What is the initial approach to a patient presenting with upper gastrointestinal (UGI) bleeding?

Initial Approach to Upper Gastrointestinal Bleeding

Immediately initiate aggressive volume resuscitation with crystalloids (1-2 liters of normal saline or lactated Ringer's), transfuse red blood cells when hemoglobin falls below 70-80 g/L (80 g/L threshold for cardiovascular disease), start intravenous proton pump inhibitors, and perform endoscopy within 24 hours of presentation after hemodynamic stabilization. 1, 2, 3, 4

Immediate Resuscitation (First Priority)

Hemodynamic stabilization must occur before any diagnostic procedures. 2

• Place two large-caliber IV cannulas in the antecubital fossae for all patients with hemodynamic compromise 2
• Infuse 1-2 liters of crystalloid solution (normal saline or lactated Ringer's) rapidly to correct hypovolemia and restore blood pressure 2, 3, 4
• If shock persists after 1-2 liters, plasma expanders are necessary as ≥20% of blood volume has been lost 2
• Target resuscitation endpoints: decreased heart rate, increased blood pressure, central venous pressure 5-10 cm H₂O, and urine output >30 mL/hour 2

Blood Transfusion Strategy:

• Transfuse when hemoglobin <70 g/L in patients without cardiovascular disease 1, 2, 4
• Use a higher threshold of 80 g/L for patients with cardiovascular disease (ischemic heart disease, heart failure) 1, 2
• Avoid targeting hemoglobin >100 g/L as this increases rebleeding risk 1

Airway Protection

• Intubate patients with high-volume bleeding before endoscopy to ensure airway protection 2
• This is particularly critical in patients with altered mental status or massive hematemesis 2

Monitoring Requirements

• Insert urinary catheter and measure hourly urine volumes for severe bleeding 2
• Continuously monitor pulse and blood pressure using automated monitors 2
• For patients with significant cardiac disease, measure central venous pressure to guide fluid replacement 2

Risk Stratification

Use the Glasgow Blatchford score to identify very low-risk patients (score ≤1) who can be managed as outpatients without hospitalization or urgent endoscopy. 1, 2, 4

High-risk features requiring urgent intervention include: 1, 2, 5

• Age >60 years
• Shock (heart rate >100 bpm AND systolic blood pressure <100 mmHg, or shock index ≥1)
• Hemoglobin <80 g/L
• Significant comorbidities (renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure)
• Repeated hematemesis or melena after initial presentation
• Persistent tachycardia or hypotension despite fluid resuscitation

Pharmacological Management

Start intravenous proton pump inhibitors immediately upon presentation. 1, 2, 4

• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy 2
• For suspected variceal bleeding in cirrhotic patients, initiate vasoactive drugs (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) 2
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in cirrhotic patients with suspected variceal bleeding 2, 4, 6
• Consider erythromycin (prokinetic agent) 30-60 minutes before endoscopy to aid visualization, though not routinely recommended 2, 7, 4

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization. 1, 2, 3, 4

Consider urgent endoscopy (within 12 hours) for high-risk patients with: 1, 2

• Hemodynamic instability despite resuscitation
• Shock index >1
• Persistent hypotension or tachycardia
• Suspected variceal bleeding

Do not delay endoscopy in patients on anticoagulants (warfarin or DOACs like apixaban). 1, 2

Alternative Diagnostic Approach When Endoscopy Cannot Be Performed

If the patient remains hemodynamically unstable after initial resuscitation or endoscopy cannot be performed due to massive bleeding, perform CT angiography (CTA) immediately to localize the bleeding source. 8, 1, 2

• CTA has sensitivity of 79-95% and specificity of 95-100% for detecting active bleeding 2
• Multiphase CT protocol includes noncontrast, late arterial, and venous phases 8
• If no source is identified by CTA in an unstable patient, perform immediate upper endoscopy 2

Visceral angiography is indicated for overt large bleeding in unstable patients, especially when the bleeding source is unclear or above/below the ligament of Treitz is uncertain. 8, 1

• Angiography detects bleeding rates ≥0.5 mL/min and allows simultaneous treatment by embolization 8
• Early angiography (within first 5 hours) is associated with significantly higher visualization of extravasation 8
• Angiography confirms bleeding in 72-80% of patients with clinical or CT-diagnosed UGIB 8

Endoscopic Therapy

For high-risk stigmata (active bleeding, visible vessel, adherent clot), use combination endoscopic therapy with epinephrine injection PLUS a second modality (thermal coagulation, sclerosant injection, or mechanical clips). 1, 2, 7, 3

• Never use epinephrine injection alone—it must always be combined with another method 2, 7
• Thermocoagulation and sclerosant injection are recommended; clips are also suggested 2
• For adherent clots, attempt dislodgement with irrigation and treat the underlying stigmata 2
• Endoscopic hemostasis is NOT indicated for low-risk stigmata (clean-based ulcer or flat pigmented spot) 2

Post-Endoscopic Management

For patients with high-risk stigmata who underwent successful endoscopic therapy, administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours. 1, 2

• After 72 hours, continue oral PPI twice daily for 14 days, then once daily 1, 2
• Duration of once-daily PPI depends on the nature of the bleeding lesion 2
• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 2

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, repeat endoscopic therapy is recommended. 2

• If repeat endoscopy fails, attempt transcatheter arterial embolization 3
• Proceed to surgery only if embolization fails to achieve hemostasis 3
• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 2, 4

Critical Pitfalls to Avoid

• Always consider an upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum—failure to do so leads to delayed diagnosis and treatment 2
• A negative nasogastric aspirate does NOT rule out UGIB (3-16% of patients with confirmed UGIB may have negative aspirate) 1, 5
• Do not use prothrombin complex concentrates routinely in patients taking DOACs prior to emergency procedures 1
• Do not perform routine second-look endoscopy, though it may be useful in selected high-risk patients 2
• For life-threatening hemorrhage in patients on apixaban, consider andexanet alfa as the specific reversal agent 1

Secondary Prevention

Test all patients for Helicobacter pylori and provide eradication therapy if positive, as this reduces ulcer recurrence and rebleeding. 2

• Testing during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 2
• For patients requiring NSAIDs, use a PPI with a COX-2 inhibitor to reduce rebleeding 2
• Restart aspirin when cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 2, 4
• Aspirin plus PPI is preferred over clopidogrel alone for reducing rebleeding 2
• Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy 2