The physical examination focuses initially on hemodynamic evaluation. Assessing a patient's volume status with blood pressure monitoring and heart rate (HR) evaluation is crucial to determining the critical nature of the GI bleed. Patients with hemodynamic instability, suggested by HR greater than 100 beats/min, systolic blood pressure (SBP) less than 100 mm Hb, or the presence of orthostatic hypotension (defined by drop in SBP of > 20 mm Hb or rise in HR of > 20 beats/min from lying to sitting or sitting to standing) or the presence of syncope suggest a loss of blood volume of greater than 10% and indicates an urgency for volume resuscitation.
Other aspects of initial examination include assessment of the abdomen and rectum. Abdominal auscultation and palpation may help to narrow down the differential diagnosis. Patients with physical examination findings of peritonitis or clinical concern for perforation should be triaged for computed tomographic (CT) scan prior to further workup. Rectal examination is essential to confirm the presence of melena and support the etiology of UGIB and to help distinguish UGIB from lower gastrointestinal bleeding (LGIB). Patients in whom UGIB needs to be further confirmed and in whom endoscopy is being considered may benefit from nasogastric (NG) tube placement and gastric lavage. NG lavage provides supporting information of UGIB by witnessing the return of bright red blood or coffee ground material. It allows for the determination of ongoing UGIB: bright red blood that does not clear with lavage suggests active UGIB while clearance of red blood and return of coffee ground material suggest recent UGIB that may have stopped. Finally, NG lavage may allow for clearance of gastric contents facilitating views of the stomach on upper endoscopy. Some physicians advocate for NG lavage in all patients suspected of UGIB; in our practice, we determine its role in diagnosis and management on a case-by-case basis.
Laboratory studies supplement the assessment made on initial physical examination. The patient's Hb should be assessed immediately with a complete blood count (CBC) and compared to previous Hb levels to assess change; however the Hb level can be misleading in acute UGIB if there has not been sufficient time for the cardiovascular system to equilibrate and reflect the blood loss. Other laboratory values that may assist in the assessment are the blood urea nitrogen (BUN) and creatinine, the ratio of which can often be greater than 20:1 in patients with UGIB. All patients with evidence of GI bleeding should have a type-and-cross match sent to establish blood type given the possible need for blood transfusion.
The goals of initial management focus on resuscitation. Additionally, management decisions must be made to minimize ongoing bleeding and to minimize the impact of the UGIB on other organ systems (Figure 36–1).
Resuscitation is initiated and driven by amount of blood loss as assessed on CBC and by hemodynamic compromise. All patients should have 2 large-bore peripheral venous access catheters or a central venous access placed. Patients with altered mental status or respiratory compromise should be intubated for airway protection. Patients with significant hemodynamic compromise should be admitted to the ICU for close monitoring and management. Volume replacement should be initiated immediately with normal saline or lactated Ringer solution. Colloid solutions can be given.
The goal of blood transfusion is to increase the delivery of oxygen to the tissues. The need for blood transfusion is based on initial Hb and assessment of whether UGIB is ongoing and significant. Patients with massive UGIB may benefit from an aggressive transfusion strategy; patients with clinically stable UGIB and low-risk or intermediate-risk UGIB are more likely to benefit from a restrictive transfusion strategy. A recent RCT of patients with acute UGIB comparing a restrictive transfusion strategy (transfusion for Hb < 7) versus a liberal transfusion strategy (transfusion for Hb < 9) found that patients with a restrictive transfusion strategy had higher probability of survival at 6 weeks, decreased rates of rebleeding, and lower number of adverse events. This benefit is most clearly understood in patients with cirrhosis and portal hypertension-related variceal bleeding.6 Aggressive reconstitution of blood volume has previously been shown to induce rebound increases in portal pressure, which may precipitate rebleeding of varices; a restrictive transfusion strategy was shown to be beneficial in these patients. Additionally, a restrictive transfusion strategy was shown to be beneficial in patients with nonvariceal UGIB, which may be due to decreased transfusion-related complications, decreased transfusion-related abnormalities in coagulation, or decreased cardiac complications such as pulmonary edema.6 Patients should be evaluated on a case-by-case basis for transfusion needs, taking into consideration age, coexisting comorbidities, and hemodynamic status; however, a restrictive transfusion strategy is favored.
Patients should concurrently have prothrombin time (PT) and activated partial thromboplastin time (aPTT) levels checked and corrected as necessary. In patients with ongoing GI bleeding, the goal international normalized ratio (INR) is less than 1.5 and fresh frozen plasma (FFP) can be given to achieve this in the short term. Patients who are hemodynamically stable can proceed to upper endoscopy while transfusion is being given. A recent study demonstrated no difference in risk of rebleeding following endoscopic therapy in patients with mild-to-moderate elevated INR compared to normal INR.7 Patients with history of thrombocytopenia should have platelet levels checked and corrected to values greater than 50,000/mm3.
After the initial management, the focus is on minimizing ongoing UGIB. UGIB is often divided between nonvariceal bleeding and variceal bleeding and initial assessment for chronic liver disease helps to differentiate these possibilities. The most common cause of nonvariceal UGIB is peptic ulcer disease (PUD). Thus, to reduce ongoing bleeding from this potential cause, all patients are recommended to receive intravenous (IV) proton pump inhibitor (PPI) therapy until further risk stratification is completed. This is generally given in the form of intravenous pantoprazole starting with a bolus of 80 mg followed by a continuous infusion of 8 mg/h. A RCT of patients receiving PPI infusion versus placebo prior to endoscopy revealed lower need for endoscopic intervention and decreased length of hospital stay in patients treated with pre-endoscopic PPI.8 PPI therapy is thought to stabilize blood clot and reduce risk of bleeding by decreasing levels of gastric acid, which can inhibit platelet aggregation and lead to clot lysis.9
Patients in whom chronic liver disease is suspected and who have a risk of variceal bleeding are recommended to receive pharmacologic therapy in conjunction with endoscopic therapy as well. Somatostatin and somatostatin analogues such as octreotide and vapreotide have been evaluated in the pre-endoscopic period for patients in whom variceal bleeding is suspected. Octreotide is the only medication of this class currently available in the United States; intravenous octreotide infusion starting with 50 μg bolus followed by 50 μg/h continuous infusion is recommended to be given in all patients in whom variceal bleeding is suspected followed by early endoscopy. A meta-analysis of 8 randomized trials revealed improved endoscopic control of initial bleeding in patients who received pharmacologic therapy in addition to endoscopic therapy.10 Terlipressin, a synthetic analogue of vasopressin, has also been evaluated and been shown to be effective in acute variceal bleeding; however, this medication is not yet available in the United States. A recent study comparing somatostatin, octreotide, and terlipressin in a randomized fashion showed no difference in the hemostatic effects or safety between these medications.11
Additionally, patients with cirrhosis and suspected UGIB are recommended to receive short-term prophylactic antibiotics. Prophylactic antibiotics are intended to decrease the risk of bacterial infection such as spontaneous bacterial peritonitis and other infections; studies evaluating the role of prophylactic antibiotics have shown decreased rates of infection and improved survival.12 Norfloxacin 400 mg twice daily given orally for 7 days is the recommended antibiotic, though other fluoroquinolones have also been shown to be effective. Additionally, IV ceftriaxone 1 g/d has been studied and shown to be effective.