From the Guidelines
The management of an upper gastrointestinal (GI) bleed requires prompt assessment and intervention, with a focus on hemodynamic stabilization, acid suppression, and targeted endoscopic therapy, as recommended by the most recent guidelines 1.
Initial Assessment and Stabilization
Initially, focus on hemodynamic stabilization with two large-bore IV lines (18-gauge or larger) for fluid resuscitation using crystalloids. For patients with significant bleeding, transfuse packed red blood cells to maintain hemoglobin above 7 g/dL (or 9 g/dL in those with cardiovascular disease) 1.
Acid Suppression and Endoscopic Therapy
Start proton pump inhibitor therapy immediately with IV pantoprazole 80 mg bolus followed by 8 mg/hour infusion or omeprazole 80 mg bolus followed by 8 mg/hour. Perform urgent endoscopy within 24 hours (within 12 hours for active bleeding) to identify the source and provide endoscopic therapy as needed. For non-variceal bleeding, options include epinephrine injection, thermal coagulation, or mechanical clips. For variceal bleeding, band ligation is preferred for esophageal varices, while cyanoacrylate glue injection is used for gastric varices 1.
Post-Endoscopic Care
After endoscopic control, continue oral PPI therapy (e.g., pantoprazole 40 mg twice daily) for 2-8 weeks depending on the bleeding source. This algorithm is effective because it addresses both hemodynamic stabilization and bleeding control while reducing rebleeding risk through acid suppression and targeted endoscopic intervention 1.
Some key points to consider in the management of upper GI bleed include:
- Early risk stratification using validated prognostic scales 2
- The use of high-dose intravenous proton-pump inhibition after successful endoscopic therapy to decrease rebleeding and mortality in patients with high-risk stigmata 2
- The importance of testing for Helicobacter pylori infection and providing eradication therapy if infection is present 3, 4
From the Research
Algorithm for Management of Upper GI Bleed
The management of upper GI bleed involves several steps, including:
- Resuscitation with intravenous fluids and blood transfusion as needed 5, 6
- Administration of proton pump inhibitors (PPIs) and prokinetic agents such as erythromycin 5
- Use of antibiotics and vasoactive drugs in patients with cirrhosis 5
- Endoscopy within 24 hours, with earlier endoscopy considered in patients at high risk 5, 6
- Endoscopic treatment for variceal bleeding and high-risk non-variceal bleeding 5
Risk Stratification
Risk stratification is important in determining the management of upper GI bleed, with clinical prediction guides such as the Glasgow-Blatchford bleeding score used to assess risk 6
- Patients with low risk can be managed as outpatients, while those with higher risk require hospitalization and closer monitoring 5, 6
Medical Therapy
Medical therapy for upper GI bleed includes:
- Proton pump inhibitors (PPIs) to reduce gastric acid production 5, 6, 7
- High-dose PPI treatment for the first 72 hours post-endoscopy to reduce rebleeding risk 6
- Pre-endoscopic PPI use may reduce the need for endoscopic haemostatic treatment, but its effect on other clinical outcomes is uncertain 8
Endoscopic Treatment
Endoscopic treatment for upper GI bleed includes:
- Ligation for esophageal varices and tissue glue for gastric varices 5
- Injection, thermal probes, or clips for lesions with active bleeding or non-bleeding visible vessel 5
- Endoscopic haemostatic treatment at index endoscopy may be reduced with pre-endoscopic PPI use 8
Rebleeding and Surgery
Rebleeding is managed with repeat endoscopic therapy, and subsequent bleeding may require interventional radiology or surgery 5, 6
- Surgery may be required in cases where endoscopic treatment fails to control bleeding 6