Acute Nonvariceal Upper Gastrointestinal Bleeding

Background

• Acute nonvariceal upper gastrointestinal (GI) bleeding is a medical emergency involving bleeding from a site in the GI tract that is proximal to the ligament of Treitz, most commonly within the reach of an adult upper endoscope.
• The most common sources of acute nonvariceal bleeding are peptic ulcers, mucosal erosions (esophagitis, gastritis, duodenitis), or Mallory-Weiss tears. Other causes include gastrointestinal angiodysplasia (GIAD, also called angioectasia)/arteriovenous malformation, malignancy of the upper GI tract, and Dieulafoy lesion.
• Acute nonvariceal upper GI bleeding may be associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin and the presence of H. pylori.
• Common findings in patients who present with acute nonvariceal upper GI bleeding include:
  • lightheadedness, weakness, hypotension, tachycardia, or cold hands/feet due to hypovolemia or anemia
  • hematemesis, coffee ground emesis, melena, or hematochezia (in the setting of rapid upper GI bleeding)
• Hemodynamic instability at the time of presentation, presence of major comorbidities, older age, and higher Rockall score or Albumin, International normalized ratio, Mental status, Systolic blood pressure, age ≥ 65 (AIMS65) score are predictors of mortality. The risk of recurrence is dependent on the nature of bleeding lesion (ulcer versus GIAD). In case of bleeding ulcers, the recurrence depends on the ability to discontinue NSAIDS and/or eradicate H. pylori.

Initial Evaluation and Pre-endoscopic Therapy

• Assess volume status and the need for aggressive resuscitation (Strong recommendation).
  • Start fluid resuscitation with crystalloid solutions (Strong recommendation). Fluids should be titrated carefully, even in the context of fluid responsiveness, and especially in the presence of elevated intravascular filling pressures or extravascular lung water.
  • Transfuse red blood cells for hemoglobin ≤ 7 g/dL (Strong recommendation), or < 8 g/dL in patients with a history of acute or chronic cardiovascular disease (Strong recommendation). Higher thresholds may also be considered based on clinical factors such as hypotension.
• Assess coagulation status and the need to correct anticoagulation. Correct coagulopathy if present in patients without absolute contraindications, but correction should not delay endoscopy (Strong recommendation).
• Use an initial (pre-endoscopic) risk scale such as the Glasgow-Blatchford score (GBS) score to stratify patient risk (Strong recommendation). Consider emergency department discharge to outpatient endoscopy for patients with a GBS ≤ 1 (Strong recommendation), which includes all or most of the following:
  • urea nitrogen < 18.2 mg/dL
  • hemoglobin ≥ 13 g/dL for men (12 g/dL for women)
  • systolic blood pressure ≥ 110 mm Hg
  • pulse < 100 beats/minute
  • absence of melena, syncope, cardiac failure, and liver disease
• Pre-endoscopic medications
  • Consider high-dose IV proton pump inhibitor therapy before endoscopy to decrease likelihood of higher risk stigmata of hemorrhage at endoscopy, but do not delay endoscopy (Weak recommendation). High-dose therapy includes regimens such as an 80 mg bolus followed by 8 mg/hour infusion.
  • Consider erythromycin 250 mg IV infusion 20-120 minutes prior to endoscopy to improve visualization and help reduce the need for a repeat endoscopy, particularly in patients with clinically severe or ongoing active bleeding (Weak recommendation).
• Nasogastric or orogastric lavage should not be performed routinely in patients with acute upper gastrointestinal bleeding (Strong recommendation). If performed, findings of blood or coffee-ground-like material suggests the likelihood of upper GI bleeding and may suggest a high-risk lesion, but negative aspirate may not rule out upper GI bleeding.
• Prophylactic endotracheal intubation for airway protection before upper endoscopy should not be performed routinely, but is indicated for selected patients with ongoing active hematemesis, encephalopathy, agitation, or inability to control airway (Strong recommendation).

