What are the initial management steps for a patient with upper GI bleeding, potentially complicated by anticoagulant use or underlying conditions like bleeding disorders or liver disease?

Management of Upper Gastrointestinal Bleeding

Initiate immediate resuscitation with crystalloid fluids for hemodynamically unstable patients, transfuse at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start high-dose IV PPI therapy, perform endoscopy within 24 hours, and use combination endoscopic therapy for high-risk lesions. 1, 2

Initial Resuscitation and Hemodynamic Stabilization

Place two large-bore IV cannulae in the anticubital fossae and rapidly infuse 1-2 liters of crystalloid (normal saline or balanced crystalloids like Ringer's lactate) targeting falling pulse rate, rising blood pressure, and urine output >30 mL/hour. 2, 3 Avoid overly aggressive fluid resuscitation targeting normal blood pressure, as this may exacerbate bleeding and disrupt coagulation. 2

Airway Protection

Consider elective or emergent tracheal intubation for airway protection prior to endoscopy in patients with massive hematemesis or concomitant hepatic encephalopathy. 1, 2 This is particularly critical when high-volume bleeding is present. 2

Blood Transfusion Strategy

Transfuse red blood cells at hemoglobin <80 g/L for patients without cardiovascular disease. 1, 2 This restrictive strategy is based on evidence showing improved outcomes compared to liberal transfusion. 1

Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (e.g., ischemic heart disease, heart failure). 1, 2 The exact threshold is not rigidly defined but typically ranges from 90-100 g/L based on clinical context. 1

Risk Stratification

Use the Glasgow Blatchford Score (GBS) ≤1 to identify very low-risk patients who can be safely managed as outpatients without hospitalization or urgent endoscopy. 1, 2 These patients have very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention. 1, 4

Do not use the AIMS65 prognostic score for risk stratification, as evidence does not support its utility for identifying low-risk patients. 1

High-Risk Features Requiring ICU Admission

• Age >60 years with shock (heart rate >100 bpm and systolic blood pressure <100 mmHg) 2
• Hemoglobin <100 g/L 2
• Significant comorbidities: renal insufficiency, liver disease, disseminated malignancy, ischemic heart disease, heart failure 2
• Fresh red blood in emesis or nasogastric aspirate 5

Pre-Endoscopic Pharmacological Management

Start high-dose IV PPI therapy immediately upon presentation: 80 mg IV bolus followed by 8 mg/hour continuous infusion. 1, 2 This may downstage endoscopic lesions and decrease the need for endoscopic intervention, but should not delay endoscopy. 1, 2

Do not use promotility agents (e.g., metoclopramide) routinely before endoscopy. 1 However, consider IV erythromycin 250 mg given 30-120 minutes prior to endoscopy in patients with clinically severe or ongoing active bleeding, as this significantly improves endoscopic visualization and reduces need for second-look endoscopy. 6

Nasogastric Tube Placement

Consider nasogastric tube placement in selected patients, as findings may have prognostic value (presence of bright blood is an independent predictor of rebleeding), but do not use routinely. 1, 5

Management of Anticoagulation

Do not delay endoscopy for reversal of anticoagulation in patients receiving vitamin K antagonists or DOACs. 1, 2 Proceed with endoscopy while simultaneously correcting coagulopathy. 2

Reversal of Warfarin in Severe Hemorrhage

For severe hemorrhage in patients on warfarin, administer 5-25 mg (rarely up to 50 mg) parenteral vitamin K1. 7 In emergency situations, administer 200-500 mL fresh frozen plasma or commercial Factor IX complex to return clotting factors to normal. 7 Note that vitamin K1 takes a minimum of 1-2 hours for measurable improvement in prothrombin time. 8

Consider transfusion of fresh frozen plasma and platelets in cirrhotic patients with significant coagulopathy and/or thrombocytopenia. 1

Special Considerations for Cirrhosis and Variceal Bleeding

Admit patients with suspected acute variceal hemorrhage to an ICU setting. 1 Maintain hemoglobin at approximately 8 g/dL, as vigorous resuscitation leads to increases in portal pressure, more rebleeding, and higher mortality. 1

Start short-term prophylactic antibiotics in all cirrhotic patients with GI hemorrhage: norfloxacin 400 mg PO BID for 7 days (or IV ciprofloxacin if oral not possible). 1 In patients with advanced cirrhosis (Child B/C), IV ceftriaxone 1 g/day is more effective than oral norfloxacin. 1 This decreases bacterial infections, increases survival, and reduces early rebleeding. 1

Initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) as soon as variceal bleeding is suspected, even before endoscopy. 1, 2 Continue for 3-5 days. 2

