Urgent considerations

See Differentials for more details

All patients experiencing an acute UGIB should be admitted to hospital and placed on continuous cardiac monitoring and pulse oximetry.

Identifying high risk patients

Scoring systems have been developed in an attempt to risk-stratify patients who present to the accident and emergency department with upper gastrointestinal (GI) bleeding.

Scoring systems can be used to identify patients at high risk of death who need urgent endoscopy (within the next 12 hours), who are stable enough to be admitted and have early endoscopy (within 24 hours), or who can be discharged home from the emergency department.[8] Currently, formal scoring systems are more commonly used in the research setting because of perceived complexity of calculations and the number of scores that exist, but some physicians use them in routine clinical practice.

Guidelines vary in their recommendations as to which is the most appropriate risk assessment tool to use.[9][10][11][12] In the UK, the National Institute for Health and Care Excellence recommends that all patients with acute upper gastrointestinal bleeding should be risk-assessed using the GBS at first assessment and the full Rockall score after endoscopy.[9]

Rockall scoring system [ Rockall Score for Upper Gastrointestinal Bleeding Opens in new window ]

  • Includes clinical criteria as well as endoscopic findings to identify patients at risk of adverse outcome after acute UGIB. A score of 8 or higher carries a high risk of mortality.[13][14]

Glasgow-Blatchford bleeding score (GBS) [ Blatchford Score for Gastrointestinal Bleeding Opens in new window ]

  • The GBS is calculated using the following parameters: urea, Hb, systolic blood pressure, heart rate, melaena at presentation, syncope at presentation, and presence of liver disease or cardiac failure. A score of ≥6 is associated with >50% risk of needing an intervention.[15][16]

  • The GBS is more sensitive than the Rockall score and is recommended by international consensus guidelines.[8][10]​​[17]

AIMS65 (Albumin, International normalised ratio, Mental state, Systolic blood pressure and Age ≥65 years) score

  • Designed to predict mortality in adults presenting with acute UGIB, this score does not rely on endoscopic data and can be calculated in the accident and emergency department.

  • A low AIMS65 score should not be used to dictate discharge.[18]

Age, Blood tests and Comorbidities (ABC) score

  • In one international multi-centre validation study the ABC score was a good predictor of mortality and outperformed the AIMS65.[19]

Child-Pugh and Model for End-stage Liver Disease (MELD) scores

  • The European Society of Gastrointestinal Endoscopy (ESGE) recommends that patients with compensated advanced chronic liver disease presenting with suspected acute variceal bleeding be risk stratified according to the Child-Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.[20]

Specific considerations

UGIB causing hypotension, tachycardia, orthostasis, or other signs of hypovolaemic shock must be managed swiftly, and patients should be considered for admission to the intensive care unit.

Severe hypovolaemia or hypovolaemic shock

  • Two large-bore intravenous lines should be placed immediately for adequate venous access. Crystalloid fluids should be infused to maintain adequate blood pressure. Balanced crystalloids may be preferable to normal saline in critically ill patients in intensive care.[21]

    Venepuncture and phlebotomy animated demonstration
    Venepuncture and phlebotomy animated demonstration

    How to take a venous blood sample from the antecubital fossa using a vacuum needle.

    ​​

Blood product transfusions

  • Packed red blood cells should be transfused in patients with evidence of ongoing active blood loss or in patients who have experienced significant blood loss or cardiac ischaemia.[23] Fresh frozen plasma should be used to correct coagulopathy (as is commonly seen in patients with underlying liver disease).[23] However, correction of coagulopathy should, in general, not delay endoscopy.[8] In cases of non-variceal bleeding where adequate perfusion cannot be maintained by other means, vasopressors can be used.

  • In haemodynamically stable patients with acute UGIB and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy should be used, with a haemoglobin threshold of ≤70 g/L (7 g/dL) prompting red blood cell transfusion and a post-transfusion target haemoglobin of 70-90 g/L (7-9 g/dL).[8][20]​​[24]

  • Recommendations regarding optimal platelet count targets in patients with active non-variceal UGIB are informed by expert opinion due to a lack of evidence.[25]

  • Some patients with cirrhosis will have hypersplenism and may not respond appropriately to platelet transfusion.[26]

  • Once haemodynamically stabilised, patients with non-variceal UGIB can proceed to endoscopy.

Antisecretory therapy

  • A proton-pump inhibitor (PPI) is warranted, and this can be administered intravenously or orally.[27][28][29][30] [ Cochrane Clinical Answers logo ] [Evidence C]​​ Intravenous PPI choices include omeprazole, pantoprazole, lansoprazole, and esomeprazole.

Antiplatelet/anticoagulant therapy

  • A review of US and international guidelines concludes that anticoagulant reversal agents should be reserved for use only in life-threatening scenarios.[31]

  • For patients on warfarin presenting with an acute bleed, the American College of Gastroenterology (ACG) guidelines suggest against giving fresh frozen plasma or vitamin K; if needed, they suggest prothrombin complex concentrate (conditional recommendation, very low certainty evidence).[32]

  • For patients on direct oral anticoagulants, the ACG guidelines suggest against prothrombin complex concentrate administration (conditional recommendation, very low certainty evidence).[32]

  • European and British guidelines recommend the following:[33]

    • Withhold oral anticoagulant and correct coagulopathy according to the severity of haemorrhage and the patient’s thrombotic risk; involve a consultant cardiologist/haematologist and do not delay endoscopy or radiological intervention (strong recommendation, low quality evidence).

