What is the management approach for a patient with upper gastrointestinal bleeding?

Management of Upper Gastrointestinal Bleeding

Immediately initiate resuscitation with crystalloid fluids, transfuse at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start IV PPI therapy before endoscopy, and perform endoscopy within 24 hours with combination endoscopic therapy for high-risk stigmata. 1, 2, 3

Initial Resuscitation and Stabilization

• Begin crystalloid fluid resuscitation immediately to restore hemodynamic stability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour 1, 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 1
• 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, 3
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (specific threshold not defined but consensus supports >80 g/L) 4, 1, 2, 3
• This restrictive transfusion strategy improves outcomes compared to liberal transfusion 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 1, 2, 3
• Do not use the AIMS65 score for risk stratification as it is not recommended for identifying low-risk patients 1, 3
• Key risk factors for poor outcomes include: age >60 years, shock (heart rate >100 bpm and systolic blood pressure <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, and elevated urea, creatinine, or aminotransferase levels 1, 2
• Consider nasogastric tube placement as findings may have prognostic value, with bright blood in aspirate being an independent predictor of rebleeding 4, 1

Pre-Endoscopic Pharmacologic Management

• Start high-dose IV PPI 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, 1, 3
• Do not use H2-receptor antagonists as they are not recommended for acute ulcer bleeding 3
• Do not use promotility agents routinely before endoscopy to increase diagnostic yield 4, 1, 3

Special Considerations for Suspected Variceal Bleeding

• If variceal bleeding is suspected (patient with cirrhosis), initiate vasoactive drug therapy immediately: terlipressin 2 mg/4 hours for first 48 hours then 1 mg/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 (ceftriaxone or norfloxacin) in patients with cirrhosis and suspected variceal bleeding 1

Anticoagulation Management

• Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs); proceed with endoscopy and hemostatic therapy as needed 4, 1, 3

Endoscopic Management Timing

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 4, 1, 2, 3
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation 1, 2, 3
• If 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

High-Risk Stigmata (Active Bleeding or Visible Vessel)

• Endoscopic hemostatic therapy is mandatory for high-risk stigmata 4, 2
• Use combination therapy with thermocoagulation or sclerosant injection PLUS epinephrine injection as first-line endoscopic treatment 4, 1, 2, 3
• Through-the-scope clips are suggested as an effective alternative or additional modality 4, 1, 2, 3
• Never use epinephrine injection alone as it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 4, 1, 2
• No single method of thermal coaptive therapy is superior to another 4
• TC-325 (hemostatic powder) is suggested as temporizing therapy when conventional endoscopic therapies are not available or fail, but not as sole treatment 4, 1

Adherent Clot

• Perform targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion 4, 1
• The role of endoscopic therapy for ulcers with adherent clots is controversial; endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient 4

Low-Risk Stigmata (Clean-Based Ulcer or Nonprotuberant Pigmented Dot)

• Endoscopic hemostatic therapy is not indicated for low-risk stigmata 4, 1

Post-Endoscopic Pharmacologic Management

For High-Risk Stigmata After Successful Endoscopic Therapy

• Administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours 4, 1, 2, 3
• This high-dose continuous infusion reduces rebleeding rates, mortality rates, and need for surgery compared to placebo or H2-receptor antagonists 1
• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily for duration dependent on the nature of the bleeding lesion 1, 2, 3
• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole 1

For Variceal Bleeding

• Continue vasoactive drugs and antibiotics for 3-5 days 1

Post-Endoscopic Care and Monitoring

• Hospitalize patients with high-risk stigmata for at least 72 hours after endoscopic hemostasis 1, 3
• Low-risk patients can be fed within 24 hours after endoscopy and may be discharged promptly 4, 2, 3
• Routine second-look endoscopy is not recommended 1, 2
• Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 1

Management of Rebleeding

• Attempt repeat endoscopic therapy as the first approach for rebleeding 1, 2, 3
• If repeat endoscopic therapy fails, obtain surgical consultation or consider interventional radiological embolization 3
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1

Helicobacter pylori Management

• Test all patients with bleeding peptic ulcers for H. pylori and provide eradication therapy if present 1, 2, 3
• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1, 2
• Testing during acute bleeding has increased false-negative rates; confirmatory testing outside the acute context may be necessary 1, 2
• Confirm eradication after treatment 3

Secondary Prevention and Antiplatelet/Anticoagulant Management

• Resume aspirin as soon as cardiovascular risk outweighs bleeding risk, usually within 7 days (though often earlier) 1, 2, 3
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 1, 2
• Use PPI therapy in all patients with previous ulcer bleeding receiving single or dual antiplatelet therapy 1, 2, 3
• For patients requiring NSAIDs after UGIB, use a COX-2 inhibitor plus PPI to reduce rebleeding risk 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1

Critical Pitfalls 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
• Findings suggestive of upper GI source include: brisk rectal bleeding with hemodynamic compromise, history of peptic ulcer disease, portal hypertension, elevated blood urea/creatinine ratio, and use of antiplatelet drugs 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
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1