In an upper gastrointestinal bleed, what intravenous bolus medications should be administered, including for suspected esophageal or gastric variceal bleeding in a cirrhotic patient?

Bolus Medications for Upper Gastrointestinal Bleeding

For suspected variceal bleeding in cirrhotic patients, immediately administer octreotide 50 mcg IV bolus (or terlipressin 2 mg IV if available outside the US), followed by ceftriaxone 1 g IV; for non-variceal bleeding, give omeprazole 80 mg IV bolus. 1, 2, 3, 4

Variceal Bleeding (Suspected or Confirmed Cirrhosis)

Vasoactive Drug - First Priority

• Octreotide 50 mcg IV bolus immediately upon presentation, even before endoscopic confirmation 1, 2
• Can repeat the 50 mcg bolus within the first hour if ongoing bleeding 1
• Follow with continuous infusion of 50 mcg/hour for 2-5 days 1, 2, 4
• Terlipressin 2 mg IV bolus is the preferred alternative where available (not in US), given every 4 hours initially 3, 4
• Terlipressin is the only vasoactive drug proven to reduce bleeding-related mortality 3

Antibiotic Prophylaxis - Equally Critical

• Ceftriaxone 1 g IV as a single dose initially, then continue daily for up to 7 days 1, 2, 4
• This reduces bacterial infections, rebleeding, and mortality 1
• Antibiotic prophylaxis is associated with a significant reduction in overall mortality (RR 0.79) and marked reduction in rebleeding episodes (RR 0.53) 1

Pre-Endoscopy Prokinetic (Optional but Recommended)

• Erythromycin 250 mg IV given 30-120 minutes before endoscopy to optimize visualization 1, 4
• Check QT interval prior to administration 1

Non-Variceal Bleeding (Peptic Ulcer Disease)

Proton Pump Inhibitor

• Omeprazole 80 mg IV bolus immediately 1
• Follow with continuous infusion of 8 mg/hour for 72 hours after successful endoscopic therapy 1
• High-dose PPI therapy reduces rebleeding rates, blood transfusion requirements, and hospital stay in ulcer bleeding patients 1
• PPI bolus before endoscopy accelerates resolution of bleeding signs and reduces need for endoscopic therapy 1

Critical Decision Points

When Etiology is Unclear

• Start with octreotide 50 mcg IV bolus plus ceftriaxone 1 g IV if cirrhosis is suspected based on clinical features (ascites, jaundice, spider angiomata, known liver disease) 1, 5, 6
• 30% of cirrhotic patients bleed from non-variceal sources, but the vasoactive drug approach is safer to initiate empirically 1
• Can add PPI after endoscopy if non-variceal source confirmed 1

Timing Considerations

• All bolus medications should be given immediately upon presentation, before endoscopy 1, 3, 4, 6
• Do not delay vasoactive drugs waiting for endoscopic confirmation in suspected variceal bleeding 3, 6
• Endoscopy should be performed within 12 hours after hemodynamic stabilization 1, 4

Common Pitfalls to Avoid

• Do not use H2 receptor antagonists - they do not reliably increase gastric pH to 6 and show no convincing benefit 1
• Do not give beta-blockers acutely - these are for prophylaxis only, not acute bleeding management 2
• Do not delay antibiotics - they must be started immediately in suspected variceal bleeding, not after endoscopy 1, 4
• Do not stop octreotide after successful endoscopy - continue for 2-5 days to prevent early rebleeding 2

Supportive Bolus Therapy

Fluid Resuscitation

• Use crystalloid or colloid for initial volume resuscitation through 2 large-bore peripheral IVs or central access 1

Transfusion Strategy

• Maintain restrictive red blood cell transfusion with hemoglobin threshold of 7 g/dL 1, 4
• Target hemoglobin 7-9 g/dL to avoid increasing portal pressure 1, 2, 4