How should I initially assess and manage a patient who presents with acute upper gastrointestinal bleeding?

Approach to Patients with Upper Gastrointestinal Bleeding

Begin immediate resuscitation with 1–2 liters of isotonic crystalloid through two large-bore IV lines, transfuse packed red blood cells when hemoglobin falls below 80 g/L (70 g/L if no cardiovascular disease), start high-dose intravenous proton pump inhibitor therapy before endoscopy, and perform upper endoscopy within 24 hours after hemodynamic stabilization—or within 12 hours if the patient remains unstable. 1, 2, 3

Immediate Resuscitation and Hemodynamic Stabilization

Airway protection takes absolute priority. If the patient has active hematemesis with altered mental status, severe hypoxemia (oxygen saturation <90%), or respiratory compromise, perform endotracheal intubation before any endoscopic procedure to prevent massive aspiration. 1, 2

Vascular Access and Fluid Resuscitation

• Place two large-bore peripheral IV lines (18-gauge or larger in the antecubital fossae) immediately. 2
• Administer 1–2 liters of isotonic crystalloid solution (normal saline or Ringer's lactate) rapidly to restore blood pressure, targeting heart rate reduction, systolic blood pressure increase, central venous pressure 5–10 cm H₂O, and urine output >30 mL/hour. 2, 3
• Crystalloids are preferred over colloids because colloids have not demonstrated survival benefit and are more expensive. 2
• If shock persists after 1–2 liters, at least 20% of blood volume has been lost and plasma expanders are necessary. 2

Blood Transfusion Strategy

• Transfuse packed red blood cells when hemoglobin is <80 g/L (8 g/dL) in patients without cardiovascular disease. 2, 3, 1
• Use a higher threshold (hemoglobin <100 g/L) for patients with ischemic heart disease, heart failure, or other cardiovascular comorbidities. 2, 3
• Target hemoglobin 70–100 g/L in patients without cardiac disease; target ≥100 g/L in those with cardiovascular disease. 1

Monitoring

• Insert a urinary catheter and record hourly urine output, targeting >30 mL/hour in patients with severe bleeding. 2, 1
• Apply continuous automated blood pressure and heart rate monitoring for hemodynamically unstable patients. 2
• Calculate the shock index (heart rate ÷ systolic blood pressure); a value >1 signals instability requiring urgent intervention. 1

Risk Stratification

High-Risk Features Requiring ICU Admission

• Age >60 years is an independent predictor of mortality (30% mortality in patients >90 years versus rare in those <40 years). 2, 3
• Shock defined as heart rate >100 bpm and systolic blood pressure <100 mmHg. 2, 3
• Hemoglobin <100 g/L at presentation. 2, 3
• Major comorbidities: renal failure, liver failure, ischemic heart disease, heart failure, or disseminated malignancy. 2, 3
• Altered mental status is an independent predictor of mortality. 1
• Active arterial bleeding from peptic ulcer in a shocked patient carries an 80% risk of continuing bleeding or death. 2

Low-Risk Identification

• Glasgow Blatchford Score ≤1 reliably identifies very low-risk patients who may be discharged without hospitalization or urgent endoscopy. 2, 1
• The AIMS65 score should not be used for risk stratification. 2

Post-Endoscopic Risk Assessment

• Rockall score >8 predicts very high mortality risk and is the best validated scale for predicting death (area under ROC curve 0.73–0.81). 3, 2
• Low-risk stigmata (clean-based ulcer or flat pigmented spot) have excellent prognosis and do not require endoscopic intervention. 2, 3

Pre-Endoscopic Pharmacologic Management

Proton Pump Inhibitor Therapy

• Start high-dose intravenous PPI therapy immediately upon presentation, before endoscopy. 2, 1
• Administer pantoprazole 80 mg IV bolus followed by continuous infusion at 8 mg/hour. 1, 2
• Pre-endoscopic PPI may downstage endoscopic lesions and decrease the need for intervention, but must not delay endoscopy. 2

Variceal Bleeding Suspected (Cirrhosis, Ascites, Chronic Alcohol Use)

• Start vasoactive therapy immediately when variceal bleeding is suspected: octreotide (50 µg IV bolus then 50 µg/hour infusion) or somatostatin (250 µg IV bolus then 250 µg/hour infusion). 1, 2
• Administer antibiotic prophylaxis promptly: ceftriaxone 1 g IV daily or norfloxacin 400 mg PO twice daily. 1, 2
• Continue both vasoactive agents and antibiotics for 3–5 days regardless of initial endoscopic findings. 1, 2
• Variceal hemorrhage carries approximately 10% mortality despite modern therapies. 1

What NOT to Do

• Do not routinely use promotility agents (e.g., erythromycin) before endoscopy—they do not improve outcomes. 2, 1
• Do not delay endoscopy in patients receiving anticoagulants (warfarin or direct oral anticoagulants). 2
• Nasogastric tube placement is not required routinely; it may be considered in selected patients for prognostic information (bright blood indicates active bleeding), but avoid in unsedated patients due to aspiration risk. 2, 3

