What is the comprehensive emergency management protocol for acute upper gastrointestinal bleeding, including resuscitation, reversal of anticoagulation, pharmacologic therapy, risk stratification, endoscopy timing, endoscopic hemostasis, and post‑bleed care?

Comprehensive Emergency Management of Acute Upper Gastrointestinal Bleeding

Immediate Resuscitation (First Priority)

Hemodynamic stabilization must be achieved before any diagnostic procedure, including endoscopy. 1

• Establish two large-bore peripheral IV lines (18-gauge or larger in the antecubital fossae) immediately in all patients with hemodynamic compromise 1
• Infuse 1–2 liters of isotonic crystalloid solution (normal saline or Ringer's lactate) rapidly, targeting heart rate reduction, systolic blood pressure increase, central venous pressure 5–10 cm H₂O, and urine output >30 mL/hour 1
• Crystalloids are preferred over colloids because colloids have not demonstrated survival benefit and are more expensive 1
• Insert a urinary catheter in patients with severe bleeding and monitor hourly urine output, aiming for >30 mL/hour 1
• Apply continuous automated blood pressure and heart rate monitoring for hemodynamically unstable patients 1

Airway Protection

In patients with severe hypoxemia (oxygen saturation ≈85%) and altered mental status, perform immediate endotracheal intubation before any endoscopic procedure to prevent massive aspiration 2

Blood Transfusion Strategy

• Transfuse packed red blood cells when hemoglobin falls below 80 g/L (8 g/dL) in patients without cardiovascular disease 1, 2
• Use a higher hemoglobin threshold (typically 100 g/L) for patients with underlying cardiovascular disease (ischemic heart disease, heart failure) 1

Risk Stratification

Use the Glasgow Blatchford score to identify very low-risk patients who can be managed as outpatients without hospitalization or urgent endoscopy. 1, 2

• A Glasgow Blatchford score ≤1 reliably identifies very low-risk patients who may be discharged with outpatient follow-up 1, 2
• Do not use the AIMS65 prognostic score for risk stratification, as it is not recommended 1

High-Risk Features Requiring ICU Admission

• Age >60 years (mortality rare in patients <40 years, but 30% in those >90 years) 1, 2
• Shock defined as heart rate >100 bpm and systolic blood pressure <100 mmHg 1
• Hemoglobin <100 g/L at presentation 1, 2
• Major comorbidities: renal failure, liver failure, ischemic heart disease, heart failure, or disseminated malignancy 1, 2
• Altered mental status (independent predictor of mortality) 2
• Post-endoscopic Rockall score >8 predicts very high mortality 2

Nasogastric Tube Placement

• Nasogastric tube placement may be considered in selected patients for prognostic information (bright blood in aspirate indicates higher rebleeding risk), but is not required routinely 1, 2
• Routine nasogastric tube placement does not improve clinical outcomes and is associated with increased complications, so avoid as standard practice 2

Reversal of Anticoagulation

Do not delay endoscopy in patients receiving anticoagulants (warfarin or direct oral anticoagulants). 1, 2

Pre-Endoscopic Pharmacologic Therapy

Proton Pump Inhibitor Therapy

Initiate high-dose intravenous proton pump inhibitor therapy immediately upon presentation, before endoscopy. 2, 3

• Administer pantoprazole 80 mg IV bolus immediately 2
• High-dose IV PPI may downstage endoscopic lesions and reduce the need for endoscopic intervention, but must not delay endoscopy 1, 2

Promotility Agents

Do not use promotility agents (such as erythromycin) routinely before endoscopy, as they do not improve clinical outcomes 1, 2

Special Considerations for Suspected Variceal Bleeding

In patients with known or suspected liver cirrhosis, chronic alcohol use, or physical signs of chronic liver disease (ascites, spider angiomas, jaundice), presume variceal bleeding until proven otherwise. 2

• Start vasoactive therapy immediately: octreotide 50 µg IV bolus then 50 µg/hour continuous infusion, or somatostatin 250 µg IV bolus then 250 µg/hour continuous infusion 2
• Administer antibiotic prophylaxis immediately: ceftriaxone 1 g IV daily or norfloxacin 400 mg PO twice daily 2
• Continue both vasoactive agents and antibiotics for 3–5 days regardless of initial endoscopy findings 2

Timing of Endoscopy

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

Urgent Endoscopy (Within 12 Hours)

For high-risk patients, perform urgent endoscopy within 12 hours after airway protection and initial resuscitation in the following situations: 2, 3

• Persistent hemodynamic instability (shock index ≥1)
• Altered mental status
• Suspected variceal bleeding
• Ongoing active bleeding

Endoscopic Hemostasis

High-Risk Stigmata (Active Bleeding or Visible Vessel)

For lesions with high-risk stigmata, use combination endoscopic therapy: epinephrine injection plus a second modality. 1, 2

• Recommended combination: epinephrine injection plus thermal coagulation (bipolar electrocoagulation or heater probe), sclerosant injection, or through-the-scope clips 1
• Epinephrine injection alone is insufficient and must never be used as sole therapy because it provides suboptimal efficacy 1, 2
• Thermocoagulation and sclerosant injection are strongly recommended (strong recommendation, low-quality evidence) 1
• Through-the-scope clips are suggested (conditional recommendation, very low-quality evidence) 1

