What is the initial treatment protocol for a patient presenting with an upper GI bleed, particularly those with a history of NSAID use or taking anticoagulants?

Upper GI Bleed Treatment Protocol

Immediate Resuscitation (First Priority)

Establish two large-bore IV cannulae in the antecubital fossae and begin aggressive fluid resuscitation with crystalloid (normal saline or lactated Ringer's) to restore blood pressure and end-organ perfusion. 1, 2

• Infuse 1-2 liters of normal saline rapidly to correct volume losses; if shock persists after this volume, plasma expanders are needed as ≥20% of blood volume has been lost 1, 2
• Target adequately resuscitated state: urine output >30 ml/hour, central venous pressure 5-10 cm H₂O, decreased heart rate, and increased blood pressure 1, 2
• Insert urinary catheter and measure hourly volumes in severe bleeds (pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L) 1
• Use automated monitors for continuous pulse and blood pressure measurement 1, 2
• In patients with significant cardiac disease, measure central venous pressure to guide fluid replacement decisions 1, 2
• Protect the airway by intubating patients with high-volume hematemesis before endoscopy 2

Blood Transfusion Strategy

Transfuse red blood cells when hemoglobin is <80 g/L (8 g/dL) in patients without cardiovascular disease. 1, 2

• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (target post-transfusion hemoglobin ≥100 g/L) 1, 3
• Give O-negative blood only in extreme circumstances when rapid cross-matching is not possible 1
• Transfuse when bleeding is extreme (active hematemesis with shock) or hemoglobin <100 g/L in acute bleeding 1

Pharmacological Management (Start Immediately)

Initiate high-dose intravenous proton pump inhibitor therapy immediately upon presentation: pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion. 1, 2

• Pre-endoscopic PPI therapy may downstage endoscopic lesions and decrease need for intervention but should not delay endoscopy 1, 2
• Do NOT use promotility agents routinely before endoscopy 1, 2
• For suspected variceal bleeding in cirrhotic patients, start vasoactive drugs (octreotide 50 μg/hour continuous infusion with 50 μg bolus) and antibiotic prophylaxis (ceftriaxone or norfloxacin) immediately 2

Anticoagulation Management

Do not delay endoscopy in patients receiving anticoagulants (warfarin, DOACs). 1, 4

• For patients on warfarin with acute GI bleeding, suggest against giving fresh frozen plasma or vitamin K; if reversal is needed, use prothrombin complex concentrate over fresh frozen plasma 4
• For patients on DOACs, suggest against PCC administration 4
• For dabigatran, suggest against idarucizumab administration 4
• For rivaroxaban or apixaban, suggest against andexanet alfa administration 4
• For patients on antiplatelet agents, suggest against platelet transfusions 4
• For patients on cardiac aspirin for secondary prevention, do not hold it; if already interrupted, resume on the day hemostasis is endoscopically confirmed 4

Risk Stratification

Use the Glasgow Blatchford Score (GBS) to identify very low-risk patients (score 0-1) who can be discharged without hospitalization or urgent endoscopy. 1, 2, 3

• Do NOT use the AIMS65 score for discharge decisions as it has lower sensitivity (78-82%) and misclassifies ~20% of high-risk patients 3
• High-risk features requiring admission: age >60 years, pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L, significant comorbidities (renal insufficiency, liver disease, malignancy, cardiac disease) 1, 2
• Admit high-risk patients to monitored setting for at least 24 hours 2

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization. 1, 2

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability 2
• If patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before endoscopy 2
• Erythromycin infusion (250 mg IV 30-60 minutes before endoscopy) is suggested to improve visualization 5

Endoscopic Therapy Based on Findings

For high-risk stigmata (active spurting/oozing, visible vessel), use combination endoscopic therapy: epinephrine injection PLUS thermal coagulation (bipolar electrocoagulation or heater probe) or mechanical therapy (clips). 1, 2, 5

• Never use epinephrine injection alone—it provides suboptimal efficacy and must be combined with another method 1, 2
• Thermocoagulation and sclerosant injection are strongly recommended for high-risk stigmata 1
• Through-the-scope clips are conditionally suggested 1
• For adherent clots, perform targeted irrigation to attempt dislodgement, then treat underlying lesion 1, 2
• Hemostatic powder (TC-325) is suggested as temporizing therapy when conventional therapies fail or are unavailable, but not as sole treatment 1, 5
• Do NOT perform endoscopic therapy for low-risk stigmata (clean-based ulcer or flat pigmented spot) 1, 2

Post-Endoscopic Pharmacological Management

After successful endoscopic hemostasis of high-risk lesions, continue high-dose PPI therapy (pantoprazole 8 mg/hour continuous infusion) for exactly 72 hours. 2, 5

• After 72 hours, switch to oral PPI twice daily for 14 days, then once daily 1, 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 2
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 2

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, attempt repeat endoscopic therapy first. 2, 5

• If repeat endoscopic therapy fails, proceed to transcatheter arterial embolization 5
• Surgery is reserved for cases where both endoscopic therapy and embolization fail 5
• Routine second-look endoscopy is not recommended, though may be useful in selected high-risk patients 2, 5

H. pylori Management

Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if positive. 2

• Eradication reduces ulcer recurrence and rebleeding rates in complicated ulcer disease 2
• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside acute context may be necessary 2

Discharge Criteria for Low-Risk Patients

Discharge patients who meet ALL of the following: hemoglobin >100 g/L, hemodynamically stable (pulse <100 bpm AND systolic BP >100 mmHg), age <60 years, minimal/no comorbidities, and low-risk endoscopic findings (clean-based ulcer, Mallory-Weiss tear, or normal endoscopy). 1, 3

• Observe for 4-6 hours post-endoscopy before discharge 3
• Ensure adequate social support and accessibility to hospital 3
• Initiate appropriate therapy (PPI, H. pylori eradication if positive, NSAID counseling) before discharge 3

Critical Pitfalls to Avoid

• Never discharge patients with high-risk endoscopic findings (active bleeding, visible vessel, adherent clot) 3
• Always consider upper GI source in hemodynamically unstable patients presenting with bright red blood per rectum 2
• Avoid NSAIDs completely in patients with recent upper GI bleeding; use tramadol as first-line alternative analgesic when acetaminophen fails 6
• Do not use epinephrine injection as monotherapy—always combine with thermal or mechanical therapy 1, 2