Approach to acute upper gastrointestinal bleeding in adults - UpToDate - Fisiologia I (2024)

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Official reprint from UpToDatewww.uptodate.com © 2024 UpToDate, Inc. and/or its affiliates. All Rights Reserved.Approach to acute upper gastrointestinal bleeding inadultsINTRODUCTIONPatients with acute upper gastrointestinal (GI) bleeding commonly present withhematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarrystools). The initial evaluation of patients with acute upper GI bleeding involves anassessment of hemodynamic stability and resuscitation if necessary. Diagnostic studies(usually endoscopy) follow, with the goals of diagnosis, and when possible, treatment of thespecific disorder.The diagnostic and initial therapeutic approach to patients with clinically significant (ie, thepassage of more than a scant amount of blood) acute upper GI bleeding will be reviewedhere. While there is variability among guidelines, this approach is generally consistent with amultidisciplinary international consensus statement updated in 2019, a 2012 guidelineissued by the American Society for Gastrointestinal Endoscopy, a 2021 guideline issued bythe American College of Gastroenterology, a 2015 guideline issued by the European Societyof Gastrointestinal Endoscopy, and a 2021 update issued by the European Society ofGastrointestinal Endoscopy [1-5]. The causes of upper GI bleeding, the endoscopicmanagement of acute upper GI bleeding, and the management of active varicealhemorrhage are discussed separately. (See "Causes of upper gastrointestinal bleeding inadults" and "Overview of the treatment of bleeding peptic ulcers" and "Overview of themanagement of patients with variceal bleeding" and "Methods to achieve hemostasis inpatients with acute variceal hemorrhage".)A table outlining the major causes, clinical features, and emergency management of acutesevere upper gastrointestinal bleeding in adults is provided ( table 1).®������: John R Saltzman, MD, FACP, FACG, FASGE, AGAF������� ������: Loren Laine, MD������ ������: Anne C Travis, MD, MSc, FACG, AGAFAll topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through:May 2024.This topic last updated:Mar 05, 2024.6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 1/51https://www.uptodate.com/https://www.uptodate.com/external-redirect?target_url=https%3A%2F%2Fwww.asge.org%2Fdocs%2Fdefault-source%2Feducation%2Fpractice_guidelines%2Fdoc-b4349a10-9b72-463e-ac70-f394c7aa20b4.pdf%3Fsfvrsn%3D6&token=u%2FCznNxH1a%2Bn%2BHqAw%2FWW4Yg6gCiox5E82%2FxGq0BjZ8B9CvnvS19r25Xc9Q746FvmRb57egnYFmhiOST5I9OF1qQhddpqoeKgR%2FU9SYBWclzYEjGb9W2jLFdmcFTVOQRpVoau9hC93TXktboHpOiP3K8AtSQsFLDSFqHlsS1NKKs%3D&TOPIC_ID=2548https://www.uptodate.com/external-redirect?target_url=https%3A%2F%2Fwww.asge.org%2Fdocs%2Fdefault-source%2Feducation%2Fpractice_guidelines%2Fdoc-b4349a10-9b72-463e-ac70-f394c7aa20b4.pdf%3Fsfvrsn%3D6&token=u%2FCznNxH1a%2Bn%2BHqAw%2FWW4Yg6gCiox5E82%2FxGq0BjZ8B9CvnvS19r25Xc9Q746FvmRb57egnYFmhiOST5I9OF1qQhddpqoeKgR%2FU9SYBWclzYEjGb9W2jLFdmcFTVOQRpVoau9hC93TXktboHpOiP3K8AtSQsFLDSFqHlsS1NKKs%3D&TOPIC_ID=2548https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1-5https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/contributorshttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/contributorshttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/contributorshttps://www.uptodate.com/home/editorial-policyINITIAL EVALUATIONThe initial evaluation of a patient with a suspected clinically significant acute upper GI bleedincludes a history, physical examination, and laboratory tests. The goal of the evaluation is toassess the severity of the bleed, identify potential sources of the bleed, and determine ifthere are conditions present that may affect subsequent management. The informationgathered as part of the initial evaluation is used to guide decisions regarding triage,resuscitation, empiric medical therapy, and diagnostic testing.Factors that are predictive of a bleed coming from an upper GI source identified in a meta-analysis included a patient-reported history of melena (likelihood ratio [LR] 5.1-5.9), melenicstool on examination (LR 25), blood or coffee grounds detected during nasogastric lavage (LR9.6), and a ratio of blood urea nitrogen to serum creatinine greater than 30 (LR 7.5) [6]. Onthe other hand, the presence of blood clots in the stool made an upper GI source less likely(LR 0.05). Factors associated with severe bleeding included red blood detected duringnasogastric lavage (LR 3.1), tachycardia (LR 4.9), or a hemoglobin level of less than 8 g/dL (LR4.5-6.2).Bleeding