Urgent considerations

See Differentials for more details

All patients experiencing an acute UGIB should be admitted to the 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 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.[7] 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.

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.[8][9]

Glasgow-Blatchford bleeding score (GBS) [ Blatchford score for gastrointestinal bleeding Opens in new window ]

  • The GBS is calculated using the following parameters: BUN, Hb, systolic blood pressure, heart rate, melena 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.[10][11]

  • The GBS is more sensitive than the Rockall score and is recommended by international consensus guidelines.[7][12]​​[13]

AIMS65 (Albumin, International normalized 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 emergency department.

  • A low AIMS65 score should not be used to dictate discharge.[14]

Age, Blood tests and Comorbidities (ABC) score

  • In one international multicenter validation study the ABC score was a good predictor of mortality and outperformed the AIMS65.[15]

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.[16]

Specific considerations

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

Severe hypovolemia or hypovolemic 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.[17]

    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 ischemia.[19] Fresh frozen plasma should be used to correct coagulopathy (as is commonly seen in patients with underlying liver disease).[19] However, correction of coagulopathy should, in general, not delay endoscopy.[7] In cases of nonvariceal bleeding where adequate perfusion cannot be maintained by other means, vasopressors can be used.

  • In hemodynamically stable patients with acute UGIB and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy should be used, with a hemoglobin threshold of ≤7 g/dL (70  g/L) prompting red blood cell transfusion and a posttransfusion target hemoglobin of 7-9 g/dL (70-90 g/L).[7][16]​​[20]

  • Recommendations regarding optimal platelet count targets in patients with active nonvariceal UGIB are informed by expert opinion due to a lack of evidence.[21]

  • Some patients with cirrhosis will have hypersplenism and may not respond appropriately to platelet transfusion.[22]

  • Once hemodynamically stabilized, patients with nonvariceal UGIB can proceed to endoscopy.

Antisecretory therapy

  • A proton-pump inhibitor (PPI) is warranted, and this can be administered intravenously or orally.[23][24][25][26] [ Cochrane Clinical Answers logo ] [Evidence C]​​ Intravenous PPI choices include omeprazole, pantoprazole, lansoprazole, and esomeprazole in the US.

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.[27]

  • 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).[28]

  • For patients on direct oral anticoagulants, the ACG guidelines suggest against prothrombin complex concentrate administration (conditional recommendation, very low certainty evidence).[28]

Endoscopy

  • In appropriate settings, endoscopy can be used to triage patients in the emergency department and assess the need for inpatient admission.[29][30][31]

  • In general, if possible, endoscopy should be performed within 24 hours of hospital admission, once hemodynamically stable.[12][13][23]​​​​​​​​​[32][33][34][35]

  • Options for nonvariceal bleeding include:[2][12][36]

    • 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 epinephrine to induce tamponade together with:

      • Another sclerosant, or

      • Cautery, or

      • Clips

    • Hemostatic powder applied as a spray to control acute bleeding, followed by an adjunctive therapeutic modality (e.g., thermal or mechanical therapy) to provide durable hemostasis.[37][38] Hemostatic powders are available in the US and in some other parts of the world.[39][40][41][42][43]

  • Options for variceal bleeding include:[16][44]​​

    • Variceal ligation

    • Sclerotherapy.

Hematemesis or inability to protect airway

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

Variceal UGIB

  • For variceal UGIB, intravenous octreotide, a long-acting somatostatin analog, should be infused as an intravenous bolus, followed by continuous intravenous infusion for 2 to 5 days.[31][45]​​​​ Many clinicians continue infusion for 3 days, but the duration is often individualized. Alternative vasoactive drugs (e.g., terlipressin, vasopressin, somatostatin) may be used, if available.[16][45][46]​​​

  • Upper gastrointestinal endoscopy should be performed within 24 hours to confirm the diagnosis and allow treatment with endoscopic variceal ligation or sclerotherapy.[35]

    • In one systematic review, timing of endoscopy (urgent [≤12 hours] or nonurgent [>12 hours]) did not affect mortality or rebleeding rate in patients with acute variceal bleeding.[47]

  • Transjugular intrahepatic portosystemic shunting (TIPS) may be used to treat patients at high risk of failed endoscopic variceal ligation or rebleeding following successful endoscopic hemostasis.[16][45]​​​[48]

    • A balloon tamponade device can be used to quell the bleeding until the shunt is placed (Sengstaken-Blakemore for esophageal varices; Linton-Nachlas for gastric varices).[31][45]​​[48]

    • TIPS is less effective in patients with gastric varices, compared with esophageal varices, but may be used if there is significant inflow from the coronary vein and/or significant complications due to portal hypertension.[31]

  • Patients who have cirrhosis and present with UGIB are at increased risk of developing bacterial infections. Prophylactic antibiotics reduce the risk of infection, recurrent hemorrhage, and death, and should be administered for up to 7 days, in line with local protocols.​[16][31][45][48]​​​​ 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 visualization during upper GI endoscopy.

  • Erythromycin is not recommended for routine use because it has not consistently been shown to improve clinical outcomes.[7][49][50]

  • However, for patients with suspected acute variceal hemorrhage, the ESGE recommends, in the absence of contraindications, intravenous erythromycin be given 30 to 120 minutes prior to upper GI endoscopy.[16]

  • 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.[12] One systematic review found that pre-endoscopy erythromycin may improve visualization of the gastric mucosa and slightly reduce the need for blood transfusion.[50]​ However, it was uncertain whether it has any effect on mortality, rebleeding or adverse events.[50]​​ [ Cochrane Clinical Answers logo ] [Evidence C]

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