What is the best approach for managing a patient with upper GI bleeding, possibly due to peptic ulcers, and a history of anticoagulant use?

Management of Upper Gastrointestinal Bleeding

For patients with upper GI bleeding, initiate immediate resuscitation with crystalloids targeting hemodynamic stability, transfuse at hemoglobin <80 g/L (higher if cardiovascular disease present), start high-dose IV PPI therapy immediately, perform endoscopy within 24 hours after stabilization, and use combination endoscopic therapy (epinephrine injection plus thermal coagulation or clips) for high-risk stigmata lesions. 1, 2

Initial Resuscitation and Stabilization

Resuscitation must occur before any diagnostic procedures and focuses on restoring end-organ perfusion. 3, 2

• Place two large-caliber IV lines in the antecubital fossae for all patients with hemodynamic compromise 3
• Administer crystalloid fluids (most patients require 1-2 liters of saline) to achieve heart rate reduction, blood pressure increase, central venous pressure 5-10 cm H₂O, and urine output >30 mL/hour 3, 2
• If shock persists after 2 liters, plasma expanders are necessary as ≥20% of blood volume has been lost 3
• Insert urinary catheter and measure hourly volumes for patients with severe bleeding 3
• In patients with high-volume bleeding, intubate before endoscopy to protect the airway 3

Blood Transfusion Strategy

Use a restrictive transfusion approach based on cardiovascular status. 1, 2

• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 1, 2
• This restrictive strategy (hemoglobin <80 g/L) improves outcomes and is supported by moderate-quality evidence 2

Risk Stratification

Identify very low-risk patients who can be managed as outpatients and high-risk patients requiring intensive monitoring. 1, 2

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who can be managed as outpatients without hospitalization or urgent endoscopy 1, 2
• High-risk features include: age >60 years, shock (heart rate >100 bpm and systolic blood pressure <100 mmHg), hemoglobin <100 g/L, significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure) 3
• Admit high-risk patients to a monitored setting for at least the first 24 hours 3

Anticoagulation Management in Active Bleeding

Do not delay endoscopy in patients receiving anticoagulants, but consider reversal for life-threatening bleeding. 1

For Patients on Warfarin:

• Withhold warfarin to facilitate hemostasis 1
• For life-threatening bleeding with INR >2.5, administer 4-factor prothrombin complex concentrate (PCC) plus low-dose vitamin K 1
• Do not delay endoscopy for life-threatening bleeding until normalization of INR 1
• Avoid higher doses of vitamin K (>5 mg) in patients with high thromboembolic risk 1

For Patients on Dual Antiplatelet Therapy (DAPT):

• Continue aspirin and withhold clopidogrel in patients on DAPT with aspirin and clopidogrel who are receiving PPI infusion 1
• Do not withhold both antiplatelet agents simultaneously due to high risk of stent thrombosis 1
• Resume P2Y12 receptor inhibitor (clopidogrel) within 5 days after endoscopic hemostasis in patients with drug-eluting coronary stents 1
• Discuss with cardiologist before discontinuation, particularly in patients with acute coronary syndrome within 6 months 1

For Patients on Single Antiplatelet Therapy:

• Do not transfuse platelets in patients receiving antiplatelet agents with GI bleeding, as it does not reduce rebleeding and may be associated with higher mortality 1

Pre-Endoscopic Pharmacologic Management

Start high-dose IV PPI therapy immediately upon presentation, before endoscopy. 1, 2

• Administer PPI therapy immediately to downstage endoscopic lesions and decrease the need for endoscopic intervention 1, 2
• Pre-endoscopic PPI should not delay endoscopy 1, 2
• Do not use H2-receptor antagonists for acute ulcer bleeding 1
• Do not routinely use somatostatin or octreotide for acute ulcer bleeding (unless suspected variceal bleeding) 1
• Do not use promotility agents routinely before endoscopy 1, 2

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial stabilization. 1, 3, 2

• Consider earlier endoscopy (within 12 hours) for high-risk patients with hemodynamic instability after initial resuscitation 1, 3, 2
• If patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy 3
• Endoscopy successfully identifies the bleeding source in 95% of cases and allows simultaneous therapeutic intervention 3

