What are the initial and subsequent management steps for a patient with an upper GI bleed, considering potential complications and high risk of rebleeding?

Upper GI Bleed Management

Initial Resuscitation and Stabilization

Immediate resuscitation with crystalloid fluids and correction of hypovolemia must occur before any diagnostic or therapeutic procedures, targeting hemodynamic stability with heart rate reduction, blood pressure normalization, central venous pressure of 5-10 cm H₂O, and urine output >30 mL/hour. 1, 2

• Place two large-bore intravenous cannulae in the antecubital fossae for all patients with hemodynamic compromise 1, 3
• Infuse 1-2 liters of normal saline to correct volume losses in most patients; if shock persists after this volume, plasma expanders are needed as ≥20% of blood volume has been lost 1, 2
• Insert a urinary catheter and measure hourly urine output in severe bleeding cases 1
• Use continuous automated monitoring of pulse and blood pressure 1
• In patients with significant cardiac disease, measure central venous pressure to guide fluid replacement decisions 1
• For massive bleeding with hemodynamic instability, consider airway protection with intubation before endoscopy 2

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin is <80 g/L (7-8 g/dL) in patients without cardiovascular disease, targeting a hemoglobin range of 70-90 g/L. 2, 3, 4, 5

• Use a higher hemoglobin threshold (≥100 g/L or 10 g/dL) for patients with underlying cardiovascular disease, active ischemic heart disease, or significant comorbidities 1, 2, 3
• O-negative blood can be given in extreme circumstances, though rapid cross-matching is usually possible 1

Risk Stratification

Clinical stratification into low-risk and high-risk categories is essential before endoscopy to guide management intensity and disposition. 1

Low-Risk Patients (Mild-Moderate Bleed)

• Normal pulse and blood pressure, hemoglobin >100 g/L, age <60 years, and insignificant comorbidity 1
• Glasgow-Blatchford score ≤1 identifies very low-risk patients who can be discharged with outpatient follow-up without hospitalization or urgent endoscopy 2, 4, 5
• Admit to general medical ward with hourly vital signs monitoring 1
• Perform endoscopy on the next available list (within 24 hours) 1

High-Risk Patients (Severe Bleed)

• Age >60 years, pulse >100 bpm, systolic blood pressure <100 mmHg, hemoglobin <100 g/L, or shock index >1 (heart rate ÷ systolic BP) 1, 2, 3
• Significant comorbidities including renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, or heart failure 2
• Fresh red blood in hematemesis, nasogastric aspirate, or on rectal examination 1, 2
• Admit to monitored setting (ICU or high-dependency unit) for at least 24 hours 1, 2
• Perform endoscopy within 24 hours after hemodynamic stabilization, or within 12 hours for hemodynamically unstable patients 2, 3

Pre-Endoscopic Pharmacological Management

Start high-dose intravenous proton pump inhibitor therapy immediately upon presentation with suspected upper GI bleeding. 2

• Administer pantoprazole 80 mg IV bolus or equivalent PPI 2
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy 2
• Consider erythromycin 250 mg IV infusion 30-60 minutes before endoscopy as a prokinetic agent to clear the stomach of blood and clots 6, 7, 5
• Do NOT routinely use other promotility agents 2

Special Considerations for Suspected Variceal Bleeding

• Initiate vasoactive drug therapy immediately if variceal bleeding is suspected: terlipressin 2 mg IV every 4 hours for first 48 hours, then 1 mg every 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 2
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in patients with cirrhosis and suspected variceal bleeding 2

Endoscopic Management

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization, with earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability. 2, 3

• Endoscopy should only be performed after adequate resuscitation is achieved 1, 2
• In hemodynamically unstable patients (shock index >1) who remain unstable despite resuscitation, consider urgent CT angiography to localize bleeding before endoscopy 2, 3

Endoscopic Therapy Based on Stigmata

For high-risk stigmata (active spurting or oozing, non-bleeding visible vessel), use combination endoscopic therapy with epinephrine injection PLUS a second hemostasis modality. 2, 5

• Never use epinephrine injection alone—it must always be combined with thermal coagulation (bipolar electrocoagulation, heater probe) or mechanical therapy (clips) 1, 2, 5
• Recommended combination: epinephrine injection plus bipolar electrocoagulation, heater probe, or through-the-scope clips 2, 5
• For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 2
• Hemostatic powder (TC-325) is suggested as temporizing therapy for actively bleeding ulcers, but not as sole treatment 2, 5

Do NOT perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or flat pigmented spot). 2

Post-Endoscopic Pharmacological Management

Following successful endoscopic therapy in patients with high-risk stigmata, administer high-dose PPI therapy: pantoprazole 80 mg IV bolus followed by continuous infusion of 8 mg/hour for exactly 72 hours. 1, 2

• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily for a duration dependent on the bleeding lesion 2
• This regimen reduces rebleeding rates, blood transfusion requirements, and duration of hospital stay 1
• For variceal bleeding, continue vasoactive drugs and antibiotics for 3-5 days 2

Post-Endoscopic Monitoring

Closely monitor all patients with major upper GI hemorrhage following endoscopy with continuous observation of pulse, blood pressure, and urine output. 1

• High-risk patients should remain hospitalized in a monitored setting for at least 72 hours after endoscopic hemostasis 2
• Patients who are hemodynamically stable 4-6 hours after endoscopy can be allowed to drink and start a light diet 1
• Do NOT routinely perform second-look endoscopy 2

Management of Rebleeding

If clinical evidence of rebleeding occurs (fresh melena or hematemesis, falling blood pressure, rising pulse, falling central venous pressure), perform repeat endoscopy to confirm rebleeding. 1

• Attempt endoscopic therapy on one occasion for confirmed rebleeding 1
• If repeat endoscopic therapy fails, proceed to transcatheter arterial embolization as second-line intervention 5
• Surgery is reserved for patients with uncontrolled hemorrhage that cannot be stopped by endoscopic or radiologic intervention 1
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 2

Secondary Prevention

All patients with upper GI bleeding should be tested for Helicobacter pylori and receive eradication therapy if infection is present, as this reduces ulcer recurrence and rebleeding. 2

• Testing during acute bleeding may have increased false-negative rates; consider confirmatory testing outside the acute context 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 2
• For patients requiring aspirin, restart when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2
• For patients requiring NSAIDs, use a cyclooxygenase-2 inhibitor with a PPI to reduce rebleeding 2

Critical Pitfalls to Avoid

• Never delay resuscitation to perform endoscopy—hemodynamic stabilization must occur first 1, 2
• Never use epinephrine injection alone for endoscopic therapy—always combine with thermal or mechanical modality 1, 2
• Always consider an upper GI source in hemodynamically unstable patients, even when presenting with bright red blood per rectum 2, 3
• Do not routinely perform second-look endoscopy in all patients after initial treatment 2
• Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs) 2