How should I initially manage an adult patient with an acute upper gastrointestinal (GI) bleed, including hemodynamic stabilization, risk stratification, and special considerations for elderly patients with cardiovascular disease, renal impairment, or who are on anticoagulant or antiplatelet therapy?

Initial Management of Acute Upper GI Bleeding in Adults

Immediate Resuscitation and Hemodynamic Stabilization

Establish two large-bore peripheral IV lines immediately and begin aggressive crystalloid resuscitation with 1-2 liters of isotonic saline or lactated Ringer solution to restore blood pressure and end-organ perfusion. 1, 2

• Most patients require 1-2 liters of crystalloid; if shock persists after this volume, at least 20% of blood volume has been lost and plasma expanders are necessary 1
• Insert a urinary catheter and monitor hourly urine output (goal >30 mL/hour) in patients with severe bleeding 3, 1
• Use continuous automated blood pressure and heart rate monitoring for hemodynamically unstable patients 3, 1

Blood Transfusion Strategy

• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease 1, 4
• Use a higher hemoglobin threshold (closer to 100 g/L) for patients with underlying cardiovascular disease, including elderly patients with ischemic heart disease or heart failure 1, 5
• This restrictive transfusion strategy improves outcomes compared to liberal transfusion 1

Airway Protection

• Intubate patients with altered mental status, severe hypoxemia (oxygen saturation <85%), or massive hematemesis before endoscopy to prevent aspiration 1
• This is a critical step that must not be delayed in high-risk patients 1

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Risk Stratification

Use the Glasgow-Blatchford Score (GBS) immediately upon presentation to stratify risk. 1, 4, 5

Very Low-Risk Patients (GBS ≤1)

• Can be safely managed as outpatients with outpatient endoscopy 1, 4
• Do not require hospitalization or urgent intervention 1, 4

High-Risk Features Requiring ICU Admission

• Age >60 years 3, 1
• Shock (heart rate >100 bpm AND systolic blood pressure <100 mmHg) 3, 1
• Hemoglobin <100 g/L 3, 1
• Significant comorbidities: renal failure, liver failure, ischemic heart disease, heart failure, disseminated malignancy 3, 1
• Altered mental status 1

The Rockall score can be used after endoscopy to predict rebleeding and mortality risk, with scores >8 indicating very high mortality risk 3

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Pre-Endoscopic Pharmacological Management

Start intravenous proton pump inhibitor therapy immediately upon presentation with an 80 mg IV bolus of pantoprazole (or equivalent) followed by continuous infusion at 8 mg/hour. 1, 4, 2

• Pre-endoscopic PPI therapy downstages endoscopic lesions and decreases the need for therapeutic intervention 1
• This should not delay endoscopy 1

Suspected Variceal Bleeding (Cirrhosis Patients)

• Start 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) to all cirrhotic patients with suspected variceal bleeding 1, 6, 2

What NOT to Do

• Do not use promotility agents (erythromycin) routinely before endoscopy—they do not improve outcomes 1
• Do not routinely place nasogastric tubes 1

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Timing of Endoscopy

Perform endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization. 1, 4, 5, 2

Earlier Endoscopy (Within 12 Hours)

• Consider urgent endoscopy (within 12 hours) for high-risk patients with ongoing hemodynamic instability despite resuscitation 1, 4
• However, urgent (<12 hours) endoscopy does not improve outcomes compared to early (≤24 hours) endoscopy in most patients 4

Critical Pitfall

• Never perform endoscopy before adequate hemodynamic resuscitation and airway protection in unstable patients 1

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Endoscopic Hemostasis

High-Risk Stigmata (Active Bleeding or Visible Vessel)

Use combination endoscopic therapy: epinephrine injection PLUS a second modality (contact thermal coagulation, mechanical clips, or sclerosant injection). 1, 4, 2

• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1, 4
• Combination therapy is superior to any single treatment 3, 1

Adherent Clots

• Perform targeted irrigation to attempt clot dislodgement, then treat the underlying lesion with combination therapy 1, 4

Low-Risk Stigmata (Clean-Based Ulcer or Flat Pigmented Spot)

