What is the management approach for a patient presenting with upper GI bleeding, potentially with a history of bleeding disorders or anticoagulant use?

Management of Upper Gastrointestinal Bleeding

Immediately resuscitate with crystalloid fluids (0.9% NaCl or Ringer's lactate), transfuse red blood cells at hemoglobin <80 g/L (or higher threshold if cardiovascular disease present), start intravenous proton pump inhibitor therapy without delay, and perform endoscopy within 24 hours after hemodynamic stabilization—do not delay endoscopy for coagulopathy correction in anticoagulated patients. 1, 2

Initial Resuscitation and Hemodynamic Stabilization

• Place two large-bore IV catheters and initiate aggressive volume resuscitation with isotonic crystalloids (0.9% NaCl or Ringer's lactate preferred) to restore hemodynamic stability 1, 3
• Balanced crystalloids like Ringer's lactate may reduce acute kidney injury risk compared to normal saline, particularly in vulnerable populations 2
• Transfuse red blood cells at hemoglobin threshold <80 g/L for patients without cardiovascular disease 1, 2, 3
• Use a higher transfusion threshold (≥80-100 g/L) for patients with underlying coronary artery disease, acute coronary syndromes, or cardiovascular disease 1, 2
• Restrictive transfusion strategy (maintaining hemoglobin ≥70 g/L) improves survival and reduces recurrent bleeding in severe acute upper GI bleeding 1
• Correct hypothermia and acidosis immediately, as they worsen coagulopathy and perpetuate bleeding 1

Risk Stratification

• Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who may not require hospitalization, though apply this cautiously in patients with chronic kidney disease given their inherently higher mortality risk 2
• Do NOT use the AIMS65 score for risk stratification 2
• Assess volume of visualized blood loss, absolute and relative laboratory values, rate of blood loss, response to transfusion, and hemodynamics to determine severity 1

Management of Anticoagulation and Coagulopathy

Critical Principle: Do Not Delay Endoscopy

• Correction of coagulopathy is recommended but should NOT delay endoscopy 1, 2, 4
• Endoscopic treatment may be safely performed in patients with INR <2.5 1
• Mild to moderate coagulation defects (INR 1.3-2.7) do not predict rebleeding, transfusion requirement, surgery, length of stay, or mortality 1

Specific Anticoagulant Management

• For patients on direct oral anticoagulants (DOACs) with serious bleeding and DOAC level >50 ng/mL, consider anticoagulant reversal 1
• Measure PT, aPTT, or DOAC-specific assays to assess clinically relevant anticoagulant levels 1
• Dabigatran is the only oral anticoagulant that can be removed by hemodialysis 1
• Do NOT routinely administer platelets for patients on antiplatelet agents (aspirin, P2Y12 inhibitors)—systematic reviews show no benefit for intracranial hemorrhage, and this likely extends to GI bleeding 1

Correction of Underlying Hemostatic Defects

• Administer platelets and/or clotting factors to correct iatrogenic or acquired coagulopathies 1
• Consider anti-fibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) in patients with hepatic dysfunction 1
• In patients with portal hypertension and esophageal varices, use plasma cautiously as large volumes may increase portal pressure and exacerbate bleeding 1
• Use viscoelastic testing (TEG or ROTEM) for assessment of hemostatic function in patients with liver disease, as PT, INR, and aPTT may not be reliable 1

Pre-Endoscopic Pharmacologic Management

• Start intravenous proton pump inhibitor therapy immediately upon presentation to potentially downstage endoscopic lesions 2, 5
• Do NOT delay endoscopy for PPI administration—PPIs should be given while preparing for endoscopy, not instead of it 2
• Consider proton pump inhibitor infusions over intermittent intravenous administration for more aggressive medical management 1
• Administer prokinetic agents (erythromycin) 30-60 minutes before endoscopy to aid in diagnosis by clearing the stomach 5, 6
• For patients with suspected or known liver disease, liberalize octreotide infusions 1
• Give scheduled antiemetics to reduce aspiration risk and improve patient comfort 1

Endoscopic Management

Timing

• Perform endoscopy within 24 hours of presentation for all admitted patients after initial stabilization with crystalloids and blood products 2, 5, 6
• Earlier endoscopy (after resuscitation) should be considered for high-risk patients with hemodynamic instability 6
• Do not delay endoscopy for coagulopathy correction—proceed with endoscopy while correcting coagulopathy simultaneously 2, 4

Endoscopic Therapy Techniques

• Provide endoscopic hemostasis therapy for high-risk stigmata including active bleeding, non-bleeding visible vessel, or adherent clot 3, 5
• Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk stigmata—NEVER use epinephrine injection alone 4, 3, 5
• Recommended modalities include bipolar electrocoagulation, heater probe, through-the-scope clips, or sclerosant injection combined with epinephrine 3, 5
• Injection, thermal, and mechanical methods can each be used, but epinephrine must always be combined with another method to increase success of achieving hemostasis 5

Post-Endoscopic Care

• Administer high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) for exactly 72 hours after successful endoscopic therapy for high-risk stigmata 2, 3
• Continue oral PPI twice daily through 14 days, then once daily 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 3
• Admit high-risk patients to a monitored setting (ICU or step-down unit) for at least the first 24 hours 1

Management of Recurrent Bleeding

• Treat recurrent ulcer bleeding with repeat endoscopic therapy 6
• If bleeding persists after repeat endoscopy, manage with interventional radiology (angiography with embolization) or surgery 6
• Early involvement of appropriate services (surgery, interventional radiology, gastroenterology) for definitive management is critical, particularly for bleeding at critical sites 1

Resumption of Antithrombotic Therapy

• Restart aspirin when cardiovascular risks outweigh GI risks (usually within 7 days for secondary prophylaxis) 2, 3, 6
• Prefer aspirin plus PPI therapy over clopidogrel alone to reduce rebleeding risk 2
• Resume anticoagulation as soon as possible when thromboembolic risk is high (e.g., mechanical heart valve, acute pulmonary embolism) once hemostasis is secured 4
• Outcomes appear better when antithrombotic agents are reintroduced early rather than withheld indefinitely 6

Secondary Prevention

• Test all patients for Helicobacter pylori and provide eradication therapy if positive—this reduces ulcer recurrence and rebleeding 3
• Avoid NSAID use in patients with history of upper GI bleeding 3
• Patients with established high-risk cardiovascular disease should NOT stop aspirin therapy (secondary prophylaxis) in the setting of GI bleeding 3

Multidisciplinary Coordination

• Hospitals should develop institution-specific protocols for multidisciplinary management with access to an endoscopist trained in endoscopic hemostasis 1
• Support staff trained to assist in endoscopy should be available for urgent procedures 1
• Involve gastroenterology, surgery, interventional radiology, and critical care simultaneously for complex cases 4

Common Pitfalls to Avoid

• Never delay endoscopy waiting for INR normalization—mild to moderate coagulopathy does not preclude safe endoscopic therapy 1, 2, 4
• Never use epinephrine injection alone—always combine with thermal or mechanical therapy 4, 3, 5
• Do not over-transfuse—restrictive strategy (hemoglobin ≥70 g/L) improves outcomes except in cardiovascular disease 1
• Do not routinely give platelets for antiplatelet therapy—no evidence of benefit and potential for harm 1
• Do not withhold aspirin indefinitely in patients requiring cardiovascular prophylaxis—restart early with PPI coverage 2, 3