Treatment for Upper GI Bleed (Possibly NSAID-Related)
Immediately start IV proton pump inhibitor therapy upon presentation, perform endoscopy within 24 hours after initial resuscitation, and if NSAID-related ulcer bleeding is confirmed with high-risk stigmata requiring endoscopic therapy, administer high-dose PPI (80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours). 1, 2, 3
Initial Resuscitation and Stabilization
Resuscitate with crystalloids first to restore end-organ perfusion and correct hypovolemia before any diagnostic procedures. 2, 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. 2
Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease. 1, 2, 3 Use a higher hemoglobin threshold (typically <100 g/L) for patients with underlying cardiovascular disease. 1, 2
Discontinue the NSAID immediately as NSAIDs are a major cause of peptic ulcer bleeding and continuing therapy increases rebleeding risk. 5
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 These patients may be discharged after stabilization.
Key risk factors for rebleeding and mortality include: 2
- Age >60 years
- Shock (heart rate >100 bpm and systolic blood pressure <100 mmHg)
- Hemoglobin <100 g/L
- Significant comorbidities (renal insufficiency, liver disease, ischemic heart disease)
Pre-Endoscopic Pharmacologic Management
Start IV PPI therapy immediately upon presentation, before endoscopy is performed. 1, 2, 3 Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy. 2, 5
Do not use promotility agents routinely before endoscopy. 2
Endoscopic Management
Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization. 1, 2, 3 Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability. 2
Endoscopic Therapy Based on Findings
For high-risk stigmata (active bleeding or visible vessel), use combination endoscopic therapy: thermocoagulation or sclerosant injection PLUS epinephrine injection. 1, 2 Through-the-scope clips are also suggested. 1, 2
Never use epinephrine injection alone as it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy. 1, 2
For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion. 1, 2
For low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot), do not perform endoscopic hemostatic therapy. 2
Post-Endoscopic Pharmacologic Management
For high-risk stigmata that underwent successful endoscopic therapy, administer high-dose PPI: 80 mg IV bolus followed by continuous infusion of 8 mg/hour for exactly 72 hours. 1, 2 This is when rebleeding risk is highest.
After 72 hours, transition to oral PPI twice daily for 14 days, then once daily. 1, 2 The duration depends on the nature of the bleeding lesion.
Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis. 1, 2, 4
Do not perform routine second-look endoscopy, though it may be useful in selected high-risk patients. 1, 2
Testing for H. pylori
Test all patients for Helicobacter pylori and provide eradication therapy if present, with confirmation of eradication. 1, 2 Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease. 1
Important caveat: Tests for H. pylori may have increased false-negative rates during acute bleeding. 1 If initial testing is negative, perform confirmatory testing outside the acute context. 1
Management of Recurrent Bleeding
For recurrent bleeding after initial endoscopic therapy, attempt repeat endoscopic therapy first. 1 If endoscopic therapy fails again, consider transcatheter arterial embolization before proceeding to surgery. 3, 6
Seek surgical consultation for patients for whom endoscopic therapy has failed. 1
Secondary Prevention for NSAID-Related Bleeding
If the patient absolutely requires an NSAID after recovery, recognize that traditional NSAID plus PPI OR COX-2 inhibitor alone still carries clinically important rebleeding risk. 1, 5
The combination of PPI plus COX-2 inhibitor is recommended to reduce recurrent bleeding risk beyond COX-2 inhibitor alone. 1, 5 This is superior to either agent alone.
Avoid NSAIDs entirely if possible in patients with a history of ulcer complications, as they are in the very high-risk category. 5
Restarting Antiplatelet Therapy (If Applicable)
If the patient was taking aspirin for cardiovascular prophylaxis, restart it when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). 1, 2, 3
Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy. 1, 2
Common Pitfalls to Avoid
- Never delay endoscopy for PPI administration - start PPI immediately but proceed with endoscopy within 24 hours. 2, 5
- Never use epinephrine injection as monotherapy - always combine with thermal or mechanical therapy. 1, 2
- Don't miss an upper GI source in patients presenting with bright red blood per rectum and hemodynamic instability - always consider upper GI bleeding in this scenario. 2
- Don't rely on negative H. pylori testing during acute bleeding - repeat testing after the acute episode if initially negative. 1