What is the management approach for a patient presenting with Upper Gastrointestinal Bleeding (UGIB)?

Management of Upper Gastrointestinal Bleeding

Immediately resuscitate with crystalloids (preferably balanced solutions like Ringer's lactate), transfuse red blood cells at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start IV proton pump inhibitors, and perform endoscopy within 24 hours after stabilization—or within 12 hours for high-risk patients with hemodynamic instability. 1, 2

Initial Resuscitation and Stabilization

• Use crystalloids (normal saline or Ringer's lactate) for initial volume resuscitation, not colloids, as colloids provide no mortality benefit and are more expensive 2
• Balanced crystalloids like Ringer's lactate may reduce acute kidney injury compared to normal saline 2
• Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this may exacerbate bleeding and disrupt coagulation 2
• 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

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 1, 2
• This restrictive transfusion strategy (compared to liberal transfusion) improves outcomes 1

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
• Do not use the AIMS65 prognostic score for risk stratification 1

High-Risk Features Requiring Admission

• Age >60 years 1
• Shock (heart rate >100 bpm and systolic blood pressure <100 mmHg) 1
• Hemoglobin <100 g/L 1
• Significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure) 1
• Fresh red blood in emesis or nasogastric aspirate 1
• Elevated urea, creatinine, or serum aminotransferase levels 1

Nasogastric Tube Considerations

• Nasogastric tube placement can be considered as findings may have prognostic value 1, 2
• Presence of bright blood in the aspirate is an independent predictor of rebleeding 1
• However, 3-16% of patients with UGIB may have a negative nasogastric aspirate 3

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitors

• Start intravenous proton pump inhibitor therapy immediately upon presentation 1, 2
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention 1, 2
• Do not delay endoscopy for PPI administration 1, 2

Prokinetic Agents

• Do not use promotility agents routinely before endoscopy 1
• Erythromycin may be given 30-60 minutes before endoscopy and may aid in diagnosis, but is not routinely recommended 4, 5

Variceal Bleeding Considerations

• For suspected variceal bleeding in patients 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) 1

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization 3, 1, 2
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 1, 2
• For variceal bleeding, patients may require endoscopy within 12 hours 6
• Emergency endoscopy is indicated in patients with persistent hemorrhage resulting in deviations of vital signs or requiring repeated transfusions 3

Endoscopic Therapy Based on Lesion Characteristics

High-Risk Stigmata (Active Bleeding, Visible Vessel, Adherent Clot)

• Use combination endoscopic therapy: epinephrine injection PLUS a second hemostasis modality (contact thermal coagulation, sclerosant injection, or mechanical therapy with clips) 1, 2
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1, 2
• Thermocoagulation and sclerosant injection are recommended 1
• Through-the-scope clips are also suggested 1
• Combination therapy is superior to any single treatment 1

Adherent Clots

• Perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 1
• Attempts to dislodge clots with hemostatic, pharmacologic, or combination treatment of the underlying stigmata are supported by data 1

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

• Do not perform endoscopic hemostatic therapy for low-risk stigmata 1

Temporizing Measures

• TC-325 (hemostatic powder) is suggested as temporizing therapy, but not as sole treatment, in patients with actively bleeding ulcers 1

Variceal Bleeding Endoscopic Therapy

• Use ligation for esophageal varices 5
• Use tissue glue for gastric varices 5

Post-Endoscopic Pharmacological Management

High-Dose PPI Therapy for High-Risk Stigmata

• Administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours in patients with high-risk stigmata who underwent successful endoscopic therapy 1, 2
• This high-dose continuous infusion reduces rebleeding rates, mortality rates, and need for surgery compared to H2-receptor antagonists or placebo 1
• After 72 hours, continue oral PPI twice daily for 14 days, then once daily for a duration dependent on the nature of the bleeding lesion 1, 2

Variceal Bleeding Post-Endoscopic Care

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

Drug Interaction Considerations

• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole, which inhibit CYP2C19 and reduce clopidogrel's active metabolite 1

Hospital Management and Monitoring

• High-risk patients should be admitted to a monitored setting for at least the first 24 hours 1
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 1
• Patients considered at low risk for rebleeding after endoscopy can be fed within 24 hours 1

Management of Recurrent Bleeding

• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 1
• If bleeding persists after repeat endoscopy, consider interventional radiology (transcatheter arterial embolization) or surgery 1, 5
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1, 5

Secondary Prophylaxis and Prevention

Helicobacter pylori Eradication

• Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if infection is present 1, 2
• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1

Restarting Antithrombotic Therapy

• Restart acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) for patients requiring cardiovascular prophylaxis 1, 2
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 1, 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 1, 2
• For patients who require NSAIDs, a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding 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
• Do not perform routine second-look endoscopy, though it may be useful in selected high-risk patients 1
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 1
• UGIB ceases spontaneously in 75% of cases, so focus on aggressive resuscitation and hemodynamic stability first 3