What is the management for an adult patient with a history of chronic steroid use for conditions like rheumatoid arthritis or lupus, presenting with upper gastrointestinal bleeding secondary to steroid use?

Management of Upper Gastrointestinal Bleeding Secondary to Steroid Use

Manage steroid-induced upper GI bleeding identically to other nonvariceal upper GI bleeding, with immediate high-dose IV proton pump inhibitor therapy, urgent endoscopy within 24 hours, and combination endoscopic hemostasis for high-risk lesions—steroids increase bleeding risk but do not change the fundamental treatment approach. 1, 2

Initial Resuscitation

• Place two large-caliber IV lines and begin crystalloid resuscitation immediately, targeting heart rate <100 bpm, systolic blood pressure >100 mmHg, and urine output >30 mL/hour 1, 2
• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease; use a higher threshold (likely 90-100 g/L) for those with cardiac comorbidities 1, 2
• Insert urinary catheter and use automated blood pressure monitoring for patients with severe bleeding 1
• Consider endotracheal intubation before endoscopy if massive hematemesis is present to protect the airway 1

Risk Stratification

• Calculate the Glasgow Blatchford score immediately—patients with scores ≤1 can be managed as outpatients without hospitalization or urgent endoscopy 1, 2
• Recognize that age >60 years, shock (HR >100 and SBP <100), hemoglobin <100 g/L, and significant comorbidities (including the underlying condition requiring steroids) are major risk factors for rebleeding and mortality 1
• The combination of corticosteroids with NSAIDs dramatically increases bleeding risk compared to either agent alone 3—actively search medication history for concurrent NSAID use, which is common and often over-the-counter

Immediate Pharmacologic Management

• Start pantoprazole 80 mg IV bolus immediately upon presentation, even before endoscopy, followed by continuous infusion at 8 mg/hour 1, 4, 5
• Administer erythromycin 250 mg IV 30-60 minutes before endoscopy to improve gastric visualization by promoting gastric emptying 4, 2
• Do NOT give NSAIDs, aspirin, or traditional analgesics for abdominal pain—these worsen bleeding and are absolutely contraindicated 4

Endoscopic Management

• Perform endoscopy within 24 hours of presentation after initial stabilization for all hospitalized patients 6, 1, 2
• Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or mechanical clips) for high-risk stigmata including active bleeding, visible vessel, or adherent clot 6, 1
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1
• For adherent clots, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion 1
• Do NOT perform endoscopic therapy for low-risk stigmata (clean-based ulcer or flat pigmented spot) 1

Post-Endoscopic Management

• Continue high-dose PPI infusion (8 mg/hour) for exactly 72 hours after successful endoscopic hemostasis in patients with high-risk stigmata 1, 4, 5
• Transition to oral PPI 40 mg twice daily for 14 days, then once daily for 6-8 weeks total to allow complete mucosal healing 1, 4, 5
• Keep high-risk patients hospitalized for at least 72 hours after endoscopic hemostasis 1
• Feed low-risk patients within 24 hours after endoscopy 6

H. pylori Management

• Test all patients for H. pylori infection using methods appropriate for the acute bleeding context (recognizing that acute bleeding increases false-negative rates) 6, 1
• Provide eradication therapy if H. pylori is present, as this reduces ulcer recurrence and rebleeding rates 6, 1, 4
• Consider confirmatory testing outside the acute context if initial testing is negative 6

Management of Recurrent Bleeding

• Attempt repeat endoscopic therapy for recurrent bleeding after initial successful hemostasis 1
• If second endoscopic attempt fails, proceed to interventional radiology (angiography with embolization) or surgery 2

Critical Steroid-Specific Considerations

• Corticosteroids are a well-established risk factor for GI bleeding, particularly when combined with NSAIDs or anticoagulants 3—the risk increases 4-5 fold with this combination
• Continue necessary steroid therapy during acute bleeding management—do not abruptly discontinue steroids as this creates additional risks for the underlying condition (e.g., adrenal crisis in chronic users) [@general medical knowledge@]
• Initiate PPI prophylaxis indefinitely for patients requiring continued steroid therapy after the acute bleeding episode resolves 1, 4, 7

Antiplatelet/Anticoagulant Management

• If the patient requires aspirin for cardiovascular prophylaxis, restart it when cardiovascular risks outweigh GI risks (usually within 7 days) with concomitant PPI therapy 1, 4
• Use aspirin plus PPI rather than clopidogrel alone to reduce rebleeding risk 1
• Avoid omeprazole specifically in patients taking clopidogrel due to CYP2C19 interaction—use pantoprazole instead 8
• Continue PPI therapy indefinitely for patients requiring antiplatelet or anticoagulant therapy 1

Common Pitfalls to Avoid

• Do not delay endoscopy in patients receiving anticoagulants—proceed after initial stabilization 1
• Do not perform routine second-look endoscopy—it is not recommended except in highly selected high-risk cases 6, 1
• Do not use promotility agents routinely before endoscopy except erythromycin in specific circumstances 1
• Recognize that symptoms are poor predictors of serious lesions—complications may occur without warning symptoms 3
• PPI therapy is adjunctive to endoscopic hemostasis, not a replacement—never delay endoscopy because PPIs have been started 4