Upper GI Bleed: Causes and Management
Common Causes
Peptic ulcer disease accounts for 50-70% of all nonvariceal upper GI bleeding cases, making it by far the most common etiology 1. Other important causes include:
- Gastritis and esophagitis are frequent non-ulcer sources 2
- Variceal bleeding in patients with cirrhosis or portal hypertension 3
- Mallory-Weiss tears from forceful vomiting 2
- Malignancy should be considered, particularly in older patients 2
The key risk factors include Helicobacter pylori infection, NSAID use, anticoagulant therapy, and age >60 years 1, 3, 2.
Initial Resuscitation and Stabilization
Begin immediate crystalloid fluid resuscitation to restore hemodynamic stability, targeting heart rate reduction, blood pressure increase, and urine output >30 mL/hour 4. 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 4.
Blood Transfusion Strategy
- Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 4, 5
- Use a higher hemoglobin threshold (>80 g/L) for patients with underlying cardiovascular disease 4, 5
- Restrictive transfusion strategies improve outcomes compared to liberal approaches 6
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 5, 7. This is critical for resource allocation and avoiding unnecessary admissions 2.
High-Risk Features Requiring Hospitalization
- Age >60 years, shock (HR >100 bpm and SBP <100 mmHg), hemoglobin <100 g/L, and significant comorbidities 5
- Fresh red blood in emesis or nasogastric aspirate, melena, and elevated urea/creatinine ratio 5
- Comorbidities such as renal insufficiency, liver disease, disseminated malignancy, and heart failure significantly increase mortality risk 5
Pre-Endoscopic Pharmacologic Management
Start high-dose IV PPI therapy immediately upon presentation, before endoscopy 4, 5. This recommendation is based on evidence that pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention 4, 7.
- Administer pantoprazole or omeprazole 80 mg IV bolus as initial therapy 7
- Pre-endoscopic PPI should not delay endoscopy 5
- Do not routinely use promotility agents before endoscopy 5
Special Considerations for Suspected Variceal Bleeding
- Initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) immediately if variceal bleeding is suspected 4
- Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in patients with cirrhosis 4
Endoscopic Management
Timing
Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 4, 5, 7. Earlier endoscopy (within 12 hours) is recommended for high-risk patients with hemodynamic instability after initial resuscitation 4, 5.
Endoscopic Therapy Based on Lesion Characteristics
Combination therapy with thermocoagulation or sclerosant injection PLUS epinephrine injection is recommended as first-line endoscopic treatment for high-risk stigmata (active bleeding or visible vessel) 4, 5, 7. This combination is superior to either treatment alone 1, 7.
- Never use epinephrine injection alone—it must always be combined with thermal or mechanical therapy 5, 7
- Endoscopic clips are suggested as an effective hemostatic option 4, 7
- TC-325 hemostatic powder is suggested as temporizing therapy only, not as sole treatment 7
- For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 5, 7
- Do not perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot) 5
Post-Endoscopic Pharmacologic Management
Administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours after successful endoscopic therapy for high-risk stigmata 4, 7. This high-dose regimen reduces rebleeding rates, mortality, and need for surgery compared to placebo or H2-receptor antagonists 7.
- After 72 hours, transition to oral PPI twice daily for 14 days, then once daily 4, 7
- The duration of once-daily therapy depends on the nature of the bleeding lesion 4, 7
- This is a class effect applicable to both omeprazole and pantoprazole 7
Post-Endoscopic Care
- High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 7
- Patients at low risk for rebleeding can be fed within 24 hours 5, 7
- Routine second-look endoscopy is not recommended, though it may be useful in selected high-risk patients 1, 7
Helicobacter pylori Management
Test all patients with bleeding peptic ulcers for H. pylori and provide eradication therapy if present 4, 5, 7. Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 4, 5.
- Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 5, 7
Management of Recurrent Bleeding
For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 4. If repeat endoscopy fails:
- Consider transcatheter arterial embolization as the next step 2
- Proceed to surgery if hemostasis is not obtained with embolization 2
- Early surgical consultation may be particularly beneficial in patients at high risk for failed endoscopic retreatment 7
For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 4, 3.
Secondary Prevention and Antiplatelet/Anticoagulant Management
Resume aspirin as soon as cardiovascular risk outweighs bleeding risk, usually within 7 days 4, 5. Outcomes appear better when antithrombotic agents are reintroduced early 6.
- Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 4, 5
- PPI therapy is recommended in all patients with previous ulcer bleeding receiving single or dual antiplatelet therapy 4, 5, 7
- Continue PPI therapy indefinitely for patients requiring antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 5, 7
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 4
- Never use epinephrine injection alone for endoscopic hemostasis—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 5, 7
- Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs) 5
- H2-receptor antagonists are not recommended due to limited efficacy compared to proton pump inhibitors 7
- Somatostatin and octreotide are not recommended in routine management of nonvariceal upper GI bleeding 7