    • Give intravenous vitamin K and four-factor prothrombin complex concentrate (PCC) to patients on vitamin K antagonists who are haemodynamically unstable (strong recommendation, low quality evidence). Use fresh frozen plasma if PCC is not available (weak recommendation, very low quality evidence).

    • Consider reversal agents in patients with haemodynamic instability who take direct oral anticoagulants (weak recommendation, low to very low quality evidence).

    • Restart anticoagulation following acute UGIB in patients with an indication for long-term anticoagulation (strong recommendation, low quality evidence).

Endoscopy

  • In appropriate settings, endoscopy can be used to triage patients in the accidental and emergency department and assess the need for inpatient admission.[34][35][36]

  • In general, if possible, endoscopy should be performed within 24 hours of hospital admission, once haemodynamically stable.[10][17]​​[27]​​​​​​[37]​​[38][39][40]

  • Options for non-variceal bleeding include:[2][10][41]

    • Thermal cautery (heater probes, bipolar probes, argon plasma coagulation)

    • Mechanical clips (either small through-the-scope clips or over-the-scope clips)

    • Injection of saline or diluted adrenaline to induce tamponade together with:

      • Another sclerosant, or

      • Cautery, or

      • Clips

    • Haemostatic powder applied as a spray to control acute bleeding, followed by an adjunctive therapeutic modality (e.g., thermal or mechanical therapy) to provide durable haemostasis.[42][43] Haemostatic powders are available in the US and in some other parts of the world.[44][45][46][47][48]

  • Options for variceal bleeding include:[20][49]​​

    • Variceal ligation

    • Sclerotherapy.

Haematemesis or inability to protect airway

  • Patients with ongoing, significant haematemesis, or those who may not be able to protect their airway for any reason (active haematemesis, altered mental status, etc.) and are at risk for aspiration, should be considered for endotracheal intubation before undergoing endoscopy.

Variceal UGIB

  • For variceal UGIB, the National Institute for Health and Care Excellence recommends terlipressin, a vasopressin analogue, given intravenously until bleeding has stopped or for a maximum of 5 days unless otherwise indicated.[9][50]​​ Alternatively, octreotide or somatostatin can be infused as an intravenous bolus, followed by continuous intravenous infusion for 2 to 5 days.​​[20][51]​​​​​ 

  • Upper gastrointestinal endoscopy should be performed within 24 hours to confirm the diagnosis and allow treatment with endoscopic variceal ligation or sclerotherapy.[40]

    • In one systematic review, timing of endoscopy (urgent [≤12 hours] or non-urgent [>12 hours]) did not affect mortality or re-bleeding rate in patients with acute variceal bleeding.[52]

  • Transjugular intrahepatic portosystemic shunting (TIPS) may be used to treat patients at high risk of failed endoscopic variceal ligation or re-bleeding following successful endoscopic haemostasis.[20][53]​​​[54]

    • A balloon tamponade device can be used to quell the bleeding until the shunt is placed (Sengstaken-Blakemore for oesophageal varices; Linton-Nachlas for gastric varices).[36][53]​​[54]

    • TIPS is less effective in patients with gastric varices, compared with oesophageal varices, but may be used if there is significant inflow from the coronary vein and/or significant complications due to portal hypertension.[36]

  • Patients who have cirrhosis and present with UGIB are at increased risk of developing bacterial infections. Prophylactic antibiotics reduce the risk of infection, recurrent haemorrhage, and death, and should be administered for up to 7 days, in line with local protocols.​[20][36][53][54]​​​​ BMJ: management of gastrointestinal bleeding Opens in new window

Consideration of pre-endoscopy erythromycin

  • Erythromycin stimulates gastric contractions and can promote clearance of gastric contents prior to endoscopy in patients with upper GI bleeding. These contents can include retained food, liquid blood, as well as solid clots. Clearance of gastric contents enhances visualisation during upper GI endoscopy.

  • Erythromycin is not recommended for routine use because it has not consistently been shown to improve clinical outcomes.[8][55][56]​​

  • However, for patients with suspected acute variceal haemorrhage, the ESGE recommends, in the absence of contraindications, intravenous erythromycin be given 30 to 120 minutes prior to upper GI endoscopy.[20]

  • Intravenous infusion of erythromycin before endoscopy may be considered to improve diagnostic yield and decrease the need for repeat endoscopy, particularly in patients with clinically severe or ongoing active UGIB.[10] One systematic review found that pre-endoscopy erythromycin may improve visualisation of the gastric mucosa and slightly reduce the need for blood transfusion.[56]​ However, it was uncertain whether it has any effect on mortality, re-bleeding or adverse events.[56] [ Cochrane Clinical Answers logo ] [Evidence C]

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