Management of Bleeding Risks

Patient Assessment and Monitoring

• The American Association for the Study of Liver Diseases recommends considering medication interactions, especially with antiplatelet and anticoagulant agents, in patients with bleeding risks 1
• Clinical predictors of increased risk include age >65 years, shock, poor health status, comorbidities, low initial hemoglobin, melena, and transfusion requirement, with strong evidence 2
• Presence of blood in nasogastric tube aspirate has prognostic value and can predict poor outcome and need for emergency endoscopy, with strong evidence 2
• The Glasgow-Blatchford score should be used for risk stratification to identify patients at very low risk (score ≤1), as recommended by the American College of Physicians 3

Post-Treatment Care

• Monitoring for signs of rebleeding is crucial during the first 72 hours, which is the period of highest risk 1
• Endoscopy should be performed within 24 hours of presentation and initial stabilization, with strong evidence 3, 2, 4
• Endoscopy should not be delayed for mild to moderate coagulopathy (INR <2.5), as recommended by the American College of Physicians 4
• Lesions with a high risk of rebleeding (active bleeding or visible vessel) require endoscopic therapy, which should include combination therapy (such as epinephrine injection combined with thermocoagulation or sclerosant injection), with strong evidence 3, 2, 4
• Clips or thermocoagulation, alone or with epinephrine injection, are recommended endoscopic treatments, while epinephrine injection alone is not recommended, with strong evidence 2, 3, 4

Pharmacological Management

• High-dose proton pump inhibitors (PPIs) should be initiated before endoscopy and continued for 72 hours after endoscopic therapy for high-risk lesions, with strong evidence 3, 5
• The recommended dose of IV PPIs is 80 mg bolus followed by 8 mg/hour continuous infusion, as recommended by the American College of Gastroenterology 3, 5
• Patients should be switched to oral PPIs twice daily for the next 11 days (to complete 14 days), with moderate-quality evidence supporting this regimen 3, 5
• The total duration of PPI therapy should be 6-8 weeks to allow for complete mucosal healing, with strong evidence 5
• ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding in patients requiring secondary cardiovascular prophylaxis, with strong evidence 2, 3, 4

Infection Management and Prevention

• All patients with bleeding peptic ulcers should be tested for H. pylori, and eradication therapy should be provided if infection is present, with strong evidence 2, 3, 6
• Long-term PPI therapy is not recommended unless the patient has ongoing NSAID use or other risk factors, but is recommended for patients requiring continued antiplatelet therapy (single or dual) with a history of ulcer bleeding, with strong evidence 5

Discharge and Follow-up

• Early hospital discharge may be considered in selected patients with low risk of rebleeding, as recommended by the American College of Physicians 3
• Patients should be warned about possible transient symptoms due to rebound acid hypersecretion when discontinuing PPIs after prolonged treatment, which can persist for up to 8 weeks after discontinuation but generally resolve within 6 months 7