Endoscopic Management Timing

Perform endoscopy within 24 hours of presentation for all admitted patients after initial hemodynamic stabilization. 1, 2, 6, 4 This is the standard recommendation with strong evidence. 1

Consider earlier endoscopy (within 12 hours) for high-risk patients with:

• Hemodynamic instability persisting despite resuscitation 1, 6
• In-hospital bloody emesis or nasogastric aspirate 6
• Contraindication to interruption of anticoagulation 6

Do not perform urgent (<12 hours) endoscopy routinely, as patient outcomes are not improved compared to early (≤24 hours) endoscopy. 4

Endoscopic Therapy Based on Forrest Classification

High-Risk Stigmata (Forrest Ia, Ib, IIa)

Use combination endoscopic therapy: epinephrine injection PLUS a second modality (contact thermal coagulation, mechanical therapy such as clips, or sclerosant injection). 1, 2, 4 Never use epinephrine injection alone, as it provides suboptimal efficacy. 1, 2, 6, 4

For actively bleeding ulcers (Forrest Ia, Ib), use epinephrine injection plus contact thermal or mechanical therapy. 4

For nonbleeding visible vessel (Forrest IIa), use contact or noncontact thermal therapy, mechanical therapy, or sclerosant injection, each as monotherapy or combined with epinephrine. 4

Adherent Clot (Forrest IIb)

Perform targeted irrigation to attempt clot dislodgement, then treat any underlying active bleeding or visible vessel with appropriate endoscopic therapy. 1, 2 The role of endoscopic therapy for adherent clots is controversial; intensive PPI therapy alone may be sufficient if clot cannot be removed. 1

Low-Risk Stigmata (Forrest IIc, III)

Do not perform endoscopic hemostatic therapy for flat pigmented spots (Forrest IIc) or clean-based ulcers (Forrest III). 1, 2, 6 These patients can be discharged on standard oral PPI therapy once daily. 6

Post-Endoscopic Pharmacological Management

Administer high-dose PPI therapy for exactly 72 hours in patients with high-risk stigmata who underwent successful endoscopic therapy: 80 mg IV bolus followed by 8 mg/hour continuous infusion. 1, 2, 4 This is when rebleeding risk is highest. 9

After 72 hours, continue oral PPI twice daily for 14 days, then once daily. 2, 5 Duration depends on the nature of the bleeding lesion and whether H. pylori eradication is achieved. 5

Alternative regimens include high-dose PPI as IV bolus dosing (twice-daily) or oral formulation (twice-daily). 4

Management of Recurrent Bleeding

For recurrent bleeding after initial endoscopic therapy, attempt repeat endoscopic therapy, preferably using cap-mounted clips. 2, 4

If second endoscopic attempt fails, proceed to transcatheter angiographic embolization (TAE). 2, 4 Surgery is indicated when TAE is not locally available or after failed TAE. 4

Do not perform routine second-look endoscopy. 1, 5, 6

Secondary Prevention and Long-Term Management

H. pylori Testing and Eradication

Test all patients with peptic ulcer bleeding for H. pylori in the acute setting and initiate eradication therapy if positive. 5, 6 Retest patients with negative acute testing, as false-negative rates are increased during acute bleeding. 5 Document successful eradication, as this reduces ulcer recurrence and rebleeding. 5, 6

Restarting Antiplatelet Therapy

For patients requiring low-dose aspirin for secondary cardiovascular prophylaxis, do not interrupt aspirin. 4 If interrupted, restart as soon as possible, preferably within 3-5 days. 4

For patients with high-risk peptic ulcer (Forrest Ia, Ib, IIa, IIb), restart aspirin by day 3 after index endoscopy, provided adequate hemostasis has been established. 6 For low-risk ulcers (Forrest IIc, III), resume immediately following endoscopy. 6

Use aspirin plus PPI therapy rather than clopidogrel alone to reduce rebleeding. 2, 5

Restarting Anticoagulation

Resume anticoagulation as soon as bleeding is controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. 4 Consider the rapid onset of action of DOACs compared to vitamin K antagonists. 4

Continue PPI therapy indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis. 2, 5

Critical Pitfalls to Avoid

• Never use epinephrine injection as monotherapy—always combine with thermal or mechanical therapy. 1, 2, 6, 4
• Do not delay endoscopy for correction of coagulopathy in anticoagulated patients. 1, 2
• Do not perform overly aggressive fluid resuscitation targeting normal blood pressure in variceal bleeding, as this increases portal pressure and worsening bleeding. 1, 2
• Always consider upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum. 2 Failure to do so leads to delayed diagnosis and treatment. 2
• Do not forget antibiotic prophylaxis in cirrhotic patients, as this significantly reduces mortality. 1