What is the initial management and workup for a patient presenting with upper gastrointestinal bleeding (UGIB)?

Initial Management and Workup for Upper Gastrointestinal Bleeding

The initial management of UGIB prioritizes immediate resuscitation with crystalloid fluids, restrictive blood transfusion (hemoglobin <80 g/L for patients without cardiovascular disease), risk stratification using the Glasgow Blatchford score, and esophagogastroduodenoscopy within 24 hours after hemodynamic stabilization. 1, 2, 3

Immediate Resuscitation (First Priority)

Hemodynamic stabilization must occur before any diagnostic procedures. 1, 2

Venous Access and Fluid Resuscitation

• Place two large-bore intravenous cannulas (18-gauge or larger) in the antecubital fossae for all hemodynamically compromised patients 2, 3
• Infuse normal saline or Ringer's lactate to achieve falling heart rate, rising blood pressure, central venous pressure of 5-10 cm H₂O, and urine output >30 mL/hour 4, 2, 3
• Most patients require 1-2 liters of crystalloid solution; if shock persists after this volume, plasma expanders are necessary as ≥20% of blood volume has been lost 4, 2, 3

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 2, 3, 5
• Use a higher hemoglobin threshold (typically <100 g/L) for patients with underlying cardiovascular disease 2, 3
• Avoid overtransfusion as restrictive transfusion strategies improve outcomes 5, 6

Airway Protection

• Intubate patients with massive hematemesis or altered mental status before endoscopy to protect the airway 2

Risk Stratification (Concurrent with Resuscitation)

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who can be managed as outpatients without hospitalization or urgent endoscopy. 2, 3

High-Risk Features Requiring Admission

• Age >60 years 2, 3
• Hemodynamic instability (heart rate >100 bpm, systolic blood pressure <100 mmHg, shock index ≥1) 1, 2, 3
• Hemoglobin <100 g/L 2, 3
• Fresh red blood in emesis or nasogastric aspirate (independent predictor of rebleeding) 4, 2, 3
• Significant comorbidities: renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure 2, 3

Nasogastric Tube Placement

• Consider nasogastric tube placement for prognostic value, though not routinely required 4, 2
• Presence of bright red blood in aspirate is an independent predictor of rebleeding 4, 2
• Do not delay management if nasogastric tube placement is unsuccessful or complicated 1

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitors

• Start intravenous PPI therapy immediately upon presentation for all patients with suspected nonvariceal UGIB 2, 3, 5
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy 2, 3

Prokinetic Agents

• Consider erythromycin 250 mg IV 30-60 minutes before endoscopy to improve visualization by promoting gastric emptying 7, 5
• Do not use prokinetic agents routinely; reserve for patients with suspected large blood clot burden 2

Special Considerations for Suspected Variceal Bleeding

• If cirrhosis or variceal bleeding is suspected, immediately start vasoactive drugs (octreotide 50 μg/hour continuous infusion with initial 50 μg bolus) and prophylactic antibiotics (ceftriaxone or norfloxacin) before endoscopy 2, 5

Diagnostic Workup

Esophagogastroduodenoscopy (EGD) - First-Line Diagnostic Test

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization 1, 2, 3
• Consider urgent endoscopy (within 12 hours) for high-risk patients with hemodynamic instability, ongoing bleeding, or shock index ≥1 2, 3
• Endoscopy must be performed by experienced endoscopists capable of therapeutic procedures 4, 3
• EGD successfully identifies the bleeding source in 95% of cases and allows simultaneous therapeutic intervention 1

CT Angiography (CTA) - For Hemodynamically Unstable Patients

• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), perform urgent CTA immediately to localize bleeding before planning endoscopic or radiological therapy 2
• CTA has sensitivity of 79-95% and specificity of 95-100% for detecting active bleeding 1, 2
• Use multiphase CT protocol: noncontrast, late arterial, and venous phases 1
• CTA is preferred over colonoscopy in unstable patients as it can localize bleeding in the upper GI tract, small bowel, or lower GI tract without bowel preparation 1

Critical Pitfall: Always Consider Upper GI Source

• In patients with hemodynamic instability presenting with bright red blood per rectum, always consider an upper GI source 2
• Approximately 10-15% of patients presenting with apparent lower GI bleeding have an upper GI source 1, 2
• If no source is identified by CTA in an unstable patient, perform immediate upper endoscopy 2

Endoscopic Therapy Based on Findings

High-Risk Stigmata (Require Endoscopic Therapy)

• Active arterial bleeding (spurting) 2, 3
• Visible vessel (non-bleeding) 2, 3
• Adherent clot (attempt dislodgement with irrigation and treat underlying stigmata) 2, 3

Endoscopic Treatment Modalities

• Use combination therapy: epinephrine injection PLUS thermal coagulation (heater probe, bipolar electrocoagulation) or mechanical therapy (clips) 2, 3, 7
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with another modality 2, 3
• Consider hemostatic powder (TC-325) as temporizing therapy for actively bleeding ulcers, but not as sole treatment 2, 8
• For variceal bleeding: esophageal band ligation for esophageal varices; tissue glue or thrombin injection for gastric varices 5, 6

Low-Risk Stigmata (No Endoscopic Therapy Needed)

• Clean-based ulcer 2, 3
• Flat pigmented spot (nonprotuberant pigmented dot) 2, 3

Post-Endoscopic Management

High-Dose PPI Therapy for High-Risk Lesions

• 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 2, 3
• After 72 hours, continue oral PPI twice daily for 14 days, then once daily for duration depending on the nature of the bleeding lesion 2, 3

Monitoring and Hospital Care

• Admit high-risk patients to a monitored setting for at least 24-72 hours after endoscopic hemostasis 2, 3
• Monitor pulse, blood pressure, and urine output continuously 4, 2
• Hemodynamically stable patients 4-6 hours after endoscopy can begin oral intake with a light diet 4

Management of Rebleeding

• For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended 2
• If repeat endoscopy fails, proceed to interventional radiology (angiographic embolization) or surgery 5, 6

Secondary Prevention

Helicobacter pylori Testing and Eradication

• Test all patients with peptic ulcer bleeding for H. pylori and provide eradication therapy if positive 2, 3
• Eradication reduces ulcer recurrence rates and rebleeding in complicated ulcer disease 4, 2, 3
• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 2

Restarting Antithrombotic Therapy

• Restart aspirin when cardiovascular risks outweigh gastrointestinal risks, usually within 7 days 2, 3
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2, 3
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 2, 3

Common Pitfalls to Avoid

• Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists or DOACs) 2
• Do not perform routine second-look endoscopy; reserve for selected high-risk patients only 2, 3
• Do not use tranexamic acid—it does not improve outcomes in UGIB 8
• Do not use epinephrine injection as monotherapy—always combine with thermal or mechanical therapy 2, 3