What is the recommended management for an upper gastrointestinal (UGI) bleed?

Management of Upper Gastrointestinal Bleeding

For patients with acute upper GI bleeding, initiate immediate resuscitation with crystalloids, transfuse at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start high-dose IV PPI therapy, perform endoscopy within 24 hours, and apply combination endoscopic therapy (thermocoagulation or sclerosant injection plus epinephrine) for high-risk stigmata, followed by 72 hours of continuous IV PPI infusion (80 mg bolus then 8 mg/hour). 1

Initial Resuscitation and Risk Stratification

Immediate stabilization is the critical first step:

• Resuscitate with crystalloids (not colloids) to restore blood pressure and end-organ perfusion 2, 3
• 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 2
• Transfuse red blood cells when hemoglobin <80 g/L in patients without cardiovascular disease 1
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 1

Risk stratification determines disposition:

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who can be managed as outpatients without hospitalization 1, 2
• Do NOT use the AIMS65 score for risk stratification 1, 2
• High-risk patients (age >60, shock with HR >100 and SBP <100, hemoglobin <100 g/L, significant comorbidities) should be admitted to monitored settings for at least 24 hours 2
• Consider nasogastric tube placement in selected patients as findings have prognostic value; bright blood in aspirate independently predicts rebleeding 1, 2

Pre-Endoscopic Management

Pharmacologic therapy should begin immediately:

• Start IV PPI therapy immediately upon presentation (pantoprazole or omeprazole 80 mg IV bolus) 2, 3
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease need for intervention but should NOT delay endoscopy 1, 2
• Do NOT use promotility agents routinely before endoscopy 1, 2
• Consider erythromycin 250 mg IV 30-60 minutes before endoscopy to enhance gastric visualization 3

Do NOT delay endoscopy in anticoagulated patients:

• Proceed with endoscopy in patients receiving vitamin K antagonists or DOACs without delay 1, 2

Endoscopic Management

Timing is critical but not emergent in most cases:

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 2
• If patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before endoscopy 2

Endoscopic therapy is lesion-specific:

• High-risk stigmata (active bleeding or visible vessel): Combination endoscopic therapy is MANDATORY 1

  • Use thermocoagulation or sclerosant injection (strong recommendation) 1
  • Through-the-scope clips are also suggested 1
  • Epinephrine injection alone provides suboptimal efficacy and MUST be combined with another method 1, 2
  • No single thermal coaptive method is superior to another 1

• Adherent clot: Perform targeted irrigation to attempt dislodgement with appropriate treatment of underlying lesion 1, 2

  • Role of endoscopic therapy is controversial; may consider therapy or intensive PPI alone 1

• Low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot): Endoscopic hemostatic therapy is NOT indicated 1, 2

• TC-325 (hemostatic powder): Use only as temporizing therapy when conventional methods fail or are unavailable, NOT as sole treatment 1

Post-Endoscopic Pharmacologic Management

High-dose PPI therapy is essential for high-risk lesions:

• Administer pantoprazole 80 mg IV bolus followed by continuous infusion at 8 mg/hour for exactly 72 hours in patients with high-risk stigmata who underwent successful endoscopic therapy 1, 2, 3
• This regimen significantly reduces rebleeding rates, mortality, and need for surgery 2
• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily for duration dependent on bleeding lesion nature 1, 2

Alternative dosing considerations:

• Intermittent IV push dosing may be safe and effective in hemodynamically stable patients, though guidelines consistently support continuous infusion based on trial evidence 2, 4, 5
• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole/esomeprazole 2

Hospital Management and Monitoring

High-risk patients require extended observation:

• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis 2
• Second-look endoscopy may be useful in selected high-risk patients but is NOT routinely recommended 2
• Patients at low risk for rebleeding after endoscopy can be fed within 24 hours 2, 6

Management of Recurrent Bleeding

Approximately 20% of patients will have continued or recurrent bleeding:

• Repeat endoscopic therapy is recommended for recurrent bleeding 6
• If repeat endoscopy fails, consider transcatheter arterial embolization as first-line therapy before surgery 7
• Surgery remains an option but carries high operative mortality in high-risk patients 7

Secondary Prophylaxis

H. pylori eradication is mandatory:

• Test ALL patients with bleeding peptic ulcers for H. pylori 2, 3
• Provide eradication therapy if positive; this significantly reduces ulcer recurrence and rebleeding rates 2, 3
• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be necessary 2

Antiplatelet and anticoagulant management:

• Restart aspirin when cardiovascular risks outweigh GI risks (usually within 7 days) 2
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 2, 3
• For patients requiring NSAIDs, use PPI with COX-2 inhibitor to reduce rebleeding 2

Critical Pitfalls to Avoid

Always consider upper GI source in hemodynamically unstable patients presenting with bright red blood per rectum:

• Failure to do so leads to delayed diagnosis and treatment 2
• Suggestive findings include brisk bleeding with hemodynamic compromise, history of peptic ulcer disease, portal hypertension, elevated BUN/creatinine ratio, and antiplatelet drug use 2

Do not use epinephrine injection alone:

• This provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1, 2

Do not perform routine second-look endoscopy:

• Reserve this only for selected high-risk patients 2