What is the initial management and treatment approach for a patient presenting with upper gastrointestinal bleeding (UGIB), considering potential differentials such as peptic ulcer disease, esophageal varices, and underlying medical conditions like liver disease or bleeding disorders?

Upper Gastrointestinal Bleeding: Differentials and Treatment

Immediate Resuscitation Takes Priority

For any patient with acute UGIB and hemodynamic instability, initiate resuscitation immediately with crystalloid fluids, targeting restoration of end-organ perfusion rather than normal blood pressure. 1, 2

Resuscitation Protocol

• Place two large-bore IV cannulae in the anticubital fossae for hemodynamically compromised patients 1
• Infuse 1-2 liters of normal saline or balanced crystalloids (Ringer's lactate preferred to reduce AKI risk) to achieve falling pulse rate, rising blood pressure, and adequate urine output >30 ml/h 1, 2
• Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this may exacerbate bleeding and disrupt coagulation 2
• Insert urinary catheter and monitor hourly urine volumes in severe cases 1
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement (target CVP 5-10 cm H2O) 1

Blood Transfusion Thresholds

• Transfuse red blood cells at hemoglobin <80 g/L for patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for patients with underlying cardiovascular disease 1, 2
• Give O-negative blood only in extreme circumstances with active hematemesis and shock, as rapid cross-matching is usually available 1

Risk Stratification Determines Management Pathway

Mild-to-Moderate Bleeding (Low Risk)

Patients with normal pulse and blood pressure, hemoglobin >100 g/L, age <60 years, and minimal comorbidity can be admitted to general medical ward with semi-elective endoscopy on the next available list. 1

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who may not require hospitalization or inpatient endoscopy 1, 3, 2
• Do NOT use AIMS65 score for risk stratification, as evidence does not support its utility 1, 3
• Very low-risk young patients with minor bleeding and no hemodynamic compromise can be discharged without endoscopy 1

Severe Bleeding (High Risk)

Patients aged >60 years with pulse >100 bpm, systolic BP <100 mmHg, hemoglobin <100 g/L, or significant comorbidities require close monitoring and urgent endoscopy after resuscitation. 1

• Admit to monitored setting with continuous automated vital sign monitoring 1
• Fast the patient until hemodynamically stable 1
• Identify liver disease immediately, as these patients require specific management including antibiotics and vasoactive drugs 1, 2

Pre-Endoscopic Pharmacotherapy

Proton Pump Inhibitors

Start intravenous PPI therapy immediately upon presentation to potentially downstage endoscopic lesions, but do not delay endoscopy for PPI administration. 1, 3, 2

• High-dose PPI infusion before endoscopy accelerates resolution of bleeding signs in ulcers and reduces need for endoscopic therapy 1
• Pre-endoscopic PPI does not improve mortality but may decrease need for endoscopic intervention 1, 4

Prokinetic Agents

Do not routinely use promotility agents (such as erythromycin) before endoscopy, as they should not be used routinely to increase diagnostic yield 1

Nasogastric Tube

Consider nasogastric tube placement in selected patients, as findings may have prognostic value 1, 2

Special Considerations for Variceal Bleeding

For patients with known or suspected cirrhosis and variceal bleeding, immediately initiate:

• Antibiotic prophylaxis (quinolones, cephalosporins, or carbapenems) to reduce mortality, bacterial infections, and rebleeding 1, 2, 5
• Vasoactive drugs (somatostatin analogues) before endoscopy 2, 5

Endoscopic Management

Timing of Endoscopy

Perform endoscopy within 24 hours of presentation for all admitted patients with acute UGIB. 1, 2, 6

• Endoscopy must only be performed after resuscitation is achieved, with stable blood pressure and CVP when possible 1
• Do not delay endoscopy for coagulopathy correction in patients on anticoagulants (vitamin K antagonists or DOACs) 1, 7, 3
• For cirrhotic patients with suspected varices, perform endoscopy within 12 hours after resuscitation 1

Endoscopic Therapy for High-Risk Stigmata

Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or clips) for high-risk lesions; never use epinephrine injection alone. 1, 7, 2, 4

• High-risk stigmata include: active bleeding, non-bleeding visible vessel, or adherent clot 1, 2, 4
• Effective methods include: bipolar electrocoagulation, heater probe, clips, or sclerosant combined with epinephrine 1, 4
• For esophageal varices: use banding ligation 1, 6
• For gastric varices: use tissue glue therapy 1, 6

Post-Endoscopic Management

Administer high-dose intravenous PPI therapy (bolus followed by continuous infusion) for 72 hours after successful endoscopic hemostasis in patients with high-risk stigmata. 1, 3, 2, 4

• Continue oral PPI twice daily through 14 days, then once daily 3
• Second-look endoscopy is not routinely recommended but may be useful in selected high-risk patients 1
• Hospitalize high-risk patients for at least 72 hours after endoscopic hemostasis 1

Management of Rebleeding

Recurrent Non-Variceal Bleeding

Treat recurrent bleeding after initial endoscopic therapy with a second endoscopic treatment; if bleeding persists or recurs again, proceed to interventional radiology or surgery. 4, 6, 8

Recurrent Variceal Bleeding

For variceal bleeding refractory to endoscopic treatment, consider emergency TIPS with covered stent (salvage TIPS). 1

For Child-Pugh class C (<14) or class B patients with active bleeding at endoscopy, consider early TIPS within 24-72 hours. 1

Common Differentials and Specific Management

Peptic Ulcer Disease (Most Common Non-Variceal Cause)

• Test all patients for H. pylori and provide eradication therapy if positive 1, 2
• Stop NSAIDs immediately; if must be resumed, use low-dose COX-2-selective NSAID plus PPI 1, 4
• Idiopathic ulcers require long-term anti-ulcer therapy 4

Esophageal Varices (Portal Hypertension)

• Combination of banding ligation and vasoactive therapy for 2 days is superior to vasoactive therapy alone 1
• Continue antibiotics and vasoactive drugs after endoscopic therapy 6
• 30% of bleeding in cirrhotic patients is non-variceal, so consider peptic ulcer disease even in cirrhosis 1

Mallory-Weiss Tears

• Usually self-limited and rarely require endoscopic therapy 6

Malignancy

• If upper GI cancer identified at endoscopy, prognosis depends on tumor stage and patient requires oncology referral 1

Anticoagulation and Antiplatelet Management

During Active Bleeding

Do not delay endoscopy for reversal of anticoagulation; proceed with endoscopy while simultaneously correcting coagulopathy. 1, 7, 3

After Hemostasis

For patients requiring cardiovascular prophylaxis, restart aspirin as soon as cardiovascular risks outweigh GI risks (usually within 7 days, ideally 1-3 days). 1, 2, 4

• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 1, 2
• For patients with massive PE or other high thrombotic risk, resume anticoagulation as soon as hemostasis is secured, as thrombotic death risk outweighs rebleeding risk 7

Critical Pitfalls to Avoid

• Never use epinephrine injection alone for endoscopic hemostasis—always combine with thermal therapy or clips 1, 7, 2, 4
• Do not use systemic thrombolytic therapy in patients with active GI bleeding, even with concurrent PE 7
• Do not discharge patients with high-risk stigmata early—they require 72-hour hospitalization minimum 1
• Do not forget to identify cirrhosis early, as management differs significantly with need for antibiotics, vasoactive drugs, and consideration of TIPS 1
• Do not overlook cardiovascular disease when setting transfusion thresholds—these patients need higher hemoglobin targets 1, 2