manifestations—Hematemesis (either red blood or coffee-ground emesis)suggests bleeding proximal to the ligament of Treitz. The presence of frankly bloody emesissuggests moderate to severe bleeding that may be ongoing, whereas coffee-ground emesissuggests more limited bleeding.The majority of melena (black, tarry stool) originates proximal to the ligament of Treitz (90percent), though it may also originate from the oropharynx or nasopharynx, small bowel, orcolon [7]. Melena may be seen with variable degrees of blood loss, being seen with as littleas 50 mL of blood [8].Hematochezia (red or maroon blood in the stool) is usually due to lower GI bleeding.However, it can occur with massive upper GI bleeding [9], which is typically associated withorthostatic hypotension. (See 'Physical examination' below.)Past medical history—Patients should be asked about prior episodes of upper GI bleeding,since up to 60 percent of patients with a history of an upper GI bleed are bleeding from thesame lesion [10]. In addition, the patient's past medical history should be reviewed toidentify important comorbid conditions that may lead to upper GI bleeding or may influencethe patient's subsequent management.Potential bleeding sources suggested by a patient's past medical history include:Varices or portal hypertensive gastropathy in a patient with a history of liver disease orexcess alcohol use●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source…2/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/6https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/7https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/8https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/9https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/10Comorbid illnesses may influence patient management in the setting of an acute upper GIbleed. Comorbid illnesses may:Medication history—A thorough medication history should be obtained, with particularattention paid to drugs that:Aorto-enteric fistula in a patient with a history of an abdominal aortic aneurysm or anaortic graft●Angiodysplasia in a patient with renal disease, aortic stenosis, or hereditaryhemorrhagic telangiectasia●Peptic ulcer disease in a patient with a history of Helicobacter pylori (H. pylori) infection,nonsteroidal anti-inflammatory drug (NSAIDs) use, antithrombotic use, or smoking●Malignancy in a patient with a history of smoking, excess alcohol use, or H. pyloriinfection●Marginal ulcers (ulcers at an anastomotic site) in a patient with a gastroentericanastomosis●Make patients more susceptible to adverse effects of anemia (eg, coronary arterydisease, pulmonary disease). Such patients may need to be maintained at higherhemoglobin levels than patients without these disorders. (See 'Blood producttransfusions' below.)●Predispose patients to volume overload in the setting of vigorous fluid resuscitation orblood transfusions (eg, renal disease, heart failure). Such patients may need moreinvasive monitoring during resuscitation. (See 'General support' below.)●Result in bleeding that is more difficult to control (eg, coagulopathies,thrombocytopenia, significant hepatic dysfunction). Such patients may need additionalhemostatic therapies. (See 'Blood product transfusions' below.)●Predispose to aspiration of GI contents into the lungs (eg, dementia, hepaticencephalopathy). Endotracheal intubation should be considered in such patients. (See'General support' below.)●Predispose to peptic ulcer formation, such as aspirin and other NSAIDs, including COX-2 inhibitors (see "NSAIDs (including aspirin): Pathogenesis and risk factors forgastroduodenal toxicity").●Are associated with pill esophagitis (see "Pill esophagitis").●Increase risk of bleeding, such as anticoagulants (including warfarin and the direct oralanticoagulants) and antiplatelet agents (eg, P2Y12 inhibitors and aspirin).●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 3/51https://www.uptodate.com/contents/aspirin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/nsaids-including-aspirin-pathogenesis-and-risk-factors-for-gastroduodenal-toxicity?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/nsaids-including-aspirin-pathogenesis-and-risk-factors-for-gastroduodenal-toxicity?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/pill-esophagitis?