Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Two large‑bore IVs; resuscitate with crystalloids; NPO; correct coagulopathy.
- Calculate Glasgow‑Blatchford score; admit vs discharge accordingly.
- Start high‑dose IV PPI; give IV erythromycin 30–90 min pre‑endoscopy if heavy clot burden.
- Early endoscopy (within 24 h) with hemostasis for high‑risk stigmata.
- Transfusion threshold Hgb <7 g/dL (higher in active ischemia); reverse anticoagulation as indicated.
- Post‑hemostasis: continue PPI protocol; test/treat H. pylori; restart antithrombotics per cardio‑GI consensus.
Clinical Synopsis & Reasoning
Resuscitate and risk‑stratify (Glasgow‑Blatchford). Administer high‑dose PPI and give pre‑endoscopy erythromycin when appropriate; perform early endoscopy with hemostasis. Transfuse at Hgb <7 g/dL unless exceptions; resume antiplatelets per risk/benefit.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| CBC, type & cross, INR | Bleed severity and readiness | Anemia/coagulopathy | Serial Hgb |
| Glasgow‑Blatchford score | Risk stratification | Endoscopy/ICU needs | ED discharge in very low risk |
| Upper endoscopy | Diagnosis + therapy | Forrest classification | Endoscopic hemostasis applied |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Pantoprazole 80 mg IV bolus then 8 mg/h x72 h | PPI | Hours | Reduces rebleeding in high‑risk stigmata | Intermittent dosing reasonable alternative |
| Erythromycin 250 mg IV pre‑endoscopy | Prokinetic | Hours | Improves visualization | QT risk |
| Tranexamic acid (selected) | Antifibrinolytic | Hours | Evidence evolving; not routine | Thrombosis risk |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACG Clinical Guideline: Upper GI and Ulcer Bleeding (2021) — Link