Endoscopic Therapy Based on Lesion Characteristics

Endoscopic hemostatic therapy is mandatory for high-risk stigmata and contraindicated for low-risk stigmata. 1, 2

High-Risk Stigmata (Active Bleeding or Visible Vessel):

• Use combination therapy: epinephrine injection PLUS thermal coagulation (heater probe or multipolar coagulation) or sclerosant injection 1, 2
• Through-the-scope clips are an effective alternative 1, 2
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with another method 1, 2
• No single method of thermal coaptive therapy is superior to another 1
• TC-325 (hemostatic powder) may be used as temporizing therapy when conventional therapies are not available or fail, but not as sole treatment 1

Adherent Clot in Ulcer Bed:

• Perform targeted irrigation to attempt dislodgement, with appropriate treatment of the underlying lesion 1, 2
• Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient 1

Low-Risk Stigmata (Clean-Based Ulcer or Nonprotuberant Pigmented Dot):

• Do not perform endoscopic hemostatic therapy 1, 2

Post-Endoscopic Pharmacologic Management

After successful endoscopic therapy for high-risk stigmata, administer high-dose PPI therapy for exactly 72 hours. 1, 3, 2

• Administer PPI as 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours 3, 2
• This regimen reduces rebleeding rates, mortality, and need for surgery compared to H2-receptor antagonists or placebo 3
• After 72 hours, continue oral PPI twice daily through day 14, then once daily for duration based on the underlying cause 1, 2
• Patients should be discharged with a prescription for single daily-dose oral PPI for duration as dictated by the underlying cause 1

Post-Endoscopic Care and Monitoring

High-risk patients require hospitalization for at least 72 hours after endoscopic hemostasis. 1, 2

• Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours 1, 2
• Low-risk patients after endoscopy can be fed within 24 hours and may be discharged promptly 1, 2
• Routine second-look endoscopy is not recommended 1, 2

Management of Rebleeding

Repeat endoscopic therapy is the first-line approach for rebleeding. 1, 2

• A second attempt at endoscopic therapy is generally recommended in cases of rebleeding 1, 2
• Seek surgical consultation for patients for whom endoscopic therapy has failed 1
• Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed 1

Helicobacter pylori Testing and Eradication

All patients with bleeding peptic ulcers must be tested for H. pylori and receive eradication therapy if positive. 1, 3, 2

• Test all patients with bleeding peptic ulcers for H. pylori and provide eradication therapy if present, with confirmation of eradication 1, 3, 2
• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 3, 2
• Testing during acute bleeding has increased false-negative rates; repeat negative H. pylori diagnostic tests obtained in the acute setting 1, 2

Resumption of Antiplatelet and Anticoagulant Therapy

Resume aspirin early when cardiovascular risks outweigh GI risks, typically within 7 days. 1, 3, 2

For Patients Requiring Aspirin:

• Resume aspirin as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding, usually within 7 days 1, 3, 2
• In a randomized trial, patients who resumed aspirin immediately after endoscopic hemostasis had 10 times lower all-cause mortality (1.3% vs 12.9%) despite numerically higher 30-day rebleeding rates 1

For Patients Requiring NSAIDs:

• Use a COX-2 inhibitor plus PPI (not COX-2 inhibitor alone or traditional NSAID plus PPI) to reduce rebleeding risk 1, 2
• Recognize that traditional NSAID plus PPI or COX-2 inhibitor alone is still associated with clinically important risk for recurrent ulcer bleeding 1

For Patients Requiring Antiplatelet or Anticoagulant Therapy:

• Use PPI therapy for all patients with previous ulcer bleeding who require single or dual antiplatelet therapy 1, 2
• Use PPI therapy for patients with previous ulcer bleeding requiring continued anticoagulant therapy (vitamin K antagonists, DOACs) 1, 2

Critical Pitfalls to Avoid

• Never use epinephrine injection alone for endoscopic therapy—always combine with thermal or mechanical therapy 1, 2
• Do not delay endoscopy in patients receiving anticoagulants 1, 2
• Do not transfuse platelets in patients on antiplatelet agents with GI bleeding 1
• Do not withhold both antiplatelet agents simultaneously in patients on DAPT due to high risk of stent thrombosis 1
• Always consider upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum 3
• Do not use H2-receptor antagonists for acute ulcer bleeding 1