• Do not perform endoscopic hemostatic therapy for low-risk stigmata 1
• These patients have excellent prognosis and do not require intervention 3

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Post-Endoscopic Management

High-Dose PPI Therapy

After successful endoscopic hemostasis of high-risk lesions, continue IV pantoprazole at 8 mg/hour for exactly 72 hours total (including the pre-endoscopic period). 1, 4, 2

• After 72 hours, switch to oral PPI twice daily for 14 days, then once daily thereafter 1
• This regimen significantly reduces rebleeding rates and mortality 1

Monitoring

• Admit high-risk patients to ICU or monitored setting for at least 72 hours after endoscopic hemostasis 1
• Approximately 20% of patients will have recurrent bleeding, accounting for most morbidity and mortality 1

Helicobacter pylori Testing

• Test all patients with peptic ulcer bleeding for H. pylori and provide eradication therapy if positive 1, 2
• Eradication reduces ulcer recurrence and rebleeding rates 1
• Testing during acute bleeding may yield false-negatives; confirmatory testing after the acute phase is advisable 1

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Management of Recurrent Bleeding

If rebleeding occurs after initial successful endoscopic therapy, attempt repeat endoscopic therapy with combination techniques or cap-mounted clips. 4, 2

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

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Special Considerations for Elderly Patients with Comorbidities

Cardiovascular Disease

• Use higher hemoglobin transfusion threshold (approaching 100 g/L rather than 80 g/L) 1, 5
• Consider central venous pressure monitoring to guide fluid resuscitation in patients with significant cardiac disease, though this has not been formally studied 3
• Age >60 years and presence of ischemic heart disease or heart failure are independent risk factors for mortality 3, 1

Renal Impairment

• Renal failure is a major comorbidity that significantly increases risk of rebleeding and mortality 3, 1
• Monitor urine output closely with urinary catheter 3, 1
• Adjust medication dosing appropriately for renal function

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Anticoagulant and Antiplatelet Management

Aspirin for Secondary Cardiovascular Prevention

Do not interrupt low-dose aspirin monotherapy for secondary cardiovascular prevention during acute upper GI bleeding. 4

• If aspirin has been interrupted, restart it as soon as hemostasis is endoscopically confirmed (preferably within 3-5 days, typically within 7 days) 1, 4, 2
• Aspirin plus PPI is preferred over clopidogrel alone for reducing rebleeding 1

Warfarin

• Do not give fresh frozen plasma or vitamin K routinely 7
• If reversal is needed, use prothrombin complex concentrate (PCC) rather than fresh frozen plasma 7
• Do not delay endoscopy in patients on warfarin 1

Direct Oral Anticoagulants (DOACs)

• Do not administer PCC for DOAC reversal 7
• Do not give idarucizumab for dabigatran or andexanet alfa for rivaroxaban/apixaban during acute GI bleeding 7
• Do not delay endoscopy in patients on DOACs 1
• Resume anticoagulation as soon as bleeding is controlled, preferably within or soon after 7 days, based on thromboembolic risk 4
• Consider the rapid onset of action of DOACs compared to warfarin when restarting 4

Dual Antiplatelet Therapy (DAPT)

• Do not give platelet transfusions 7
• Continue aspirin but consider temporary interruption of P2Y12 inhibitor (clopidogrel, ticagrelor) 1

Long-Term Management

• All patients with previous ulcer bleeding who require ongoing antiplatelet or anticoagulant therapy should receive indefinite PPI therapy 1

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Common Pitfalls to Avoid

• Never delay airway protection in severely hypoxemic or altered patients—intubate before endoscopy 1
• Never use epinephrine injection alone for endoscopic hemostasis—always combine with thermal or mechanical therapy 1, 4
• Never perform endoscopy before adequate hemodynamic resuscitation 1
• Never interrupt aspirin in patients on monotherapy for secondary cardiovascular prevention 4
• Always consider an upper GI source in patients presenting with bright red blood per rectum and hemodynamic instability 1
• Do not perform routine second-look endoscopy—it is not recommended except in selected high-risk cases 1, 4