Adherent Clots

When an adherent clot is encountered, perform targeted irrigation to attempt clot dislodgement, followed by appropriate definitive treatment of the underlying lesion 1, 2

Low-Risk Stigmata

Endoscopic hemostatic therapy is not indicated for low-risk stigmata (clean-based ulcer or flat pigmented spot), as these have an excellent prognosis 1, 2

Hemostatic Powder (TC-325)

• TC-325 is suggested as temporizing therapy only when conventional endoscopic therapies are not available or fail 1
• Do not use TC-325 as a single therapeutic strategy versus conventional endoscopic therapy 1

Routine Second-Look Endoscopy

Routine second-look endoscopy is not recommended. 1

Post-Endoscopic Pharmacologic Management

High-Risk Stigmata After Successful Endoscopic Therapy

After successful endoscopic hemostasis of high-risk lesions, administer pantoprazole 80 mg IV bolus followed by continuous infusion at 8 mg/hour for exactly 72 hours (strong recommendation, moderate-quality evidence). 1, 2

• After the 72-hour IV course, switch to oral PPI twice daily for 14 days, then once daily thereafter (duration adjusted to underlying cause) 1, 2
• This regimen significantly reduces rebleeding rates and mortality compared to H2-receptor antagonists or placebo 2

Medications NOT Recommended

• H2-receptor antagonists are not recommended for patients with acute ulcer bleeding 1
• Somatostatin and octreotide are not routinely recommended for patients with acute nonvariceal ulcer bleeding 1

Post-Endoscopic In-Hospital Management

Hospitalization Duration

Patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized in a monitored setting for at least 72 hours. 1, 2

Early Feeding

Patients at low risk after endoscopy can be fed within 24 hours. 1, 2

Management of Rebleeding

If clinical evidence of rebleeding appears (fresh hematemesis, melena, or hemodynamic deterioration), a second attempt at endoscopic therapy is generally recommended. 1, 2

• If repeat endoscopy fails, obtain CT angiography to localize the bleeding source (sensitivity 79–95%, specificity 95–100%) 2, 3
• Percutaneous transcatheter embolization is suggested as an alternative to surgery for patients in whom endoscopic therapy has failed 1, 2
• Seek surgical consultation for patients for whom endoscopic therapy has failed 1

Variceal Bleeding Specific Management

• For esophageal varices: endoscopic band ligation is first-line treatment 2
• For cardio-fundal gastric varices: cyanoacrylate glue injection is preferred 2
• Consider transjugular intrahepatic portosystemic shunt (TIPS) for recurrent variceal bleeding despite optimal endoscopic and pharmacologic therapy 2

Helicobacter pylori Testing and Eradication

All patients with bleeding peptic ulcers should be tested for Helicobacter pylori and receive eradication therapy if infection is present, with confirmation of eradication. 1, 2, 3

• Eradication of H. pylori reduces ulcer recurrence and rebleeding rates in complicated ulcer disease 2, 3
• Negative H. pylori diagnostic tests obtained in the acute setting should be repeated after the acute phase, as acute bleeding can yield false-negative results 1, 2

Secondary Prophylaxis and Discharge Management

Discharge PPI Therapy

Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying cause 1

NSAID Management

• In patients with previous ulcer bleeding who require an NSAID, recognize that a traditional NSAID plus a PPI or COX-2 inhibitor alone is still associated with clinically important risk for recurrent ulcer bleeding 1
• The combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone 1, 2

Antiplatelet Therapy

In patients who receive low-dose aspirin and develop acute ulcer bleeding, aspirin therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding (usually within 7 days). 1, 2

• In patients with previous ulcer bleeding receiving single or dual antiplatelet therapy, use PPI therapy (conditional recommendation, low-quality evidence) 1, 2
• Aspirin plus PPI is preferred over clopidogrel alone to reduce rebleeding 2

Anticoagulant Therapy

In patients with previous ulcer bleeding requiring continued cardiovascular prophylaxis with anticoagulant therapy (vitamin K antagonists, DOACs), use PPI therapy (conditional recommendation, very low-quality evidence). 1, 2

Common Pitfalls and Caveats

• Do not postpone intubation in severely hypoxemic, mentally altered patients; airway protection is the top priority before endoscopy 2
• Never perform endoscopy before adequate hemodynamic stabilization and airway protection 2, 3
• Always consider an upper GI source in patients with hemodynamic instability, even when presenting with bright red blood per rectum, as failure to do so leads to delayed diagnosis and treatment 2
• Suggestive findings for upper GI source include: brisk rectal bleeding with shock, history of peptic ulcer disease, portal hypertension, elevated blood urea/creatinine ratio, and antiplatelet drug use 2
• Do not rely on epinephrine injection alone for endoscopic hemostasis, as its efficacy is suboptimal when used in isolation 1, 2
• Testing for H. pylori during acute bleeding may have increased false-negative rates; confirmatory testing outside the acute context is necessary 2, 3
• Approximately 20% of patients will have continued or recurrent bleeding, accounting for most morbidity and mortality 3