How should an adult presenting with hematemesis from a suspected bleeding peptic ulcer be managed, and what risk‑score criteria (Glasgow‑Blatchford, Rockall) determine the need for urgent endoscopy?

Management of Peptic Ulcer Disease with Hematemesis

All adults presenting with hematemesis from suspected bleeding peptic ulcer require immediate resuscitation with a target hemoglobin ≥7 g/dL, rapid risk stratification using Glasgow-Blatchford and Rockall scores, and urgent endoscopy within 24 hours for high-risk patients, followed by high-dose PPI therapy (80 mg bolus then 8 mg/hour infusion for 72 hours) after endoscopic hemostasis. 1

Initial Assessment and Stabilization

Immediate Resuscitation Priorities

• Assess hemodynamic stability using ATLS parameters: heart rate, blood pressure, pulse pressure, respiratory rate, urine output, Glasgow Coma Scale score, and base deficit 1

• Maintain hemoglobin ≥7 g/dL during resuscitation (strong recommendation)—a restrictive transfusion strategy is superior to liberal transfusion (targeting Hb >9 g/dL) and improves outcomes 1

• Target mean arterial pressure >65 mmHg while avoiding fluid overload, using damage control resuscitation principles similar to bleeding trauma patients 1

• Obtain immediate blood work: complete blood count, type and cross-match, coagulation studies (INR >1.5 is associated with increased mortality), electrolytes, and lactate 1

Critical Medical History Elements

Document these specific factors that directly impact mortality and management 1:

• Anticoagulants and antiplatelets (warfarin, DOACs, aspirin, clopidogrel)—affect bleeding risk and require reversal consideration
• Cardiac disease (coronary artery disease, heart failure)—increases susceptibility to adverse effects of anemia
• Pulmonary disease—may limit tolerance of anemia
• Neurological conditions (dementia, altered mental status)—increase aspiration risk
• Hepatic failure—affects coagulation status

Risk Stratification Scores

Glasgow-Blatchford Score (GBS)

Use GBS to identify patients requiring intervention (blood transfusion or endoscopy) 1:

• Score ≥1 indicates need for urgent endoscopy and hospitalization
• Score of 0 may allow outpatient management in carefully selected cases
• This score helps determine need for endoscopy

Rockall Score

Use Rockall score to identify patients at risk of adverse outcomes including rebleeding and mortality 1:

• Pre-endoscopy Rockall score uses age, shock, and comorbidities
• Complete Rockall score (post-endoscopy) adds endoscopic findings
• Higher scores predict increased mortality and rebleeding risk

Most rebleeding episodes (94%) occur within 96 hours of admission, including all cases associated with shock, need for surgery, and death—observation for 96 hours is sufficient to detect most rebleeding 2

Endoscopic Management

Timing of Endoscopy

• Perform urgent endoscopy within 24 hours for patients with high-risk features: hemodynamic instability, ongoing hematemesis, melena with shock, or high Glasgow-Blatchford scores 1

• Administer erythromycin (prokinetic) before endoscopy to improve visualization and reduce need for repeat endoscopy 3

Endoscopic Hemostasis Indications

Endoscopic therapy is indicated for high-risk stigmata 4:

• Forrest 1a (spurting arterial bleeding)—requires immediate dual-modality therapy
• Forrest 1b (oozing bleeding)—requires immediate dual-modality therapy
• Forrest 2a (non-bleeding visible vessel)—strongest independent predictor of rebleeding, requires dual-modality therapy 2, 4
• Forrest 2b (adherent clot)—independent predictor of rebleeding; consider clot removal and treatment of underlying lesion 2, 4

Endoscopic Techniques

Use dual-modality endoscopic hemostasis (combination therapy is superior to single modality) 3, 4:

• Epinephrine injection (1:10,000) plus thermal therapy (heater probe, bipolar electrocoagulation)
• Epinephrine injection plus mechanical therapy (hemoclips, endoscopic suturing)
• Avoid epinephrine injection alone—insufficient for definitive hemostasis

Pharmacological Management

High-Dose PPI Therapy

After successful endoscopic hemostasis of high-risk lesions 1, 5:

