What are the initial steps in managing a patient with an upper gastrointestinal (uGI) bleed, particularly those with significant comorbidities, history of bleeding disorders, or on anticoagulant therapy?

Initial Management of Upper Gastrointestinal Bleeding

Immediately establish two large-bore IV lines in the antecubital fossae and begin aggressive crystalloid resuscitation with normal saline or Ringer's lactate, targeting hemodynamic stabilization (heart rate <100 bpm, systolic BP >100 mmHg, urine output >30 mL/hour) before any diagnostic procedures. 1, 2

Immediate Resuscitation (First 30-60 Minutes)

Venous Access and Fluid Resuscitation

• Place two large-caliber (18-gauge or larger) IV cannulas in the antecubital fossae for all patients with hemodynamic compromise 1, 2
• Infuse 1-2 liters of crystalloid (normal saline or Ringer's lactate) rapidly to correct volume losses 1, 2
• If shock persists after 2 liters, administer plasma expanders as ≥20% of blood volume has been lost 1, 2
• Target central venous pressure of 5-10 cm H₂O in adequately resuscitated patients 1

Hemodynamic Monitoring

• Insert urinary catheter and measure hourly urine output (target >30 mL/hour) 3, 1
• Use automated blood pressure monitoring for continuous pulse and BP measurement 3, 1
• In patients with significant cardiac disease, measure central venous pressure to guide fluid replacement decisions 3, 1

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease 1, 4, 2
• Use a higher hemoglobin threshold (80-100 g/L) for patients with cardiovascular disease, including ischemic heart disease or heart failure 1, 4, 2
• Avoid targeting hemoglobin >100 g/L as this may increase rebleeding risk 4

Airway Protection

• Intubate patients with massive hematemesis or altered mental status before endoscopy to protect the airway 1
• This is particularly critical when there is high-volume bleeding that may compromise respiratory status 1

Risk Stratification (Within First Hour)

Glasgow Blatchford Score

• Calculate the Glasgow Blatchford score immediately; patients with a score ≤1 can be managed as outpatients without hospitalization or urgent endoscopy 1, 4, 2
• This score identifies very low-risk patients who do not require inpatient intervention 1, 2

High-Risk Features Requiring ICU Admission

• Age >60 years 3, 1
• Shock (heart rate >100 bpm AND systolic BP <100 mmHg) 3, 1
• Hemoglobin <100 g/L 3, 1
• Significant comorbidities: renal failure, liver failure, disseminated malignancy, ischemic heart disease, heart failure 3, 1
• Fresh red blood in emesis or nasogastric aspirate 1
• Admit high-risk patients to a monitored setting (ICU or step-down unit) for at least the first 24 hours 1

Rockall Score

• The complete Rockall score (including endoscopic findings) predicts rebleeding and mortality: score <3 indicates excellent prognosis, score >8 indicates high mortality risk 3
• Age >80 years adds 2 points; comorbidities like renal/liver failure add 3 points 3

Management of Anticoagulation and Coagulopathy

Patients on Warfarin

• Do NOT delay endoscopy in patients on warfarin 1
• For life-threatening hemorrhage with INR elevation, administer vitamin K 5-25 mg IV (rarely up to 50 mg) 5
• In severe hemorrhage, give fresh frozen plasma (200-500 mL) or prothrombin complex concentrate to rapidly reverse coagulopathy 5
• Recognize that vitamin K takes 1-2 hours minimum for measurable PT improvement 6
• Factor IX complex carries thrombosis risk and should be reserved for life-threatening bleeding only 5

Patients on Direct Oral Anticoagulants (DOACs)

• Do NOT delay endoscopy in patients taking apixaban, rivaroxaban, or dabigatran 4
• Do NOT routinely use prothrombin complex concentrates prior to emergency endoscopy in DOAC patients 4
• For life-threatening hemorrhage on apixaban or rivaroxaban, consider andexanet alfa (specific reversal agent) 4
• For dabigatran, idarucizumab is the specific reversal agent 4

Patients with Bleeding Disorders or Thrombocytopenia

• Correct coagulopathy early and aggressively as this significantly decreases mortality 7
• Platelet transfusion should be considered if platelets <50,000/μL with active bleeding 1

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitors

• Start IV PPI therapy immediately upon presentation with suspected non-variceal UGIB 1, 2
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease need for intervention 1, 2
• Do NOT delay endoscopy to administer PPIs 1, 2

Prokinetic Agents

• Consider erythromycin 250 mg IV given 30-60 minutes before endoscopy to improve gastric visualization 1, 8
• Do NOT routinely use prokinetic agents in all patients 1

Variceal Bleeding Suspected (Cirrhosis Patients)

