How should I manage in the emergency department a patient with an acute upper gastrointestinal bleed from a peptic ulcer and severe iron‑deficiency anemia (hemoglobin 5.9 g/dL, microcytic anemia, ferritin 8 ng/mL)?

Management of Acute Upper GI Bleed with Severe Iron Deficiency Anemia in the Emergency Department

This patient with hemoglobin 5.9 g/dL from a bleeding peptic ulcer requires immediate packed red blood cell transfusion to a target hemoglobin of 70-90 g/dL, urgent upper endoscopy for hemostasis, high-dose intravenous proton pump inhibitor therapy, and should receive iron supplementation (preferably intravenous) once bleeding is controlled. 1

Immediate Resuscitation and Transfusion Strategy

• Transfuse packed red blood cells immediately given the hemoglobin of 5.9 g/dL, which is well below the 60 g/L (6.0 g/dL) threshold where transfusion is almost always indicated. 1

• Target hemoglobin of 70-90 g/dL (7-9 g/dL) for transfusion in this acute upper GI bleed, as international consensus guidelines recommend this restrictive strategy for critically ill patients, though the actual requirement may be higher in acute UGIB due to hemodynamic instability and ongoing bleeding risk. 1

• Consider a higher transfusion threshold (80-100 g/L) if the patient has underlying cardiac disease (ischemic heart disease, heart failure, or peripheral vascular disease), as elderly patients with UGIB often have poor tolerance for severe anemia. 1

• Establish large-bore IV access, initiate crystalloid resuscitation, and monitor hemodynamic status continuously, as hemoglobin levels less than 82 g/L in UGIB patients predict elevated cardiac troponin levels. 1

Endoscopic Management

• Perform urgent upper endoscopy (ideally within 24 hours) to identify and treat the bleeding peptic ulcer with appropriate hemostatic techniques (thermal coagulation, clips, or injection therapy). 1

• Administer pre-endoscopy erythromycin to improve visualization and outcomes, as this intervention appears beneficial and is likely underused. 2

• If coagulopathy is present, correction is recommended but should not delay endoscopy in patients with mild to moderate coagulation defects. 1

Acid Suppression Therapy

• Initiate high-dose intravenous proton pump inhibitor (PPI) therapy immediately—typically an 80 mg bolus followed by continuous infusion of 8 mg/hour for 72 hours after endoscopic hemostasis. 2

• Following IV PPI, transition to high-dose oral PPI for 11 days (particularly advantageous in patients with Rockall score ≥6). 2

• Stop NSAIDs, aspirin, and other ulcerogenic medications whenever possible. 1

Iron Deficiency Management

The severe iron deficiency (ferritin 8 ng/mL, MCV 55) requires aggressive iron repletion once bleeding is controlled:

• Intravenous iron is preferred in this setting of acute GI bleeding with severe anemia, as it restores iron levels faster than oral iron, has better tolerability, and may provide superior quality of life benefits. 3, 2

• Oral iron (if chosen) is as effective as parenteral iron at restoring hemoglobin levels after peptic ulcer bleeding and both are superior to placebo, though IV iron works more rapidly. 2

• Do not delay iron supplementation—iron deficiency anemia following acute GI bleeding is frequently underdiagnosed and undertreated, with studies showing only 7.1% of patients receive IV iron and 26.7% receive oral iron despite 75% having confirmed iron deficiency. 4

• The ferritin level of 8 ng/mL is diagnostic of iron deficiency (threshold <12 μg/dL), and the microcytosis (MCV 55) confirms chronic iron depletion. 1

Post-Stabilization Considerations

• Test for Helicobacter pylori during endoscopy and treat if positive, as eradication reduces rebleeding risk. 2

• Obtain small bowel biopsies during endoscopy, as 2-3% of patients with iron deficiency anemia have celiac disease. 1

• Arrange gastroenterology follow-up, as many patients with acute GIB-related iron deficiency have no post-discharge follow-up despite persistent anemia being common. 4, 3

• Monitor hemoglobin levels closely—patients treated with IV iron achieve ≥2 g/dL increase in 94% of cases by 4 months, compared to 80% with oral iron. 4

Critical Pitfalls to Avoid

• Do not assume the peptic ulcer alone explains the iron deficiency—unless upper endoscopy reveals carcinoma or celiac disease, consider lower GI tract evaluation as dual pathology occurs in 10-15% of patients, though this can be deferred until after acute stabilization. 1

• Do not undertransfuse—while restrictive strategies are generally preferred, this patient's hemoglobin of 5.9 g/dL represents life-threatening anemia requiring immediate correction. 1

• Do not forget iron supplementation—iron deficiency persists after acute bleeding and requires specific treatment beyond transfusion alone. 4, 3, 2

• Be aware that frequent IV iron and transfusions may rarely cause iron-induced gastric mucosal injury, though this is uncommon. 5