What is the initial management approach for a patient with upper gastrointestinal bleeding in the emergency department, considering factors such as past medical history, demographics, and use of anticoagulant or antiplatelet medications like warfarin, aspirin, or clopidogrel?

Management of Upper Gastrointestinal Bleeding in the Emergency Department

Immediate Resuscitation and Stabilization

Begin resuscitation immediately with crystalloid fluids through two large-bore IV cannulas in the antecubital fossae, targeting heart rate reduction, blood pressure increase, central venous pressure of 5-10 cm H₂O, and urine output >30 mL/hour 1, 2.

• Most patients require 1-2 liters of normal saline; if shock persists after this volume, plasma expanders are needed as ≥20% of blood volume has been lost 1, 2.
• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease; use a higher threshold (approaching 100 g/L) for patients with cardiovascular disease 3, 1, 4.
• Crystalloids are preferred over colloids for initial resuscitation as colloids show no survival benefit and are more expensive 1.

Risk Stratification

Calculate the Glasgow Blatchford score immediately; patients with a score ≤1 can be managed as outpatients without hospitalization or urgent endoscopy 3, 1, 4.

• High-risk features requiring admission include: age >60 years, shock (heart rate >100 bpm and systolic BP <100 mmHg), hemoglobin <100 g/L, and significant comorbidities (renal insufficiency, liver disease, malignancy, ischemic heart disease, heart failure) 1.
• Consider nasogastric tube placement as bright red blood in the aspirate is an independent predictor of rebleeding 1, 2.
• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1.

Pre-Endoscopic Pharmacological Management

Start intravenous proton pump inhibitor therapy immediately upon presentation with an 80 mg IV bolus followed by 8 mg/hour continuous infusion, even before endoscopy 1, 4.

• Pre-endoscopic PPI therapy may downstage endoscopic lesions and decrease the need for intervention, though it should not delay endoscopy 3, 1.
• For suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours; or octreotide 50 μg/hour continuous infusion with initial 50 μg bolus) as soon as bleeding is suspected 1.
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in patients with cirrhosis and suspected variceal bleeding 1.
• Do not use promotility agents routinely before endoscopy 1, 4.

Anticoagulation and Antiplatelet Management

Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs) or antiplatelet agents 1.

• Correct coagulopathy during initial resuscitation to reduce mortality 1.
• The decision to restart antithrombotic therapy depends on cardiovascular risk versus bleeding risk, which will be determined after endoscopic findings are known 3, 5.

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 3, 1, 4.

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1.
• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy 1.
• 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.

Endoscopic Therapy Based on Lesion Characteristics

For high-risk stigmata (active bleeding, visible vessel, or adherent clot), use combination endoscopic therapy with epinephrine injection PLUS a second hemostasis modality (contact thermal coagulation or mechanical clips) 3, 1, 4.

• Epinephrine injection alone is NOT recommended and must always be combined with thermal or mechanical therapy 3, 1, 4.
• Thermocoagulation or sclerosant injection plus epinephrine are effective first-line options 1, 4.
• Through-the-scope clips are suggested as an effective alternative 3, 1, 4.
• For adherent clots in ulcer beds, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 1, 4.
• TC-325 (hemostatic powder) is suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1, 4.
• Do not perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot) 1.

Variceal Bleeding Specific Therapy

• Use endoscopic variceal ligation for esophageal varices and tissue glue (cyanoacrylate) for gastric varices 3, 6.

Post-Endoscopic Pharmacological Management

For patients with high-risk stigmata who underwent successful endoscopic therapy, continue high-dose PPI therapy (80 mg IV bolus followed by 8 mg/hour continuous infusion) for exactly 72 hours 3, 1, 4.

• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily for a duration dependent on the nature of the bleeding lesion 3, 1, 4.
• This high-dose regimen reduces rebleeding rates, mortality, and need for surgery compared to placebo or H2-receptor antagonists 1, 4.
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 1.

Hospital Management and Monitoring

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 3, 1.
• Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 1, 4.
• Monitor pulse, blood pressure, and urine output continuously; patients who are hemodynamically stable 4-6 hours after endoscopy can begin oral intake 2.

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 1, 4.

• If repeat endoscopy fails, manage with interventional radiology or surgery 6.
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1, 6.
• Early surgical consultation may be particularly beneficial in patients at high risk for failed endoscopic retreatment 4.

Helicobacter Pylori Testing and Eradication

Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if positive 1, 4, 2.

• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1, 4, 2.
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1, 4.

Restarting Antithrombotic Therapy

For patients requiring secondary cardiovascular prophylaxis, restart aspirin as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 3, 1.

• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 3, 1.
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 3, 1, 4.
• For patients requiring NSAIDs, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 3, 1.
• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole, which inhibit CYP2C19 and reduce clopidogrel's active metabolite 1.

Critical Pitfalls to Avoid

• Never use epinephrine injection alone for endoscopic hemostasis—it provides suboptimal efficacy 3, 1, 4.
• Do not routinely perform second-look endoscopy; it may be useful only in selected high-risk patients 3, 1, 4.
• Do not use H2-receptor antagonists in acute upper GI bleeding management due to limited efficacy compared to PPIs 4.
• Do not use somatostatin or octreotide in routine management of nonvariceal upper GI bleeding 4.
• Always consider upper GI source in hemodynamically unstable patients presenting with bright red blood per rectum 1.