Timing of Endoscopy

• Perform upper endoscopy within 24 hours of presentation for all hospitalized patients after initial hemodynamic stabilization. 2, 1, 3
• Perform urgent endoscopy within 12 hours for high-risk patients with:
  • Hemodynamic instability persisting after initial resuscitation 1, 2
  • Shock index >1 1
  • Altered mental status 1
  • Suspected variceal bleeding 1
• Do not perform endoscopy before adequate volume resuscitation and airway protection, except in refractory instability where urgent hemostasis is required. 1, 2

Endoscopic Hemostatic Therapy

High-Risk Stigmata (Active Bleeding or Visible Vessel)

• Use combination endoscopic therapy: epinephrine injection plus a second modality (thermal coagulation, sclerosant injection, or through-the-scope clips). 2, 1, 3
• Epinephrine injection alone is insufficient and must never be used as sole therapy—it provides suboptimal efficacy. 2, 1, 3
• Thermocoagulation options include bipolar electrocoagulation or heater probe. 2, 3
• Hemostatic powder (TC-325) is suggested as temporizing therapy but not as sole treatment for actively bleeding ulcers. 2

Adherent Clots

• Perform targeted irrigation to attempt clot dislodgement, followed by appropriate definitive treatment of the underlying lesion. 2, 1

Low-Risk Stigmata

• Do not perform endoscopic hemostatic therapy for clean-based ulcers or flat pigmented spots—they have excellent prognosis. 2, 3

Variceal Bleeding

• Esophageal varices: Endoscopic band ligation is first-line treatment. 1
• Cardio-fundal gastric varices: Injection of cyanoacrylate glue is preferred. 1

Post-Endoscopic Management

High-Risk Lesions After Successful Hemostasis

• Continue intravenous pantoprazole at 8 mg/hour for exactly 72 hours after successful endoscopic therapy for high-risk stigmata. 1, 2
• After 72 hours, switch to oral PPI twice daily for 14 days, then once daily thereafter (duration adjusted to underlying cause). 1, 2
• Admit high-risk patients to monitored setting for at least 72 hours after endoscopic hemostasis. 1, 2

Low-Risk Patients

• Patients at low risk for rebleeding after endoscopy can be fed within 24 hours and discharged promptly. 2, 3

Helicobacter pylori Management

• Test all patients with upper GI bleeding for H. pylori and provide eradication therapy if positive. 2, 3
• Eradication reduces ulcer recurrence and rebleeding rates in complicated ulcer disease. 2, 3
• Testing during acute bleeding may yield false-negative results; perform confirmatory testing after the acute phase if initial test is negative. 3, 1

Variceal Bleeding Post-Endoscopic Care

• Continue vasoactive drugs and antibiotics for 3–5 days. 1
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding. 1

Management of Recurrent Bleeding

• Repeat endoscopic therapy is first-line for recurrent bleeding after initial endoscopic hemostasis. 2, 1
• If repeat endoscopy fails, obtain CT angiography to localize the bleeding source (sensitivity 79–95%, specificity 95–100%). 1, 2
• Visceral angiography with embolization is indicated for endoscopically refractory bleeding. 1
• Surgical intervention is reserved for patients who do not respond to both endoscopic and angiographic therapies. 1

Anticoagulation and Antiplatelet Management

Warfarin

• Discontinue warfarin immediately; if the patient is unstable, reverse with prothrombin-complex concentrate plus vitamin K. 1

Aspirin

• Aspirin for primary prevention: stop permanently. 1
• Aspirin for secondary cardiovascular prevention: restart as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days). 2, 1
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding. 2

Long-Term Management

• PPI therapy is suggested indefinitely for patients with previous ulcer bleeding who require antiplatelet or anticoagulant therapy for cardiovascular prophylaxis. 2

Common Pitfalls to Avoid

• Do not postpone intubation in severely hypoxemic or mentally altered patients—airway protection is the top priority. 1
• Do not undertake endoscopy before adequate hemodynamic stabilization and airway protection. 1, 2
• Do not rely on epinephrine injection alone for endoscopic hemostasis—its efficacy is suboptimal when used in isolation. 2, 1
• Do not assume lower GI source in hemodynamically unstable patients with bright red blood per rectum—always consider upper GI source, as failure to do so leads to delayed diagnosis and treatment. 2
• The absence of melena does not rule out upper GI bleeding—early presentation or low-volume bleeding may precede dark stools. 1

Causes of Death in Upper GI Bleeding

• Hypovolemic shock leading to inadequate tissue perfusion and oxygen delivery to vital organs (brain, heart, kidneys). 4
• Cardiovascular complications: patients with underlying cardiac disease have poor tolerance for anemia and hypotension, leading to cardiac ischemia. 4
• Sepsis: upper GI bleeding can trigger or unmask sepsis, particularly in patients with comorbidities. 4
• Variceal bleeding in cirrhosis carries high mortality even with treatment—delays in vasoactive therapy and antibiotics are fatal. 4
• Deaths are almost entirely restricted to patients with significant comorbidities (cardiac failure, renal failure, liver failure, disseminated malignancy). 4