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/warfarin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/aspirin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkSymptom assessment—Patients should be asked about symptoms as part of theassessment of the severity of the bleed and as a part of the evaluation for potential bleedingsources. Symptoms that suggest the bleeding is severe include orthostatic dizziness,confusion, angina, severe palpitations, and cold/clammy extremities.Specific causes of upper GI bleeding may be suggested by the patient's symptoms [7]:Physical examination—The physical examination is a key component of the assessment ofhemodynamic stability. Signs of hypovolemia include [7]:Examination of the stool color may provide a clue to the location of the bleeding, but it is nota reliable indicator. In a series of 80 patients with severe hematochezia (red or maroon bloodin the stool), 74 percent had a colonic lesion, 11 percent had an upper GI lesion, 9 percenthad a presumed small bowel source, and no site was identified in 6 percent [9]. Nasogastriclavage may be carried out if there is doubt as to whether a bleed originates from the upperGI tract, although is not a sensitive or specific test. (See 'Nasogastric lavage' below.)The presence of abdominal pain, especially if severe and associated with reboundtenderness or involuntary guarding, raises concern for perforation. If any signs of an acuteabdomen are present, further evaluation to exclude a perforation is required prior toendoscopy.Have been associated with GI bleeding, including selective serotonin reuptakeinhibitors (SSRI), calcium channel blockers, and aldosterone antagonists.●May alter the clinical presentation, such as bismuth, charcoal, licorice, and iron, whichcan turn the stool black.●Peptic ulcer – Upper abdominal pain●Esophageal ulcer – Odynophagia, gastroesophageal reflux, dysphagia●Mallory-Weiss tear – Emesis, retching, or coughing prior to hematemesis●Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, abdominaldistention (ascites)●Malignancy – Dysphagia, early satiety, involuntary weight loss, cachexia●Mild to moderate hypovolemia (less than 15 percent of blood volume lost) – Restingtachycardia.●Blood volume loss of at least 15 percent – Orthostatic hypotension (a decrease in thesystolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20beats per minute when moving from recumbency to standing).●Blood volume loss of at least 40 percent – Supine hypotension.●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 4/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/7https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/7https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/9Finally, as with the past medical history, the physical examination should include a search forevidence of significant comorbid illnesses. (See 'Past medical history' above.)Laboratory data—Laboratory tests that should be obtained in patients with acute uppergastrointestinal bleeding include a complete blood count, serum chemistries, liver tests, andcoagulation studies. In addition, serial electrocardiograms and cardiac enzymes may beindicated in patients who are at risk for a myocardial infarction, such as older adults, patientswith a history of coronary artery disease, or patients with symptoms such as chest pain ordyspnea. (See "Diagnosis of acute myocardial infarction".)The initial hemoglobin level in patients with acute upper GI bleeding may be at the patient'sbaseline because the patient is losing whole blood. With time, the hemoglobin level willdecline as the blood is diluted by the influx of extravascular fluid into the vascular space andby fluid administered during resuscitation. The hemoglobin level should initially bemonitored every two to eight hours, depending upon the severity of the bleed.Acute bleeding does not alter the mean corpuscular volume (MCV). If the MCV is low, it maysuggest iron deficiency,which could be caused by chronic bleeding. Anemia or otherabnormalities on the CBC that persist after recovery from the acute bleeding event should beevaluated. (See "Diagnostic approach to anemia in adults".)Because blood is absorbed as it passes through the small bowel and patients may havedecreased renal perfusion, patients with acute upper GI bleeding typically have an elevatedblood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio. Values >30:1 or >100:1,respectively, suggest upper GI bleeding as the cause [6,11-13]. The higher the ratio, the morelikely the bleeding is from an upper GI source [11].Nasogastric lavage—The use of nasogastric tube (NGT) placement in patients withsuspected acute upper GI bleeding is not recommended, as studies have failed todemonstrate a benefit with regard to clinical outcomes [5,14,15]. As an example, aretrospective study looked at whether there were clinical benefits from NGT lavage in 632patients admitted with gastrointestinal bleeding [16]. Patients who underwent NGT