Upper Gastrointestinal Bleeding

Establish large-bore peripheral IV access, obtain CBC, metabolic panel, coagulation studies, type and screen/crossmatch, and assess for ongoing hematemesis, shock, altered mentation, cardiac ischemia, cirrhosis, and antithrombotic exposure. A structured airway-breathing-circulation approach is appropriate. Routine prophylactic intubation is not supported by observational meta-analyses and has been associated with more aspiration and pneumonia; reserve it for severe hematemesis, agitation, altered consciousness, or inability to protect the airway, with early anesthesia involvement. BMJBMJUpdate on the management of upper gastrointestinal ...

Use crystalloid resuscitation with frequent reassessment. A systolic blood pressure target of 90-100 mm Hg has been suggested in guidance, while persistent hypotension after fluids warrants higher-acuity care. BMJBMJUpdate on the management of upper gastrointestinal ... Acute hematemesis with melena is typical, but brisk hematochezia with hemodynamic compromise can represent a massive upper-tract source. BMJ+1BMJAssessment of upper gastrointestinal bleeding - Differential diagnosis of symptoms | BMJ Best PracticeBMJUpdate on the management of upper gastrointestinal ...

The Glasgow-Blatchford score has the best reported discrimination among commonly used pre-endoscopic scores for need for hospital-based intervention or death. A score of 0 or 1 is the commonly recommended threshold for outpatient management in otherwise appropriate patients. BMJBMJUpdate on the management of upper gastrointestinal ... The ABC score predicts mortality across both upper and lower GI bleeding, but it is a mortality tool rather than a validated discharge rule: in validation cohorts, low (≤3), medium (4-7), and high (≥8) ABC scores corresponded to 30-day mortality of 1.0%, 7.0%, and 25%, respectively, in UGIB. BMJBMJABC score: a new risk score that accurately predicts mortality in acute upper and lower gastrointestinal bleeding: an international multicentre study | Gut

For non-life-threatening bleeding, use a restrictive red-cell transfusion strategy. In a randomized trial of 921 patients, transfusion at hemoglobin below 7 g/dL versus below 9 g/dL was associated with lower 6-week mortality; a meta-analysis of five UGIB trials found lower mortality and rebleeding with restrictive transfusion. BMJBMJUpdate on the management of upper gastrointestinal ... Evidence is insufficient to extrapolate this threshold to exsanguinating hemorrhage or acute coronary syndrome, where clinical context and ongoing loss supersede a single laboratory value. BMJBMJUpdate on the management of upper gastrointestinal ...

Patients admitted with UGIB should undergo endoscopy within 24 hours of presentation after adequate resuscitation. BMJBMJUpdate on the management of upper gastrointestinal ... In a randomized trial of patients with Glasgow-Blatchford scores of 12 or higher, urgent endoscopy within 6 hours did not reduce 30-day mortality or rebleeding compared with endoscopy at 6-24 hours. BMJBMJUpdate on the management of upper gastrointestinal ... Thus, unresolved shock, airway risk, or inadequate resuscitation should not be bypassed solely to achieve very early endoscopy.

For peptic ulcer bleeding, endoscopic therapy is indicated for active spurting or oozing (Forrest Ia/Ib) and nonbleeding visible vessel (Forrest IIa) lesions. Endotherapy reduces further bleeding and surgery versus no endotherapy in these high-risk groups. BMJBMJUpdate on the management of upper gastrointestinal ... Management of adherent clot (Forrest IIb) remains an area of guideline variation; endoscopic versus medical management alone are both described. Clean-base and flat pigmented lesions (Forrest III/IIc) do not require endoscopic hemostasis. BMJBMJUpdate on the management of upper gastrointestinal ...

Injection, thermal, and mechanical modalities are options for nonvariceal hemostasis, but dilute epinephrine should only be used to improve visualization or provide temporary control before a second modality. Epinephrine monotherapy is inferior to combination treatment for prevention of further bleeding. BMJBMJUpdate on the management of upper gastrointestinal ... If endoscopic hemostasis fails or bleeding recurs after repeat endoscopy, involve interventional radiology for transarterial embolization; surgery is a salvage option. BMJBMJUpdate on the management of upper gastrointestinal ...

