What is the appropriate management for a patient with upper GI bleeding, potentially with a history of bleeding disorders or anticoagulant use?

Medical Management of Upper Gastrointestinal Bleeding

Initial Resuscitation and Hemodynamic Stabilization

Begin immediate resuscitation with crystalloid fluids and transfuse red blood cells at a hemoglobin threshold of <80 g/L for patients without cardiovascular disease, using a higher threshold for those with cardiovascular disease. 1

• Use balanced crystalloids like Ringer's lactate rather than normal saline to reduce acute kidney injury risk, particularly in vulnerable populations 1
• A restrictive transfusion strategy maintaining hemoglobin ≥70 g/L improves survival and reduces recurrent bleeding in severe acute upper GI bleeding 1
• Correct hypothermia and acidosis immediately, as they worsen coagulopathy and perpetuate bleeding 1
• Stabilization of blood pressure and restoration of intravascular volume must precede further diagnostic and therapeutic measures 2

Risk Stratification

Use the Glasgow Blatchford score ≤1 to identify very low-risk patients who may not require hospitalization, though apply this cautiously in patients with chronic kidney disease. 1

• Approximately 80% of patients will stop bleeding spontaneously without recurrence, making identification of the high-risk 20% critical 2
• Assess volume of visualized blood loss, laboratory values, rate of blood loss, response to transfusion, and hemodynamics to determine severity 1
• The presence of bright red blood in nasogastric aspirate predicts poor outcome and need for emergency endoscopy 2

Management of Anticoagulation and Coagulopathy

Correct coagulopathy but do NOT delay endoscopy for this purpose—proceed with endoscopy while correcting coagulopathy simultaneously. 1, 3

• Endoscopic treatment may be safely performed in patients with INR <2.5 1
• For patients on direct oral anticoagulants with serious bleeding and DOAC level >50 ng/mL, consider anticoagulant reversal 1
• Dabigatran is the only oral anticoagulant that can be removed by hemodialysis 1
• Common pitfall: Never delay endoscopy waiting for INR normalization, as mild to moderate coagulopathy does not preclude safe endoscopic therapy 1

Pre-Endoscopic Pharmacologic Management

Start intravenous proton pump inhibitor therapy immediately upon presentation. 1

• Consider proton pump inhibitor infusions over intermittent intravenous administration for more aggressive medical management 1
• Administer prokinetic agents, such as erythromycin, 30-60 minutes before endoscopy to clear the stomach and aid in diagnosis 1
• High-dose intravenous pantoprazole (40 mg) significantly suppresses both maximal acid output and basal acid output compared to placebo 4

Endoscopic Management

Perform endoscopy within 24 hours of presentation for all admitted patients after initial stabilization with crystalloids and blood products. 1

• Provide endoscopic hemostasis therapy for high-risk stigmata, including active bleeding, non-bleeding visible vessel, or adherent clot 1
• Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk stigmata—never epinephrine injection alone 1, 3
• Endoscopy privileges should be reserved for practitioners properly trained according to established credentialing recommendations 2
• Support staff trained to assist in endoscopy should be available for urgent endoscopy 2

Post-Endoscopic Care

Administer high-dose PPI therapy for exactly 72 hours after successful endoscopic therapy for high-risk stigmata. 1

• Continue oral PPI twice daily through 14 days, then once daily 1
• Admit high-risk patients to a monitored setting for at least the first 24 hours 1
• Routine second-look endoscopy is not recommended 2

Management of Recurrent Bleeding

Treat recurrent ulcer bleeding with repeat endoscopic therapy, and consider interventional radiology or surgery if bleeding persists. 1

• Early involvement of appropriate services, including surgery, interventional radiology, and gastroenterology, is critical for definitive management 1
• A common strategy after failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained 5

Resumption of Antithrombotic Therapy

Restart aspirin when cardiovascular risks outweigh GI risks, usually within 7 days for secondary prophylaxis. 1

• Prefer aspirin plus PPI therapy over clopidogrel alone to reduce rebleeding risk 1
• Resume anticoagulation as soon as possible when thromboembolic risk is high, once hemostasis is secured 1, 3
• Common pitfall: Do not withhold aspirin indefinitely in patients requiring cardiovascular prophylaxis—restart early with PPI coverage 1
• In patients with massive pulmonary embolism and concurrent UGIB, the risk of PE-related death outweighs rebleeding risk once hemostasis is secured 3

Secondary Prevention

Test all patients for Helicobacter pylori and provide eradication therapy if positive to reduce ulcer recurrence and rebleeding. 2, 1

• Avoid NSAID use in patients with a history of upper GI bleeding 1
• Patients with established high-risk cardiovascular disease should not stop aspirin therapy in the setting of GI bleeding 1

Multidisciplinary Coordination

Hospitals should develop institution-specific protocols for multidisciplinary management, with access to an endoscopist trained in endoscopic hemostasis. 2, 1

• Involve gastroenterology, surgery, interventional radiology, and critical care simultaneously for complex cases 1, 3
• A multidisciplinary team with a prespecified chain of notification should be in place at hospitals with endoscopy services 2

Critical Pitfalls to Avoid

• Never use epinephrine injection alone—always combine with thermal or mechanical therapy 1, 3
• Do not over-transfuse—use a restrictive strategy to improve outcomes except in cardiovascular disease 1
• Do not routinely give platelets for antiplatelet therapy, as there is no evidence of benefit and potential for harm 1
• Do not use systemic thrombolytic therapy in patients with active bleeding 3