• Start vasoactive drug therapy immediately if variceal bleeding is suspected: 1
  • Octreotide: 50 μg/hour continuous infusion with initial 50 μg bolus, OR
  • Somatostatin: 250 μg/hour continuous infusion with initial 250 μg bolus, OR
  • Terlipressin: 2 mg IV every 4 hours for first 48 hours, then 1 mg every 4 hours
• Administer antibiotic prophylaxis (ceftriaxone 1g IV daily or norfloxacin 400 mg PO twice daily) in all cirrhotic patients with suspected variceal bleeding 1
• Continue vasoactive drugs and antibiotics for 3-5 days 1

Timing and Approach to Endoscopy

Standard Timing

• Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization 1, 4, 2
• Endoscopy should only be performed after the patient is hemodynamically resuscitated 1

Urgent Endoscopy (Within 12 Hours)

• Consider earlier endoscopy (within 12 hours after resuscitation) for high-risk patients with: 1, 4
  • Hemodynamic instability despite initial resuscitation
  • Shock index >1 (heart rate/systolic BP >1)
  • Active hematemesis
  • Suspected variceal bleeding in cirrhotic patients

Alternative Imaging When Endoscopy Cannot Be Performed

• If the patient remains hemodynamically unstable despite resuscitation or has massive ongoing bleeding, perform CT angiography immediately to localize the bleeding source 1, 4
• CTA has 79-95% sensitivity and 95-100% specificity for active bleeding 1, 4
• Visceral angiography allows simultaneous embolization if bleeding source is identified 4

Endoscopic Therapy Based on Findings

High-Risk Stigmata (Active Bleeding or Visible Vessel)

• Use combination endoscopic therapy: epinephrine injection PLUS a second modality (thermal coagulation, sclerosant injection, or mechanical 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, sclerosant injection, and through-the-scope clips are all acceptable second modalities 1, 2

Adherent Clot

• Perform targeted irrigation to attempt clot dislodgement, then treat the underlying lesion if high-risk stigmata are revealed 1, 2

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

• Do NOT perform endoscopic hemostatic therapy for clean-based ulcers or flat pigmented spots 1, 2
• These lesions have very low rebleeding risk and excellent prognosis 3

Post-Endoscopic Management

High-Dose PPI Therapy After Successful Hemostasis

• For high-risk stigmata with successful endoscopic therapy, administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours 1, 2
• After 72 hours, switch to oral PPI twice daily for 14 days, then once daily 1, 2
• This regimen significantly reduces rebleeding rates, mortality, and need for surgery 1

Monitoring and Discharge Planning

• High-risk patients should remain hospitalized for at least 72 hours after endoscopic hemostasis 1
• Do NOT perform routine second-look endoscopy 1, 2
• Second-look endoscopy may be considered only in highly selected high-risk patients 1

H. pylori Testing and Eradication

• Test all patients with peptic ulcer bleeding for H. pylori and provide eradication therapy if positive 1, 2
• Eradication reduces ulcer recurrence and rebleeding rates by approximately 50% 1, 2
• Testing during acute bleeding may have increased false-negative rates; consider confirmatory testing after discharge 1

Restarting Anticoagulation and Antiplatelet Therapy

• Restart aspirin when cardiovascular risks outweigh GI risks, typically within 7 days of the bleeding episode 1, 2
• For patients requiring aspirin, use aspirin plus PPI rather than switching to clopidogrel alone, as this reduces rebleeding 1, 2
• Continue PPI therapy indefinitely in patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 1, 2

Management of Recurrent Bleeding

First Recurrence

• Attempt repeat endoscopic therapy for first recurrence of ulcer bleeding 1
• Use the same combination approach (injection plus thermal/mechanical therapy) 1

Second Recurrence or Failed Endoscopic Therapy

• Proceed to interventional radiology (angiography with embolization) or surgery for bleeding that persists after two endoscopic attempts 1, 8
• Angiography is generally preferred over surgery in the modern era due to lower morbidity 8

Recurrent Variceal Bleeding

• Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding 1, 8

Critical Pitfalls to Avoid

• Never delay endoscopy in patients on anticoagulants—this leads to worse outcomes 4
• Never use epinephrine injection alone for high-risk lesions—always combine with thermal or mechanical therapy 1, 2
• Never perform endoscopy before achieving hemodynamic stabilization—this increases mortality 1, 7
• Always consider upper GI source in patients with hemodynamic instability presenting with bright red blood per rectum—failure to do so delays diagnosis 1
• Remember that negative nasogastric aspirate does NOT rule out UGIB (occurs in 3-16% of cases) 4
• Do not target hemoglobin >100 g/L through transfusion—this may paradoxically increase rebleeding 4
• Identify cirrhotic patients immediately as they require specific management with vasoactive drugs and antibiotics 3, 1