What is the approach and management for a patient presenting with upper gastrointestinal (UGI) bleeding, potentially with a history of peptic ulcer disease, non-steroidal anti-inflammatory drugs (NSAIDs) use, or liver disease?

Approach and Management of Upper Gastrointestinal Bleeding

Immediate Resuscitation (First Priority)

Establish two large-bore (18-gauge or larger) IV lines in the antecubital fossae and begin aggressive crystalloid resuscitation with 1-2 liters of normal saline or Ringer's lactate before any diagnostic procedures. 1 Target hemodynamic stabilization with heart rate <100 bpm, systolic blood pressure >100 mmHg, and urine output >30 mL/hour. 1 Insert a urinary catheter for hourly monitoring and use automated blood pressure monitoring for continuous assessment. 1

• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease; use a higher threshold (typically <100 g/L) for patients with cardiovascular disease. 2, 1
• If shock persists after 1-2 liters of crystalloid, plasma expanders are necessary as ≥20% of blood volume has been lost. 2
• Correct coagulopathy early with fresh frozen plasma if INR >1.5 and platelets if count <50,000/µL. 3
• For patients on anticoagulation with life-threatening hemorrhage, use specific reversal agents: andexanet alfa for apixaban/rivaroxaban, idarucizumab for dabigatran. 1

Critical pitfall: In patients with high-volume bleeding, intubate before endoscopy to protect the airway. 2 Always consider an upper GI source even when patients present with bright red blood per rectum if they have hemodynamic instability, as failure to do so leads to delayed diagnosis. 2

Risk Stratification (Immediate, Parallel to Resuscitation)

Calculate the Glasgow Blatchford score immediately upon presentation. 2, 1 Patients with a score ≤1 can be managed as outpatients without hospitalization or urgent endoscopy. 2, 1 This is the most validated tool for identifying very low-risk patients.

High-risk features requiring ICU admission include: 2

• Age >60 years
• Shock (heart rate >100 bpm and systolic BP <100 mmHg)
• Hemoglobin <100 g/L
• Significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure)

Do not use the AIMS65 score for risk stratification as it is not recommended. 2

Pre-Endoscopic Pharmacologic Management

Start intravenous proton pump inhibitor therapy immediately upon presentation. 2, 4 Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy. 2

• Administer erythromycin 250 mg IV 30-60 minutes before endoscopy as a prokinetic agent to improve visualization. 5
• Do not use H2-receptor antagonists as they are ineffective for acute ulcer bleeding. 3
• Do not use tranexamic acid. 5

For suspected variceal bleeding (patients with cirrhosis): 2

• Start vasoactive drug therapy immediately: 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
• Administer antibiotic prophylaxis with ceftriaxone or norfloxacin

Endoscopic Management (Within 24 Hours)

Perform upper endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization. 6, 2, 1 Endoscopy successfully identifies the bleeding source in 95% of cases and allows simultaneous therapeutic intervention. 2

For high-risk patients with persistent hemodynamic instability (shock index >1), consider earlier endoscopy within 12 hours. 2 If the patient remains unstable after initial resuscitation, perform CT angiography immediately to localize bleeding before endoscopy (sensitivity 79-95%, specificity 95-100%). 2

Endoscopic Therapy Based on Lesion Characteristics

For high-risk stigmata (Forrest Ia/Ib active bleeding, Forrest IIa visible vessel), use combination endoscopic therapy: epinephrine injection PLUS a second modality. 2, 1, 3 Options for the second modality include:

• Contact thermal coagulation (thermocoagulation)
• Sclerosant injection
• Through-the-scope clips
• Over-the-scope clips (OTSCs) 5

Never use epinephrine injection alone—this provides suboptimal efficacy and must always be combined with thermal or mechanical therapy. 2, 3

For adherent clots (Forrest IIb): Perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying lesion. 2

For low-risk stigmata (Forrest IIc flat pigmented spot, Forrest III clean-based ulcer): Do not perform endoscopic hemostatic therapy. 2

TC-325 hemostatic powder spray can be used as temporizing therapy but not as sole treatment in actively bleeding ulcers. 2, 5

Routine second-look endoscopy is not recommended, though it may be useful in selected high-risk patients. 2, 3

Post-Endoscopic Pharmacologic Management

For patients with high-risk stigmata who underwent successful endoscopic hemostasis, administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours. 2, 1 This regimen reduces rebleeding rates and mortality compared to placebo or H2-receptor antagonists. 2

After 72 hours: 2, 1

• Continue oral PPI twice daily for 14 days
• Then once daily for duration dependent on the bleeding lesion
• Continue PPI indefinitely in patients requiring antiplatelet or anticoagulant therapy for cardiovascular prophylaxis

For variceal bleeding: Continue vasoactive drugs and antibiotics for 3-5 days. 2

Management of Rebleeding

If clinical evidence of rebleeding occurs after initial successful treatment, repeat endoscopy with hemostasis. 3 Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality. 2

If second endoscopic attempt fails: 3

• Consider transcatheter arterial embolization
• Consider surgery as last resort
• For variceal rebleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 2

Helicobacter pylori Management

Test all patients with peptic ulcer bleeding for H. pylori using endoscopic biopsy, urea breath test, or stool antigen. 2, 1, 3 Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease. 2

If H. pylori is detected, initiate 14-day triple therapy immediately: 3

• PPI twice daily
• Clarithromycin 500 mg twice daily
• Amoxicillin 1000 mg twice daily

Critical pitfall: Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary. 2

Continue PPI for 4 weeks total after H. pylori eradication for uncomplicated duodenal ulcers, or 6-8 weeks for bleeding duodenal ulcers. 3

NSAID and Antiplatelet Management

Discontinue all NSAIDs immediately—this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 3 Avoid all NSAIDs and COX-2 inhibitors during active bleeding. 3

For patients requiring NSAIDs after recovery: Use a PPI with a cyclooxygenase-2 inhibitor to reduce rebleeding. 6, 2

For patients requiring secondary cardiovascular prophylaxis, restart aspirin when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). 6, 2, 1 Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding. 6, 2

Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs). 2, 1 For unstable hemorrhage on warfarin, reverse immediately with prothrombin complex concentrate and vitamin K. 3

Hospital Management and Discharge

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis. 6, 2 Admit high-risk patients to a monitored setting for at least the first 24 hours. 2

Feed low-risk patients within 24 hours after endoscopy, as timing does not influence hospital course. 3 All patients with upper GI bleeding can be fed within 24 hours. 2

Discharge low-risk patients immediately after stabilization (those with Mallory-Weiss tear or ulcer with clean base/flat spot). 3 Patients with Glasgow Blatchford score ≤1 can be managed as outpatients without hospitalization. 2, 1