabilization

Immediately initiate resuscitation with crystalloid fluids for all patients with acute upper GI bleeding and hemodynamic instability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour. 1, 2

• Insert two large-bore intravenous cannulae and infuse normal saline or Ringer's lactate 3
• Most patients require 1-2 liters of crystalloid; if shock persists after this volume, plasma expanders are needed as ≥20% of blood volume has been lost 1, 3
• Target central venous pressure of 5-10 cm H₂O 1, 3
• Crystalloids are preferred over colloids as colloids show no survival benefit and are more expensive 1, 2

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease. 4, 1, 2

• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 4, 1, 2
• This restrictive transfusion strategy improves outcomes and is supported by moderate-quality evidence 2

Risk Stratification

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who can be managed as outpatients without hospitalization or urgent endoscopy. 4, 1, 2, 5

• Do not use the AIMS65 prognostic score for risk stratification 4
• High-risk features include: age >60 years, hemodynamic instability (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), and fresh red blood in emesis or nasogastric aspirate 1, 2, 3
• Consider nasogastric tube placement in selected patients as findings may have prognostic value 4, 1

Pre-Endoscopic Pharmacological Management

Start high-dose intravenous proton pump inhibitor therapy 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 4, 3
• Do not use promotility agents routinely before endoscopy 4

Anticoagulation Management

Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs). 4

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization. 4, 1, 2, 5

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation 1, 2, 3
• Do not perform urgent (<12 hours) endoscopy routinely as patient outcomes are not improved compared to early endoscopy 5
• 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

For high-risk stigmata (active bleeding or visible vessel), use combination endoscopic therapy with epinephrine injection plus a second hemostasis modality (contact thermal coagulation or mechanical therapy). 4, 1, 2, 5

• Do not use epinephrine injection alone; it must always be combined with another method 1, 2
• Through-the-scope clips are an effective alternative 2
• For ulcers with nonbleeding visible vessel (Forrest IIa), use contact or noncontact thermal therapy, mechanical therapy, or sclerosant injection as monotherapy or in combination with epinephrine 5
• Endoscopic hemostatic therapy is not indicated for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot) 4
• For clots in ulcer beds, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 4
• For adherent clots, endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient 4

Post-Endoscopic Pharmacological Management

After successful endoscopic therapy for high-risk stigmata, administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours. 1, 2, 5

• After 72 hours, continue oral PPI twice daily through day 14, then once daily for duration depending on the nature of the bleeding lesion 1, 2
• High-dose PPI therapies given as intravenous bolus dosing (twice-daily) or oral formulation (twice-daily) can be considered as alternative regimens 5
• For patients with adherent clot (Forrest IIb) not treated endoscopically, administer high-dose PPI therapy 5

Hospital Management and Monitoring

Admit high-risk patients to a monitored setting 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
• Do not perform routine second-look endoscopy 1, 2
• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1

Management of Rebleeding

For recurrent bleeding after initial endoscopic therapy, perform repeat endoscopic therapy. 1, 2

• If second endoscopic therapy fails, proceed to transcatheter angiographic embolization (TAE) 5
• Surgery is indicated when TAE is not locally available or after failed TAE 5
• For recurrent bleeding, consider using a cap-mounted clip 5

Secondary Prevention: H. pylori Management

Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if positive. 1, 2, 3

• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1, 3
• Testing during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary 2

Resumption of Antithrombotic Therapy

Resume aspirin when cardiovascular risks outweigh GI risks, usually within 3-7 days. 1, 2, 3, 5

• In patients taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted during acute UGIB 5
• If interrupted, restart as soon as possible, preferably within 3-5 days 5
• 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, 2
• Administer PPI therapy for all patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 2
• Resume anticoagulation as soon as bleeding is controlled, preferably within or soon after 7 days, based on thromboembolic risk 5
• Consider the rapid onset of action of DOACs compared to vitamin K antagonists when resuming anticoagulation 5

Common Pitfalls

• 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
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1