What is the first‑line management of an upper gastrointestinal bleed?

First-Line Management of Upper Gastrointestinal Bleeding

For patients with acute upper GI bleeding, immediately initiate resuscitation if hemodynamically unstable, establish IV access, begin crystalloid fluids, transfuse red blood cells at hemoglobin <80 g/L (higher threshold if cardiovascular disease present), start high-dose intravenous PPI therapy, and perform endoscopy within 24 hours (within 12 hours if high-risk features present). 1, 2

Immediate Resuscitation (First Priority)

Hemodynamic stabilization must occur before any diagnostic procedures. 1

• Establish two large-bore peripheral IV lines in the antecubital fossae for all patients with hemodynamic compromise 3
• Administer crystalloid fluids (1-2 liters of isotonic saline or balanced crystalloids like Ringer's lactate) to restore blood pressure, targeting heart rate reduction, blood pressure increase, central venous pressure 5-10 cm H₂O, and urine output >30 mL/hour 1, 3, 2
• Crystalloids are preferred over colloids as colloids show no survival benefit and are more expensive 1, 2
• Insert urinary catheter and measure hourly urine output in severe bleeding, aiming for >30 mL/hour 1, 3
• Apply continuous automated blood pressure and heart rate monitoring for hemodynamically unstable patients 1, 3

Airway Protection

• Intubate before endoscopy in patients with massive hematemesis, altered mental status, or severe hypoxemia (oxygen saturation ≈85%) to prevent aspiration 3, 4

Blood Transfusion Strategy

• Transfuse red blood cells at hemoglobin <80 g/L (8 g/dL) in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold for transfusion in patients with underlying cardiovascular disease (ischemic heart disease, heart failure) 1, 2
• This restrictive transfusion strategy improves outcomes compared to liberal transfusion 2, 4

Risk Stratification

Identify high-risk features that predict mortality and rebleeding: 1, 3

• Age >60 years 1, 3
• Shock (heart rate >100 bpm AND systolic blood pressure <100 mmHg) 1, 3
• Hemoglobin <100 g/L (10 g/dL) 1, 3
• Major comorbidities: renal failure, liver failure, ischemic heart disease, heart failure, disseminated malignancy 1, 3

Glasgow Blatchford Score

• Use Glasgow Blatchford score ≤1 to identify very low-risk patients who may be discharged without hospitalization or urgent endoscopy 1, 2
• Do NOT use AIMS65 score for risk stratification 1

High-Risk Patients

• Admit to ICU or monitored setting for at least 24-72 hours if high-risk features present 1, 3

Pre-Endoscopic Pharmacological Management

Proton Pump Inhibitor Therapy

Start high-dose intravenous PPI therapy immediately upon presentation before endoscopy. 1, 2, 4

• Administer pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion 3, 2
• This may downstage endoscopic lesions and decrease the need for endoscopic intervention but should not delay endoscopy 1

Prokinetic Agents

• Do NOT use promotility agents (such as erythromycin) routinely before endoscopy, as they do not improve outcomes 1, 2
• The 2019 international consensus guideline explicitly recommends against routine use 1, though some older evidence suggested benefit 4, 5

Special Considerations for Suspected Variceal Bleeding

If cirrhosis, chronic alcohol use, or signs of chronic liver disease are present, presume variceal bleeding until proven otherwise: 3

• Start vasoactive therapy immediately: octreotide 50 µg IV bolus then 50 µg/hour infusion, OR somatostatin 250 µg IV bolus then 250 µg/hour infusion 3, 4
• Administer antibiotic prophylaxis: ceftriaxone 1 g IV daily OR norfloxacin 400 mg PO twice daily 3, 4
• Continue both for 3-5 days regardless of endoscopic findings 3

Anticoagulation Management

• Do NOT delay endoscopy in patients receiving anticoagulants (warfarin, DOACs) 1

Nasogastric Tube

• Consider placement in selected patients as findings may have prognostic value (bright blood predicts rebleeding), but it is not routinely required 1

Timing of Endoscopy

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

Urgent Endoscopy (Within 12 Hours)

Consider earlier endoscopy within 12 hours for high-risk patients with: 3, 2, 4

• Hemodynamic instability despite resuscitation (shock index ≥1)
• Altered mental status
• Suspected variceal bleeding
• Active ongoing bleeding

Endoscopic Hemostatic Therapy

High-Risk Stigmata (Active Bleeding or Visible Vessel)

Use combination endoscopic therapy—epinephrine injection PLUS a second modality. 1, 2

• Recommended second modalities: thermal coagulation (bipolar electrocoagulation, heater probe), sclerosant injection, or through-the-scope clips 1, 2
• Epinephrine injection alone is insufficient and must never be used as sole therapy 1, 2

Adherent Clots

• Perform targeted irrigation to attempt clot dislodgement with appropriate treatment of the underlying lesion 1

Low-Risk Stigmata

• Do NOT perform endoscopic hemostatic therapy for clean-based ulcers or flat pigmented spots 1, 3

Variceal Bleeding

• Esophageal varices: endoscopic band ligation is first-line 3, 4
• Gastric varices: cyanoacrylate glue injection is preferred 3

Post-Endoscopic Management

High-Dose PPI Therapy After Successful Hemostasis

After successful endoscopic therapy for high-risk stigmata: 1, 2

• Continue pantoprazole 8 mg/hour IV infusion for exactly 72 hours 3, 2
• Then switch to oral PPI twice daily for 14 days, followed by once daily thereafter (duration depends on underlying cause) 1, 2

Monitoring

• Maintain high-risk patients in monitored setting for at least 72 hours after endoscopic therapy 3, 2

Helicobacter pylori Testing

• Test all patients for H. pylori and provide eradication therapy if positive 3, 2
• Testing during acute bleeding has increased false-negative rates; confirmatory testing after the acute phase is advisable 3, 2

Early Feeding

• Low-risk patients can be fed within 24 hours after endoscopy and may be discharged promptly 1, 2

Management of Rebleeding

• Repeat endoscopy is recommended for clinical evidence of rebleeding (fresh hematemesis, melena, hemodynamic deterioration) 1, 2, 4
• Second attempt at endoscopic therapy is generally recommended 2, 5
• If repeat endoscopy fails, transcatheter embolization is suggested 5
• Routine second-look endoscopy is NOT recommended 3, 2

Common Pitfalls to Avoid

• Do NOT postpone intubation in severely hypoxemic or mentally altered patients—airway protection is the top priority 3
• Do NOT perform endoscopy before adequate hemodynamic stabilization and airway protection 3
• Do NOT use epinephrine injection alone for endoscopic hemostasis—its efficacy is suboptimal when used in isolation 1, 2
• Do NOT delay endoscopy to correct coagulopathy in anticoagulated patients 1
• Do NOT use liberal transfusion strategies—restrictive transfusion (hemoglobin <80 g/L) improves outcomes 2, 4