What is the initial assessment and management of an adult with an acute alcohol‑related upper gastrointestinal bleed?

Alcohol-Related Upper Gastrointestinal Bleeding: Initial Assessment and Management

In an adult with acute alcohol-related upper GI bleeding, immediately initiate hemodynamic resuscitation with crystalloid fluids, start high-dose IV proton pump inhibitor therapy (pantoprazole 80 mg bolus followed by 8 mg/hour infusion), and perform upper endoscopy within 24 hours after stabilization—or within 12 hours if the patient remains hemodynamically unstable. 1

Immediate Resuscitation and Stabilization

• Place two large-bore peripheral IV lines (18-gauge or larger in the antecubital fossae) and begin rapid infusion of 1–2 liters of isotonic crystalloid solution (normal saline or lactated Ringer's) to restore intravascular volume 1, 2
• Transfuse red blood cells when hemoglobin falls below 80 g/L (8 g/dL) in patients without cardiovascular disease; use a higher threshold (90–100 g/L) for those with ischemic heart disease or heart failure 1, 3
• Protect the airway immediately if the patient has altered mental status, severe hypoxemia (oxygen saturation <90%), or massive hematemesis—endotracheal intubation must precede endoscopy to prevent aspiration 1
• Insert a urinary catheter and monitor hourly urine output (target >30 mL/hour) in patients with severe bleeding or shock 1
• Apply continuous automated blood pressure and heart rate monitoring for hemodynamically unstable patients 1

Risk Stratification

High-risk features requiring ICU admission include: 1

• Age >60 years
• Shock (heart rate >100 bpm and systolic blood pressure <100 mmHg, or shock index >1)
• Hemoglobin <100 g/L at presentation
• Altered mental status
• Major comorbidities (renal failure, liver disease, ischemic heart disease, heart failure, disseminated malignancy)

Alcohol-specific considerations:

• Assume variceal bleeding until proven otherwise in any patient with known or suspected cirrhosis, chronic alcohol use, or stigmata of liver disease (ascites, spider angiomata, jaundice) 4, 3
• Elevated blood urea nitrogen (BUN) to creatinine ratio suggests upper GI source 5, 6
• The Glasgow Blatchford score ≤1 identifies very low-risk patients who may be managed as outpatients, but this is rare in alcohol-related bleeding with hemodynamic compromise 1, 7

Pre-Endoscopic Pharmacological Management

For all patients with suspected upper GI bleeding: 1

• Start pantoprazole 80 mg IV bolus immediately upon presentation, followed by continuous infusion at 8 mg/hour—this regimen reduces rebleeding rates and may downstage endoscopic lesions 1, 8
• Do not delay endoscopy to administer PPIs; they should be given concurrently with resuscitation 1

If variceal bleeding is suspected (cirrhosis, chronic alcohol use): 4, 3

• Initiate vasoactive drug therapy immediately:
  • Octreotide: 50 mcg IV bolus, then 50 mcg/hour continuous infusion, or
  • Somatostatin: 250 mcg IV bolus, then 250 mcg/hour continuous infusion 4
• Administer antibiotic prophylaxis (ceftriaxone 1 g IV daily or norfloxacin 400 mg PO twice daily) to reduce bacterial infections and mortality 4, 3
• Continue vasoactive drugs and antibiotics for 3–5 days regardless of endoscopic findings 4

Do not use:

• Promotility agents (erythromycin, metoclopramide) routinely—they do not improve outcomes 1, 8
• Nasogastric tube placement routinely—it does not aid diagnosis, does not affect outcomes, and causes complications in one-third of patients 5

Timing and Performance of Endoscopy

• Perform upper endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization 1, 3
• Perform urgent endoscopy within 12 hours for high-risk patients with ongoing hemodynamic instability (shock index ≥1), altered mental status, or suspected variceal bleeding 4, 1
• Endoscopy must not be performed before adequate airway protection and hemodynamic stabilization 1
• Esophagogastroduodenoscopy successfully identifies the bleeding source in 95% of cases and allows simultaneous therapeutic intervention 2, 9

Endoscopic Hemostasis

For high-risk stigmata (active bleeding, visible vessel, adherent clot): 1

• Use combination therapy: epinephrine injection PLUS a second modality (thermal coagulation, mechanical clipping, or sclerosant injection)—this is superior to any single treatment 1, 8
• Never use epinephrine injection alone—it provides suboptimal efficacy and must always be combined with thermal or mechanical therapy 1
• For adherent clots, perform targeted irrigation to attempt dislodgement, then treat the underlying lesion 1

For variceal bleeding: 4

• Esophageal varices: Band ligation is first-line therapy
• Gastric varices (cardiofundal): Cyanoacrylate injection is preferred; band ligation is inferior for long-term control but acceptable as temporizing measure
• Lesser curve gastric varices: Band ligation (similar management to esophageal varices)

For low-risk stigmata (clean-based ulcer, flat pigmented spot):

• Do not perform endoscopic hemostatic therapy—these lesions have excellent prognosis without intervention 1

Post-Endoscopic Management

After successful hemostasis of high-risk nonvariceal lesions: 1

• Continue IV pantoprazole 8 mg/hour for exactly 72 hours (this is when rebleeding risk is highest)
• Switch to oral PPI twice daily for 14 days, then once daily thereafter (duration depends on underlying cause)
• Admit high-risk patients to monitored setting for at least 72 hours after endoscopic therapy 1

After variceal bleeding control: 4

• Continue vasoactive drugs and antibiotics for 3–5 days
• Perform follow-up endoscopy to assess and treat esophageal varices that may be exacerbated by increased portal pressures
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding 4, 8

Management of Recurrent or Refractory Bleeding

If bleeding continues or recurs after initial endoscopic therapy: 1

• Attempt repeat endoscopic therapy as first-line approach
• If second endoscopy fails, proceed to CT angiography to localize bleeding source (sensitivity 79–95%, specificity 95–100%) 4, 6
• Visceral angiography with embolization is indicated for endoscopically refractory bleeding (88–100% success rate for diagnosis) 4
• Surgery is reserved for patients who fail both endoscopic and angiographic interventions 8, 7

Helicobacter pylori Testing and Eradication

• Test all patients for H. pylori and provide eradication therapy if positive—this reduces ulcer recurrence and rebleeding rates 1, 5
• Testing during acute bleeding may yield false-negative results; perform confirmatory testing after the acute phase if initial test is negative 1

Critical Pitfalls to Avoid

• Do not assume lower GI source based on bright red blood per rectum—up to 11% of patients with hematochezia have an upper GI source, especially with hemodynamic instability 5, 6
• Do not delay intubation in patients with altered mental status, severe hypoxemia, or massive hematemesis—airway protection is the top priority 1
• Do not perform endoscopy before hemodynamic stabilization—this increases mortality risk 1, 2
• Do not use epinephrine injection alone for endoscopic hemostasis—always combine with thermal or mechanical therapy 1
• Do not overlook variceal bleeding in patients with alcohol use history—initiate vasoactive drugs and antibiotics empirically if cirrhosis is suspected 4, 3
• Do not delay antibiotic prophylaxis in suspected variceal bleeding—this reduces mortality 4, 3
• If shock persists after 1–2 liters of crystalloid, plasma expanders are necessary as ≥20% of blood volume has been lost 1