What is the management approach for a patient with upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease, with possible Helicobacter pylori infection and non-steroidal anti-inflammatory drug (NSAID) use?

Management of Upper Gastrointestinal Bleeding from Peptic Ulcer Disease

For patients with UGIB from peptic ulcer disease, immediately initiate resuscitation with crystalloids, start high-dose IV PPI therapy before endoscopy, perform endoscopy within 24 hours, apply combination endoscopic therapy for high-risk stigmata, continue IV PPI infusion for 72 hours post-hemostasis, test and eradicate H. pylori, and permanently discontinue NSAIDs if possible. 1, 2

Initial Resuscitation and Stabilization

Fluid Resuscitation

• Begin immediate fluid resuscitation with crystalloids (not colloids) to restore end-organ perfusion, targeting heart rate reduction, increased blood pressure, and urine output >30 mL/hour 2, 3
• 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 3

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (though specific threshold not defined in guidelines, clinical judgment suggests 90-100 g/L) 1, 2

Risk Stratification

• Calculate the Glasgow Blatchford score immediately; patients with a score ≤1 are at very low risk and may be managed as outpatients without hospitalization or urgent endoscopy 2, 3
• High-risk features 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, heart failure) 3
• Consider nasogastric tube placement as findings have prognostic value; bright red blood in aspirate is an independent predictor of rebleeding 1, 3

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitor Therapy

• Start IV PPI therapy immediately upon presentation, before endoscopy—this is critical 2, 4
• Administer pantoprazole 80 mg IV bolus (or equivalent PPI) as soon as UGIB is suspected 2, 4
• Pre-endoscopic PPI therapy downstages endoscopic lesions and decreases the need for endoscopic intervention, though it should not delay endoscopy 1, 2

Prokinetic Agents

• Do NOT use promotility agents routinely before endoscopy to increase diagnostic yield 1, 2
• Erythromycin may be considered in selected cases to improve visualization, but this is a weak recommendation 4, 5

NSAID Management

• Discontinue nimesulide and all NSAIDs immediately upon presentation, as continuing NSAID therapy significantly increases rebleeding risk 2

Anticoagulation Considerations

• Do NOT delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs) 1, 2

Endoscopic Management

Timing of Endoscopy

• Perform endoscopy within 24 hours of presentation after initial stabilization for all hospitalized patients 1, 2, 3
• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 3
• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before endoscopy 2

Endoscopic Therapy Based on Stigmata

High-Risk Stigmata (Active Bleeding or Visible Vessel)

• Endoscopic hemostatic therapy is mandatory for high-risk stigmata 1, 2
• Use combination therapy: thermocoagulation or sclerosant injection PLUS epinephrine injection (strong recommendation) 1, 2
• Through-the-scope clips are also suggested as an option 1
• NEVER use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with another method 1, 2
• No single thermal coaptive method is superior to another 1

Adherent Clot

• Perform targeted irrigation to attempt dislodgement, with appropriate treatment of the underlying lesion 1, 2
• The role of endoscopic therapy for adherent clots is controversial; endoscopic therapy may be considered, though intensive PPI therapy alone may be sufficient 1

Low-Risk Stigmata (Clean-Based Ulcer or Flat Pigmented Spot)

• Do NOT perform endoscopic hemostatic therapy for low-risk stigmata 1, 2

Rescue Therapy

• TC-325 (hemostatic powder) is suggested as temporizing therapy when conventional endoscopic therapies are not available or fail, but NOT as sole treatment 1

Post-Endoscopic Pharmacological Management

High-Dose PPI Protocol for High-Risk Stigmata

• After successful endoscopic hemostasis of high-risk stigmata, administer pantoprazole 80 mg IV bolus followed by continuous infusion of 8 mg/hour for exactly 72 hours (strong recommendation) 2, 3, 4
• This regimen reduces rebleeding from 10.3% to 5.9% and also reduces mortality and need for surgery 2, 4
• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily 2, 3
• Continue PPI therapy for 6-8 weeks following endoscopic treatment to allow mucosal healing 4

Hospitalization Duration

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 2, 3
• Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly 1, 3

Second-Look Endoscopy

• Routine second-look endoscopy is NOT recommended 2, 3
• May be useful in selected high-risk patients, but this is not standard practice 2, 3

Management of Recurrent Bleeding

• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 2
• If bleeding persists or recurs after second endoscopic attempt, proceed to interventional radiology (angiographic embolization) or surgery 5, 6, 7

Eradication of Underlying Causes

Helicobacter pylori Testing and Eradication

• Test ALL patients with peptic ulcer bleeding for H. pylori and provide eradication therapy if present 2, 3, 4
• Confirm eradication after treatment (testing during acute bleeding may have increased false-negative rates) 2, 3
• H. pylori eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 3, 5, 8

NSAID Management After Bleeding

• Avoid NSAIDs permanently if possible in patients with a history of ulcer complications—this is the very high-risk category 2
• If NSAID is absolutely required, use the combination of PPI plus COX-2 inhibitor (this is superior to either alone but still carries clinically important rebleeding risk) 2, 4
• Traditional NSAID plus PPI OR COX-2 inhibitor alone still carries unacceptable rebleeding risk 2

Antiplatelet and Anticoagulation Management

Aspirin Resumption

• For patients requiring secondary cardiovascular prophylaxis, restart aspirin as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days, ideally 1-3 days) 2, 3
• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 2, 3

Long-Term PPI Therapy

• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 2, 3
• Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole 2

Critical Pitfalls to Avoid

• Never use epinephrine injection alone for endoscopic hemostasis—always combine with thermal or mechanical therapy 1, 2
• Never delay endoscopy in anticoagulated patients 1, 2
• Always consider an upper GI source in hemodynamically unstable patients presenting with bright red blood per rectum 2
• Do not restart NSAIDs without PPI plus COX-2 inhibitor in patients with previous ulcer bleeding 2, 4
• Do not discharge high-risk patients before 72 hours post-hemostasis 2, 3
• Do not forget to test for H. pylori and confirm eradication 2, 3, 4