In suspected variceal hemorrhage, start a vasoactive agent at presentation and continue for 2-5 days if variceal bleeding is confirmed. Somatostatin, octreotide, and terlipressin reduce portal pressure; randomized evidence summarized in the review supports improved bleeding control, with no clear difference among agents. BMJBMJUpdate on the management of upper gastrointestinal ... The supplied evidence does not provide a U.S. dosing regimen; use current institutional protocols and product-specific labeling.

Give antibiotic prophylaxis promptly in cirrhosis with UGIB. Bacterial infection occurs in 35-66% of patients with cirrhosis and variceal bleeding, and a meta-analysis found lower mortality, rebleeding, and length of stay with empiric antibiotics. Choice should reflect local resistance patterns, with treatment continued for up to 7 days. BMJBMJUpdate on the management of upper gastrointestinal ...

Endoscopic band ligation is the preferred treatment for bleeding esophageal varices. Gastric varices require anatomy-specific treatment; tissue adhesive or thrombin injection is used for most gastric variceal patterns, whereas gastric varices contiguous with esophageal varices along the lesser curvature may be banded. BMJBMJUpdate on the management of upper gastrointestinal ...

For aspirin used solely for primary prevention, discontinuation after proven UGIB is generally appropriate because absolute vascular benefit is small relative to recurrent bleeding risk. In contrast, continue aspirin used for secondary cardiovascular prevention when feasible. If temporarily withheld for life-threatening bleeding, resume after hemostasis; guideline recommendations cited in the review range from immediate resumption to within 5 days. BMJBMJUpdate on the management of upper gastrointestinal ...

In patients receiving dual antiplatelet therapy with coronary stents, obtain urgent cardiology input. If severe bleeding requires interruption, continue aspirin and withhold the P2Y12 inhibitor temporarily, then restart the P2Y12 inhibitor within 5 days. BMJBMJUpdate on the management of upper gastrointestinal ...

For severe warfarin-associated UGIB, withhold warfarin and use IV vitamin K plus four-factor prothrombin complex concentrate rather than fresh frozen plasma when reversal is necessary. BMJBMJUpdate on the management of upper gastrointestinal ... For direct oral anticoagulants, withholding the agent is generally appropriate except in life-threatening bleeding; idarucizumab and andexanet alfa are reversal options, although the supplied evidence notes cost and potential procoagulant concerns. BMJBMJUpdate on the management of upper gastrointestinal ... Reintroduce anticoagulation after hemostasis with individualized consideration of thrombotic risk; European guidance summarized in the review advises warfarin resumption within 7 days. BMJBMJUpdate on the management of upper gastrointestinal ...

Do not assign a lower-tract source solely because of hematochezia. Brisk hematochezia with hemodynamic compromise can arise from UGIB, and 11-15% of patients initially thought to have lower GI bleeding ultimately have an upper source. BMJ+1BMJDiagnosis and management of acute lower gastrointestinal ...BMJUpdate on the management of upper gastrointestinal ...

Pre-endoscopic PPI use may decrease the proportion requiring endoscopic therapy at index endoscopy but has not shown a reduction in mortality, rebleeding, or surgery; guideline positions differ, particularly when endoscopy will be delayed. BMJBMJUpdate on the management of upper gastrointestinal ... This should not substitute for resuscitation, risk assessment, or timely endoscopy.

After ulcer bleeding, ensure H. pylori assessment and follow-up retesting if initial acute-phase testing is negative. In patients exposed to NSAIDs or antithrombotics, reassess the indication, minimize avoidable bleeding-promoting drugs, and document a restart plan before discharge. Evidence supplied supports the antithrombotic principles above but does not provide a specific gastroprotection regimen for every antithrombotic scenario. BMJBMJUpdate on the management of upper gastrointestinal ...