1. Administer 80 mg pantoprazole (or equivalent PPI) IV bolus immediately
2. Follow with continuous infusion of 8 mg/hour for 72 hours
3. Transition to oral PPI 40 mg twice daily for days 4-14 (reduces rebleeding by 63% compared to once-daily dosing) 5
4. Continue PPI 40 mg once daily for total duration of 6-8 weeks to allow mucosal healing 1, 5

H. pylori Testing and Eradication

Test all patients for H. pylori before discharge 1, 5, 6:

• Preferred tests: Urea breath test (88-95% sensitivity, 95-100% specificity) or stool antigen test (94% sensitivity, 92% specificity) 5
• Caution: Tests have increased false-negative rates during acute bleeding—repeat if initially negative 5

If H. pylori positive, initiate eradication therapy (start 72-96 hours after IV PPI when oral intake feasible) 5:

First-line (clarithromycin resistance <15%) 5:

• PPI standard dose twice daily × 14 days
• Clarithromycin 500 mg twice daily × 14 days
• Amoxicillin 1000 mg twice daily × 14 days (or metronidazole 500 mg twice daily if penicillin-allergic)

Alternative (high clarithromycin resistance) 5:

• Days 1-5: PPI twice daily + amoxicillin 1000 mg twice daily
• Days 6-10: PPI twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily

Second-line (if first-line fails) 5:

• PPI twice daily × 10 days
• Levofloxacin 500 mg once daily × 10 days
• Amoxicillin 1000 mg twice daily × 10 days

Confirm eradication after treatment completion—failure to eradicate leads to 40-50% recurrence over 10 years versus 0-2% with successful eradication 5, 6

Management of Rebleeding

Second Endoscopy

If rebleeding occurs, perform emergency repeat endoscopy as first-line management 1:

• Second endoscopic hemostasis is appropriate and evidence-based
• Most patients should be hospitalized for at least 72 hours after initial hemostasis, as 60-76% of rebleeding occurs within this timeframe 5, 6

Angioembolization

Consider angioembolization in hemodynamically stable patients when 1:

• Endoscopic hemostasis fails twice, OR
• Endoscopy is not possible/feasible, AND
• Technical skills and equipment are available

Avoid routine angioembolization in unstable patients—consider only in selected cases at specialized facilities, as no data support safety compared to surgery in unstable patients 1

Surgical Intervention

Surgery is indicated when 1:

• Arterial bleeding cannot be controlled at endoscopy
• Second endoscopic hemostasis fails in hemodynamically unstable patients
• Massive ongoing hemorrhage despite resuscitation

Caution: Surgical mortality rates can reach 40% in emergency settings, making prevention of rebleeding through optimal medical and endoscopic therapy critical 1

Special Considerations

When Endoscopy is Not Available

Perform contrast-enhanced CT scan if endoscopy is unavailable—CT angiography is first-line for undifferentiated major GI hemorrhage and can detect bleeding site and degree 1

NSAID-Associated Ulcers

Discontinue all NSAIDs and aspirin immediately—this heals 95% of ulcers and reduces recurrence from 40% to 9% 5

If NSAIDs must continue, switch to selective COX-2 inhibitor (celecoxib) with long-term PPI therapy 5

Gastric Ulcers

All gastric ulcers require 6:

• Biopsy from ulcer margin and base to exclude malignancy
• Repeat endoscopy at 6 weeks to confirm healing and exclude malignancy

Critical Pitfalls to Avoid

• Do not delay endoscopy for complete resuscitation in actively bleeding patients—proceed with endoscopy while resuscitating 1
• Do not use single-modality endoscopic therapy for high-risk lesions—dual modality is superior 3, 4
• Do not fail to test for H. pylori—untreated infection leads to 40-50% recurrence 5, 6
• Do not use standard-dose PPI after high-risk bleeding—high-dose continuous infusion is required 1, 5
• Do not discharge patients before 72-96 hours after successful hemostasis of high-risk lesions—most rebleeding occurs in this window 5, 6, 2