What are the management steps for an upper gastrointestinal (UGI) bleed?

Management of Upper Gastrointestinal Bleeding

All patients with acute UGIB should undergo endoscopy within 24 hours of presentation after initial resuscitation, with high-dose intravenous PPI therapy (80 mg bolus followed by 8 mg/hour continuous infusion for 72 hours) reserved for those with high-risk stigmata who receive successful endoscopic hemostasis. 1, 2

Initial Resuscitation and Stabilization

Immediate resuscitation takes absolute priority before any diagnostic procedures:

• Restore intravascular volume with crystalloids (preferred over colloids) to achieve hemodynamic stability, targeting heart rate reduction, increased blood pressure, central venous pressure of 5-10 cm H₂O, and urine output >30 mL/hour 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 at hemoglobin <80 g/L in patients without cardiovascular disease; use a higher threshold for those with cardiovascular disease 2, 3
• Admit high-risk patients to a monitored setting (ICU or step-down unit) for at least the first 24 hours 2

Critical pitfall: Do not delay resuscitation to obtain diagnostic studies—stabilization comes first 2, 3

Risk Stratification

Use the Glasgow Blatchford score to identify very low-risk patients:

• Patients with a Glasgow Blatchford score ≤1 can be managed as outpatients without hospitalization or urgent endoscopy 2
• Do not use the AIMS65 score for risk stratification 2

High-risk features requiring intensive monitoring include:

• Age >60 years 2
• Shock (heart rate >100 bpm and systolic blood pressure <100 mmHg) 2
• Hemoglobin <100 g/L 2
• Significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure) 2
• Fresh red blood in emesis or nasogastric aspirate 2
• Elevated urea, creatinine, or serum aminotransferase levels 2

Nasogastric tube placement can provide prognostic value, with bright blood in the aspirate being an independent predictor of rebleeding. 2

Pre-Endoscopic Pharmacological Management

Start intravenous PPIs immediately upon presentation:

• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy 2
• For suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin 2 mg/4 hours for first 48 hours then 1 mg/4 hours, somatostatin 250 μg/hour continuous infusion with initial 250 μg bolus, or octreotide 50 μg/hour continuous infusion with initial 50 μg bolus) as soon as bleeding is suspected 2
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in patients with cirrhosis and suspected variceal bleeding 2
• Do not routinely use promotility agents before endoscopy 2

Erythromycin as a prokinetic may be considered to improve endoscopic visualization, though not routinely recommended. 4

Timing of Endoscopy

Standard timing:

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 1, 2
• Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs)—proceed while correcting coagulopathy simultaneously 2, 5

Earlier endoscopy (within 12 hours) is indicated for:

• Hemodynamically unstable patients (shock index >1) after initial resuscitation 2
• Suspected variceal bleeding in cirrhotic patients 2

For patients remaining hemodynamically unstable after initial resuscitation, consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy. 2

Endoscopic Therapy Based on Lesion Characteristics

High-risk stigmata requiring endoscopic hemostasis:

• Active bleeding (spurting or oozing) 1, 2
• Non-bleeding visible vessel 1, 2
• Adherent clot 1, 2

Recommended endoscopic techniques:

• Use combination therapy: epinephrine injection PLUS thermal coagulation or mechanical clips—never epinephrine injection alone 1, 2, 5
• Thermocoagulation and sclerosant injection are recommended; clips are suggested for high-risk stigmata 1, 2
• For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 2
• TC-325 (hemostatic powder) is suggested as temporizing therapy only, not as sole treatment, in patients with actively bleeding ulcers 1, 2

Low-risk stigmata NOT requiring endoscopic therapy:

• Clean-based ulcer 2
• Nonprotuberant pigmented dot (flat spot) 2

For variceal bleeding:

• Endoscopic band ligation is the preferred method for esophageal varices 3
• Endoscopic variceal obturation with cyanoacrylate injection is more effective than band ligation for gastric varices 3

Post-Endoscopic Pharmacological Management

For patients with high-risk stigmata who received successful endoscopic therapy:

• Administer high-dose PPI: pantoprazole 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours 1, 2
• After 72 hours, continue oral PPI therapy twice daily through 14 days, then once daily for a duration dependent on the nature of the bleeding lesion 1, 2

For variceal bleeding:

• Continue vasoactive drugs and antibiotics for 3-5 days 2

Pantoprazole is preferred over omeprazole and esomeprazole in patients on clopidogrel due to less CYP2C19 inhibition. 2

Hospital Monitoring and Discharge Planning

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 2

Patients considered low risk for rebleeding after endoscopy can be fed within 24 hours. 2, 3

Second-look endoscopy:

• May be useful in selected high-risk patients but is not routinely recommended 2
• Routine second-look endoscopy is not indicated 2

Management of Recurrent Bleeding

Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality. 2

For recurrent peptic ulcer bleeding:

• Repeat endoscopic therapy is recommended 2, 3
• If repeat endoscopy fails, proceed to interventional radiology (angiographic embolization) or surgery 4, 6

For recurrent variceal bleeding:

• Consider transjugular intrahepatic portosystemic shunt (TIPS) 2, 3
• Balloon tamponade may be attempted on a temporary basis for massive hemorrhage 3

Helicobacter pylori Testing and Eradication

All patients with upper GI bleeding should be tested for H. pylori and receive eradication therapy if infection is present. 2

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

Secondary Prophylaxis and Antiplatelet/Anticoagulant Management

For patients requiring antiplatelet therapy:

• Restart aspirin when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2
• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 2
• PPI therapy is suggested for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 1, 2

For patients requiring NSAIDs:

• A PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 2

In patients with massive pulmonary embolism and concurrent UGIB:

• Do NOT use systemic thrombolytic therapy given active bleeding 5
• Resume anticoagulation as soon as possible after hemostasis is secured, as the risk of PE-related death outweighs rebleeding risk 5

Special Considerations for Cirrhotic Patients

In patients with cirrhosis and severe ascites:

• Use non-selective beta blockers with caution and avoid high doses 2
• 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 2

Critical Pitfalls 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 2
• Do not use epinephrine injection alone for endoscopic hemostasis—always combine with thermal coagulation or clips 1, 2, 5
• Do not delay endoscopy for coagulopathy correction in anticoagulated patients—proceed with endoscopy while correcting coagulopathy simultaneously 2, 5
• Do not perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or flat pigmented spot) 2