Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
UGIB commonly arises from peptic ulcer disease, portal hypertension, or mucosal injury. Stabilize hemodynamics, obtain type and crossmatch, and risk‑stratify (Glasgow‑Blatchford, Rockall). Identify liver disease stigmata and encephalopathy when variceal sources are possible. Early endoscopy within 24 h is diagnostic and therapeutic; correct coagulopathy guided by clinical context rather than INR alone.
Treatment Strategy & Disposition
Administer IV PPI for suspected nonvariceal bleed; give vasoactive therapy and prophylactic antibiotics if variceal hemorrhage is likely. Perform endoscopic hemostasis for high‑risk stigmata, then transition to oral PPI and H. pylori eradication if indicated. Manage anticoagulants/antiplatelets based on thrombotic risk; resume when hemostasis secured. Admit based on risk scores and comorbidities; ICU for ongoing transfusion needs or instability.
Epidemiology / Risk Factors
- NSAIDs/alcohol; biliary disease
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC | Bleeding/anemia | Low Hgb | |
| CMP | LFTs/electrolytes | Abnormal LFTs | |
| Lipase (if pancreatitis) | Pancreatic enzyme | Elevated | |
| CT Abd/Pelvis (selected) | Complications | Findings vary |
Pre-Endoscopy Medications
| Medication | Example |
|---|---|
| PPI | Pantoprazole 80 mg IV then 8 mg/h infusion or intermittent IV |
| Erythromycin | 250 mg IV over 20–30 min before endoscopy |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Balanced crystalloids | Plasma volume expansion | Immediate | Resuscitation | Fluid overload; ED use |
| Octreotide (variceal) | Splanchnic vasoconstriction | Minutes | Acute variceal bleed | Abdominal cramps; ED use |
| Packed RBC | O₂-carrying capacity | Immediate | Transfuse to Hgb threshold | Transfusion reactions; ED use |
| PPI (IV) | H+/K+ ATPase inhibition | Hours | Non-variceal UGIB | Infection risk long-term; ED use |
| Ceftriaxone (cirrhosis) | Cephalosporin | Hours | SBP prophylaxis in variceal bleed | Allergy; ED use |
Prognosis / Complications
- Varies by etiology and bleeding severity; rebleeding/perforation
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Avoid routine tranexamic acid. Ensure clear discharge plan and NSAID avoidance; consider COX-2 plus PPI if NSAID essential.