Management of Upper Gastrointestinal Bleeding

Initial Assessment and Resuscitation

The American College of Physicians recommends using the Glasgow Blatchford score to identify patients at very low risk (score ≤1) who may not require hospitalization 1
For hemodynamically stable patients without cardiovascular disease, the American College of Physicians recommends transfusing blood when hemoglobin is <80 g/L; a higher threshold is recommended for those with cardiovascular disease 1
Administering pre-endoscopy erythromycin is recommended to enhance gastric visualization during endoscopy, as suggested by the American Gastroenterological Association 2

The American College of Gastroenterology recommends starting high-dose PPI therapy as soon as possible, even before endoscopy, with options including omeprazole or pantoprazole 80 mg IV bolus 2, 4
The American College of Gastroenterology recommends continuing high-dose PPI therapy with 80 mg IV bolus followed by 8 mg/hour continuous infusion for 72 hours after successful endoscopic therapy for high-risk stigmata 1, 2, 4, 3
After 72 hours, the American College of Gastroenterology recommends transitioning to oral PPI twice daily through day 14, then once daily PPI therapy for a total duration that depends on the nature of the bleeding lesion 1, 2, 3

The American Society for Gastrointestinal Endoscopy recommends performing endoscopy within 24 hours of presentation, earlier for high-risk patients, with techniques including thermocoagulation, sclerosant injection, and clips 5, 1
The American Society for Gastrointestinal Endoscopy recommends using combination therapy with epinephrine injection plus another modality for high-risk lesions 5, 1
Epinephrine injection alone is not recommended by the American Society for Gastrointestinal Endoscopy 5
Hemostatic powder (TC-325) can be used as temporary therapy for actively bleeding ulcers, but not as sole treatment, as recommended by the American Society for Gastrointestinal Endoscopy 1

The American College of Physicians recommends hospitalizing high-risk patients for at least 72 hours after endoscopic hemostasis 5
The American Gastroenterological Association recommends testing all patients with bleeding peptic ulcers for H. pylori infection and providing eradication therapy if positive 2, 3
For patients requiring NSAIDs, the American College of Gastroenterology recommends using a PPI with a cyclooxygenase-2 inhibitor to reduce rebleeding 5
For patients requiring cardiovascular prophylaxis, the American Heart Association recommends restarting acetylsalicylic acid (ASA) as soon as cardiovascular risks outweigh gastrointestinal risks (usually within 7 days) 5
ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding, as recommended by the American Heart Association 5

The American Gastroenterological Association recommends not relying solely on PPI therapy without endoscopic intervention in active bleeding 2, 4
The American Society for Gastrointestinal Endoscopy recommends not using epinephrine injection as the only endoscopic treatment 5
The American Gastroenterological Association recommends not discontinuing PPI therapy too early (before 6-8 weeks) as this may not allow adequate time for mucosal healing 2
The American Heart Association recommends not delaying restarting antiplatelet therapy in patients requiring cardiovascular prophylaxis 5, 3

The American Society for Gastrointestinal Endoscopy recommends that second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended 5
For patients with UGIB who require secondary cardiovascular prophylaxis, the American Heart Association recommends ASA plus PPI therapy over clopidogrel alone 5