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?

Management of Upper Gastrointestinal Bleeding

Initial Resuscitation and Stabilization

Immediately 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, targeting hemodynamic stability (heart rate <100 bpm, systolic BP >100 mmHg, urine output >30 mL/hour) before any diagnostic procedures. 1, 2

• Insert a urinary catheter to monitor hourly urine output with a target of >30 mL/hour 1, 2
• Use automated blood pressure monitoring for continuous pulse and arterial pressure measurement 1
• If shock persists after 1-2 liters of crystalloid, plasma expanders are necessary as ≥20% of blood volume has been lost 1
• Target central venous pressure of 5-10 cm H₂O in adequately resuscitated patients 1, 2
• For patients with massive bleeding and altered mental status, intubate before endoscopy to protect the airway 1

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin is <80 g/L in patients without cardiovascular disease 3, 1
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease 3, 1
• Correct coagulopathy with fresh frozen plasma if INR >1.5 and platelets if count <50,000/µL 4

Risk Stratification

Calculate the Glasgow Blatchford score immediately upon presentation; patients with a score ≤1 can be safely managed as outpatients without hospitalization or urgent endoscopy. 1, 2

High-Risk Features Requiring ICU Admission

• Age >60 years 1
• Shock (heart rate >100 bpm and systolic blood pressure <100 mmHg) 1
• Hemoglobin <100 g/L 1
• Significant comorbidities including renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, or heart failure 1
• Fresh red blood in emesis or nasogastric aspirate 1

Common Pitfall: Always consider an upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum, as failure to do so leads to delayed diagnosis and treatment 1. Suggestive findings include brisk rectal bleeding with hemodynamic compromise, history of peptic ulcer disease, portal hypertension, elevated blood urea/creatinine ratio, and use of antiplatelet drugs 1.

Pre-Endoscopic Pharmacological Management

Start intravenous proton pump inhibitor therapy immediately upon presentation with an 80 mg IV bolus of pantoprazole. 1, 4

• Pre-endoscopic PPI therapy may downstage endoscopic lesions and decrease the need for intervention, but should not delay endoscopy 1
• Do not use H2-receptor antagonists as they are ineffective for acute ulcer bleeding 4
• Do not routinely use promotility agents before endoscopy 1

Special Considerations for Suspected Variceal Bleeding

• If cirrhosis or portal hypertension is suspected, initiate 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 1
• Administer antibiotic prophylaxis (ceftriaxone or norfloxacin) in patients with cirrhosis and suspected variceal bleeding 1

Endoscopic Management

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

• For high-risk patients with hemodynamic instability (shock index >1), consider earlier endoscopy within 12 hours 1
• Endoscopy successfully identifies the bleeding source in 95% of cases and allows simultaneous therapeutic intervention 1, 4
• Do not delay endoscopy in patients receiving anticoagulants (warfarin or DOACs) 1, 2

CT Angiography for Unstable Patients

• If the patient remains hemodynamically unstable after initial resuscitation (shock index >1), consider urgent CT angiography to localize bleeding before planning endoscopic or radiological therapy 1
• CT angiography has a sensitivity of 79-95% and specificity of 95-100% for detecting active bleeding 1
• Use a multiphase CT protocol including noncontrast, late arterial, and venous phases 1

Endoscopic Therapy Based on Lesion Characteristics

Use combination endoscopic therapy with epinephrine injection PLUS a second hemostasis modality (thermal coagulation, sclerosant injection, or mechanical clips) for high-risk stigmata including active bleeding (Forrest Ia/Ib) or visible vessel (Forrest IIa). 3, 1, 2, 4

• Critical Pitfall: Never use epinephrine injection alone, as it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 3, 1
• Thermocoagulation or sclerosant injection plus epinephrine are recommended first-line options 1
• Through-the-scope clips are also effective 1
• TC-325 hemostatic powder is suggested as temporizing therapy but not as sole treatment in actively bleeding ulcers 1
• For adherent clots in ulcer beds, perform targeted irrigation to attempt dislodgement with appropriate treatment of the underlying stigmata 1

Do not perform endoscopic hemostatic therapy for low-risk stigmata (clean-based ulcer or nonprotuberant pigmented dot). 1

Post-Endoscopic Pharmacological Management

Administer high-dose PPI therapy with pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours in patients with high-risk stigmata who underwent successful endoscopic hemostasis. 3, 1, 2, 4

• This regimen reduces rebleeding rates, mortality, and need for surgery compared to placebo or H2-receptor antagonists 1
• After 72 hours, continue oral PPI twice daily for 14 days, then once daily 1, 2
• For uncomplicated duodenal ulcers, continue PPI for 4 weeks total after H. pylori eradication 4
• For bleeding duodenal ulcers, extend PPI to 6-8 weeks to ensure complete mucosal healing 4

Hospital Admission Duration

• High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis 3, 1
• Low-risk patients (Mallory-Weiss tear or ulcer with clean base/flat spot) can be discharged immediately after stabilization 4
• Routine second-look endoscopy is not recommended, though it may be useful in selected high-risk patients 3, 1

Management of Rebleeding

If clinical evidence of rebleeding occurs after initial successful treatment, repeat endoscopy with hemostasis as the first-line approach. 1, 4

• For recurrent variceal bleeding, consider transjugular intrahepatic portosystemic shunt (TIPS) 1
• If second endoscopic attempt fails, consider transcatheter arterial embolization or surgery 4
• Visceral angiography can detect bleeding ≥0.5 mL/min and allows simultaneous treatment by embolization 1

Helicobacter pylori Management

Test all patients with peptic ulcer bleeding for H. pylori using endoscopic biopsy, urea breath test, or stool antigen, and provide eradication therapy if positive. 1, 2, 4

• Initiate 14-day triple therapy: PPI twice daily, clarithromycin 500 mg twice daily, and amoxicillin 1000 mg twice daily 4
• Eradication reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease 1, 2

Common Pitfall: Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context may be necessary 1.

NSAID and Antiplatelet Management

Discontinue all NSAIDs immediately, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 4

• Avoid all NSAIDs and COX-2 inhibitors during active bleeding 4
• For patients who require NSAIDs after recovery, use a PPI with a cyclooxygenase-2 inhibitor to reduce rebleeding 3, 1

Resuming Antiplatelet Therapy

Restart aspirin when cardiovascular risks outweigh gastrointestinal risks, typically within 7 days of the bleeding episode. 3, 1, 2

• Aspirin plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding 3, 1
• Continue PPI therapy indefinitely in patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis 1, 2, 4

Anticoagulation Management

• Interrupt warfarin immediately and reverse with prothrombin complex concentrate and vitamin K for unstable hemorrhage 4
• Use specific reversal agents for life-threatening hemorrhage on DOACs: andexanet alfa for apixaban or rivaroxaban, and idarucizumab for dabigatran 2
• Add PPI therapy in patients requiring continued anticoagulation after bleeding episode 4

Important Note: Pantoprazole has less interaction concern with clopidogrel compared to omeprazole and esomeprazole, which inhibit CYP2C19 and reduce clopidogrel's active metabolite 1.

Post-Endoscopic Care and Feeding

• Feed low-risk patients within 24 hours after endoscopy, as timing does not influence hospital course 1, 4
• All patients with upper GI bleeding should be fed within 24 hours if considered low risk for rebleeding 1