What is the recommended acute management for a patient presenting with a bleeding gastric ulcer?

Acute Management of Bleeding Gastric Ulcer

Immediate Resuscitation (First 30 Minutes)

Begin aggressive crystalloid resuscitation immediately with 1-2 liters of isotonic saline through two large-bore peripheral IV lines to restore hemodynamic stability, targeting systolic blood pressure >90 mmHg, heart rate <100 bpm, and urine output >30 mL/hour. 1, 2, 3

• If shock persists after 2 liters, administer plasma expanders as ≥20% of blood volume has been lost 2, 3
• Transfuse red blood cells when hemoglobin falls below 80 g/L in patients without cardiovascular disease 1, 3
• Use a higher hemoglobin threshold (typically >80-90 g/L) for patients with ischemic heart disease, heart failure, or age >60 years 1, 2, 3
• Insert urinary catheter to monitor hourly urine output, targeting >30 mL/hour 2
• Apply continuous automated blood pressure and heart rate monitoring 2

Airway Protection in High-Risk Patients

• Intubate immediately before endoscopy if the patient has massive hematemesis, altered mental status, or severe hypoxemia (oxygen saturation <85%) to prevent aspiration 2, 3

Pre-Endoscopic Pharmacotherapy (Within First Hour)

Administer pantoprazole 80 mg IV bolus followed by continuous infusion at 8 mg/hour immediately upon presentation, before endoscopy. 1, 2, 3

• This regimen downstages endoscopic lesions and decreases the need for endoscopic intervention, though it does not replace the need for urgent endoscopy 1, 3
• Do NOT use H2-receptor antagonists—they are ineffective in acute ulcer bleeding 1, 3
• Do NOT routinely use promotility agents (erythromycin or metoclopramide) as they do not improve clinical outcomes 1, 3
• Do NOT delay endoscopy to correct coagulopathy from warfarin or DOACs—proceed with endoscopy and hemostatic therapy as needed 1, 3

Risk Stratification

Identify high-risk features that mandate ICU admission and urgent endoscopy: 1, 2

• Hemodynamic instability: heart rate >100 bpm AND systolic blood pressure <100 mmHg 1, 2
• Age >60 years 2
• Hemoglobin <100 g/L 2
• Altered mental status 2
• Major comorbidities: renal failure, liver disease, ischemic heart disease, heart failure, or disseminated malignancy 2

Endoscopic Management Timing

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

• For high-risk patients with ongoing hemodynamic instability despite resuscitation, perform urgent endoscopy within 12 hours 1, 3
• If the patient remains unstable after initial resuscitation (shock index >1), consider CT angiography to localize bleeding before endoscopy 2

Endoscopic Hemostasis Based on Forrest Classification

For high-risk stigmata (Forrest Ia: spurting bleeding, Ib: oozing bleeding, IIa: visible vessel), use combination endoscopic therapy—epinephrine injection PLUS a second modality (thermal coagulation, sclerosant injection, or through-the-scope clips). 1, 2, 3

• Epinephrine injection alone is NEVER adequate and must always be combined with thermal or mechanical therapy 1, 2, 3
• For adherent clots (Forrest IIb), perform targeted irrigation to attempt dislodgement, then treat the underlying lesion with combination therapy 1, 3
• For low-risk stigmata (Forrest IIc: flat pigmented spot, Forrest III: clean base), do NOT perform endoscopic hemostatic therapy 1, 2, 3

Post-Endoscopic Pharmacotherapy

After successful endoscopic hemostasis of high-risk lesions, continue pantoprazole 8 mg/hour IV infusion for exactly 72 hours total (including the pre-endoscopic bolus). 1, 2, 3

• After 72 hours, transition to oral PPI twice daily for 14 days, then once daily thereafter 1, 2, 3
• Duration of once-daily PPI depends on the underlying cause (see secondary prevention below) 1, 3

Post-Endoscopic Monitoring

Admit high-risk patients who received endoscopic therapy to a monitored setting (ICU or step-down unit) for at least 72 hours. 1, 3

• Low-risk patients (clean base or flat spot) can be fed within 24 hours and discharged early if hemodynamically stable with no serious comorbidities 1

Management of Rebleeding

If rebleeding occurs after initial endoscopic therapy, attempt repeat endoscopic hemostasis as the first approach. 1, 3

• If endoscopic therapy fails twice or bleeding is uncontrollable, obtain immediate surgical consultation 1, 3
• Where available, percutaneous embolization by interventional radiology is an alternative to surgery 1

Helicobacter pylori Management

Test all patients with bleeding gastric ulcers for H. pylori using biopsy during endoscopy, and initiate eradication therapy if positive. 1, 3

• Testing during acute bleeding may yield false-negative results; if initial testing is negative, repeat confirmatory testing 4-6 weeks after the acute episode 1
• Eradication of H. pylori reduces ulcer recurrence and rebleeding rates by >80% 1, 4
• Confirm eradication with urea breath test or stool antigen 4-6 weeks after completing therapy 1, 3

Secondary Prevention: Antiplatelet and NSAID Management

For patients requiring aspirin for cardiovascular prophylaxis, restart aspirin as soon as cardiovascular risk outweighs bleeding risk—typically within 1-3 days after confirmed endoscopic hemostasis, and no later than 7 days. 1, 3, 5

• Aspirin plus PPI is superior to clopidogrel alone for preventing rebleeding 1, 3, 5
• All patients with prior ulcer bleeding who require antiplatelet or anticoagulant therapy must receive indefinite PPI co-therapy 1, 3, 5
• If NSAIDs are absolutely necessary, use a COX-2 selective inhibitor plus PPI (not COX-2 inhibitor alone) 1
• For patients on dual antiplatelet therapy (DAPT), continue aspirin throughout the bleeding episode if possible; temporarily hold the P2Y12 inhibitor and resume within 5 days maximum if there is a compelling indication such as recent coronary stent 5

Critical Pitfalls to Avoid

• Do NOT delay intubation in patients with massive hematemesis, altered mental status, or severe hypoxemia—airway protection is the top priority 2, 3
• Do NOT perform endoscopy before adequate hemodynamic stabilization and airway protection 1, 2, 3
• Do NOT use epinephrine injection alone for endoscopic hemostasis—it provides suboptimal efficacy and must be combined with thermal or mechanical therapy 1, 2, 3
• Do NOT replace aspirin with clopidogrel monotherapy in patients with prior GI bleeding—aspirin plus PPI provides better protection 1, 3, 5
• Do NOT delay aspirin resumption beyond 7 days in patients requiring cardiovascular prophylaxis, as thrombotic risk escalates rapidly 1, 3, 5
• Do NOT discontinue PPI therapy once the acute bleed resolves—lifelong PPI is required for patients on antiplatelet agents with prior bleeding 1, 3, 5