Upper Endoscopy

• Perform esophagogastroduodenoscopy (EGD) within 24 hours after the patient is hemodynamically stabilized, but not within 12 hours (Strong recommendation).
• For low-risk findings (such as clean-based ulcer or flat pigmented spot, nonbleeding Mallory-Weiss tear, or erosions), consider discharge if patient has stable vital signs and hemoglobin, and no other indication for hospitalization.
• For non-ulcer bleeding, recommended treatment (endoscopic and others) varies by underlying cause. For GI angiodysplasias (also called angioectasias) or Mallory-Weiss or Dieulafoy lesions, provide endoscopic hemostasis in the setting of active bleeding (Strong recommendation).
• For peptic ulcer bleeding:
  • Differentiate high from low risk endoscopic stigmata with Forrest classification to guide endoscopic management (Strong recommendation).
  • Treat high-risk stigmata (active bleeding, visible vessel) with endoscopic therapy to reduce risk of further bleeding and surgery (Strong recommendation).
  • Treatment options for ulcers with adherent clots include attempted clot removal and endoscopic hemostasis as needed, or high-dose proton pump inhibitor therapy.
  • Endoscopic hemostasis is not recommended for flat pigmented spot or clean base ulcers and early discharge may be considered (Strong recommendation).
  • Hemostatic therapy options include injection of epinephrine (should not be used alone) or sclerosant agent, thermocoagulation, mechanical hemostasis (hemoclips [through-the-scope or cap-mounted, over-the-scope] or band ligation), and topical spray powder-based therapy.
  • For persistent bleeding (ongoing, active bleeding refractory to standard hemostatic modalities present at end of index endoscopy), consider alternative endoscopic therapies and then transcatheter angiographic embolization or surgical interventions.
• If a bleeding source is not identified on upper endoscopy, consider evaluation for obscure bleeding. See Obscure or Small Bowel Bleeding Evaluation and Management in Acute Lower Gastrointestinal Bleeding in Adults for details.
• Routine second-look endoscopy is not recommended for nonvariceal upper gastrointestinal bleeding (Strong recommendation), but may be useful in patients at high risk of recurrent bleeding, if endoscopic hemostasis was considered suboptimal, or for patients with high-risk stigmata using antiplatelet agents for secondary prophylaxis before restarting agents.

Post-endoscopic Interventions and Management

• For persistent bleeding or rebleeding, consider alternative endoscopic approaches for hemostasis. For uncontrolled bleeding or for rebleeding that cannot be controlled with a repeat endoscopy, consider 1 of the following depending on the clinical presentation of the patient and of the bleeding:
  • transcatheter angiographic embolization (Weak recommendation)
  • surgery (Weak recommendation)
• Proton pump inhibitor (PPI) therapy should be used as adjunctive treatment following endoscopic hemostasis, and may be used as an alternative to endoscopic treatment in some cases and as a follow-up regimen in patients with certain etiologies such as peptic ulcer disease or erosive esophagitis.
  • Consider high-dose PPI therapy (such as omeprazole or pantoprazole 80 mg IV bolus then 8 mg/hour infusion for 72 hours) for adherent clot (FIIb) ulcer stigmata not treated endoscopically (Strong recommendation)
  • After successful endoscopic hemostasis, start proton pump inhibitor therapy (such as omeprazole or pantoprazole 80 mg IV bolus then continuous 8 mg/hour infusion or intermittent 80 mg bolus IV or orally twice daily for 72 hours) (Strong recommendation).
  • Follow-up regimens of PPI therapy:
    • Consider PPI therapy twice daily (orally) for 2 weeks after index endoscopy in patients with high-risk bleeding due to ulcers who received endoscopic hemostasis followed by short-term high-dose PPI therapy while in the hospital (Weak recommendation). Consider following 2 weeks twice-daily PPI therapy with PPI therapy once daily.
    • Consider PPI therapy for patients with history of nonvariceal bleeding who receive dual antiplatelet therapy or ongoing anticoagulation (Weak recommendation).
    • For patients with previous NSAID induced ulcer bleeding who require NSAIDs, switch to a combination of PPI and cyclooxygenase-2 (COX-2) inhibitor at lowest effective dose to reduce risk of rebleeding (Strong recommendation). If COX-2 inhibitors (such as Celecoxib) are contraindicated by allergies or comorbidities then use a PPI with alternative NSAID.
    • For esophagitis, treat with PPI therapy. Patients with severe esophagitis (Los Angeles esophagitis classification Grade C or D, or stricture) may require increased, twice-daily standard PPI dosing.
• Eradicate Helicobacter pylori if present in patients with peptic ulcer bleeding (Strong recommendation). Negative H. pylori tests obtained during active hemorrhage should be repeated after hemorrhage resolution due to the high false-negative results rate (Strong recommendation).
• For patients with nonsteroidal anti-inflammatory drug (NSAID) induced ulcer bleeding, resume NSAIDs after achievement of hemostasis unless the NSAIDS can be safely discontinued (Strong recommendation).