lavagewere matched with patients with similar characteristics who did not undergo NGT lavage.NGT lavage was associated with a shorter time to endoscopy. However, there were nodifferences between those who underwent NGT lavage and those who did not with regard tomortality, length of hospital stay, surgery, or transfusion requirement. Similarly, in arandomized trial with 280 patients with upper GI bleeding, there were no differences inrebleeding rates or mortality between patients who underwent NGT lavage and those whodid not [17].NGT lavage may be used when it is unclear if a patient has ongoing bleeding and thus mightbenefit from an early endoscopy. In addition, NGT lavage can be used to remove particulate6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 5/51https://www.uptodate.com/contents/diagnosis-of-acute-myocardial-infarction?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/diagnostic-approach-to-anemia-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/6,11-13https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/11https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/5,14,15https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/16https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/17matter, fresh blood, and clots from the stomach to facilitate endoscopy. (See "Inpatientplacement and management of nasogastric and nasoenteric tubes in adults", section on'Tube placement'.)The presence of red blood or coffee ground material in the nasogastric aspirate alsoconfirms an upper GI source of bleeding and predicts whether the bleeding is caused by alesion at increased risk for ongoing or recurrent bleeding [16,18]. However, lavage may notbe positive if bleeding has ceased or arises beyond a closed pylorus. Nasogastric aspirationof nonbloody bilious fluid suggests that the pylorus is open and that there is no active upperGI bleeding distal to the pylorus [9].We suggest that patients only undergo NGT lavage if particulate matter, fresh blood, or clotsneed to be removed from the stomach to facilitate endoscopy. An alternative to NGT lavagein this situation is to use a prokinetic such as erythromycin. (See 'Prokinetics' below.)GENERAL MANAGEMENTHemodynamically unstable patients—While the principles behind the management of allpatients with upper gastrointestinal bleeding are similar, there are some specialconsiderations when it comes to patients presenting with hemodynamic instability (shock,orthostatic hypotension) ( table 1).Intravenous access—Adequate peripheral access should be attained with either two 18gauge or larger intravenous catheters and/or a large-bore, single-lumen central cordis.Fluid resuscitation—Fluid resuscitation should begin immediately and should not bedelayed pending transfer of the patient to an intensive care unit. The approach to fluidresuscitation in patients who are hemodynamically unstable is discussed in detail elsewhere.(See "Evaluation of and initial approach to the adult patient with undifferentiatedhypotension and shock", section on 'Hemodynamic support'.)Transfusion—For patients with active/brisk bleeding and hypovolemia, transfusion shouldbe guided by hemodynamic parameters (eg, pulse and blood pressure), the pace of thebleeding, estimated blood loss, and the ability to stop the bleeding, rather than by serialhemoglobin measurements. If the initial hemoglobin level is low (<7 g/dL) transfusionsshould be initiated [19,20]. In an acutely hemorrhaging patient, however, transfusionsupport should not be delayed while awaiting laboratory test results. (See "Indications andhemoglobin thresholds for RBC transfusion in adults", section on 'Acute bleeding'.)Patients without active bleeding who become hemodynamically stable with fluidresuscitation are managed like other patients who are hemodynamically stable. For moststable patients, a restrictive transfusion strategy is appropriate (transfuse if hemoglobin is6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 6/51https://www.uptodate.com/contents/inpatient-placement-and-management-of-nasogastric-and-nasoenteric-tubes-in-adults?sectionName=TUBE%20PLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H522921948&source=see_link#H522921948https://www.uptodate.com/contents/inpatient-placement-and-management-of-nasogastric-and-nasoenteric-tubes-in-adults?sectionName=TUBE%20PLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H522921948&source=see_link#H522921948https://www.uptodate.com/contents/inpatient-placement-and-management-of-nasogastric-and-nasoenteric-tubes-in-adults?sectionName=TUBE%20PLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H522921948&source=see_link#H522921948https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/16,18https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/9https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?sectionName=Hemodynamic%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H87905475&source=see_link#H87905475https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?sectionName=Hemodynamic%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H87905475&source=see_link#H87905475https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/19,20https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681<7g/dL [<70 g/L] rather than at a higher hemoglobin) ( algorithm 1). (See 'Blood producttransfusions' below.)Medications and endoscopy—The approach to medications (eg, proton pump inhibitors)and endoscopy are similar for patients with hemodynamic instability compared with patientswho are hemodynamically stable. It is particularly important to ensure that these patientsare adequately resuscitated prior to undergoing upper endoscopy. (See 'Medications' belowand 'Upper endoscopy' below.)Triage—All patients with hemodynamic instability or active bleeding (manifested byhematemesis, bright red blood per nasogastric tube, or hematochezia) should be admittedto an intensive care unit for resuscitation and close observation with automated bloodpressure monitoring, electrocardiographic monitoring, and pulse oximetry.A table outlining the emergency management of acute severe upper gastrointestinalbleeding is provided ( table 1).Other patients can be admitted to a regular medical ward, though we suggest that alladmitted patients with the exception of low-risk patients receive electrocardiographicmonitoring. Outpatient management may be appropriate for some low-risk patients.Determining the appropriate site of care for a patient can be facilitated using riskstratification scores, such as the Glasgow-Blatchford score. Use of these scores isrecommended in the International Consensus Group guideline [1]. (See 'Risk stratification'below.)General support—Patients should receive supplemental oxygen by nasal cannula andshould receive nothing per mouth. Two large caliber (18 gauge or larger) peripheralintravenous catheters or a central venous line should be inserted. For patients who arehemodynamically unstable, two 16 gauge intravenous catheters and/or a large-bore, single-lumen central cordis should be placed.Elective endotracheal intubation in patients with ongoing hematemesis or altered respiratoryor mental status may facilitate endoscopy and decrease the risk of aspiration. However,among patients who are critically ill, elective endotracheal intubation has been associatedwith worse outcomes. Our approach is to proceed with intubation in patients deemed high-risk for aspiration, including those with massive upper gastrointestinal (GI) bleeding oraltered mental status.A case control study with 200 patients with upper GI bleeding who were critically ill foundthat patients who had elective endotracheal intubation were more likely than patients whowere not intubated to have adverse cardiopulmonary outcomes based on a compositeoutcome that included pneumonia, pulmonary edema, acute respiratory distress syndrome,and cardiac arrest [21]. Of note, the presence of respiratory distress prior to intubation was6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 7/51https://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/21not reported and the mean Glasgow Coma Scale score was 14.7 (+/- 0.95), indicating thataltered mental status was absent in the majority of patients. Patients who were electivelyintubated were more likely to suffer cardiopulmonary complications compared with patientswho were not intubated (20.0 versus 6.0 percent). In particular, patients who were intubatedwere more likely to be diagnosed with pneumonia within 48 hours (14.0 versus 2.0 percent).Fluid resuscitation—Adequate resuscitation and hemodynamic stabilization is essentialprior to endoscopy to minimize treatment-associated complications [22]. Patients with activebleeding should receive intravenous fluids (eg, 500 mL of normal saline or lactated Ringer'ssolution over 30 minutes) while being typed and cross-matched for blood transfusion. Therate of fluid resuscitation will in part depend on whether the patient is hemodynamicallyunstable. Patients at risk of fluid overload may require intensive monitoring.If the blood pressure fails to respond to initial resuscitation efforts, the rate of fluidadministration should be increased. In some patients, temporary support with vasopressordrugs may be required. (See "Evaluation of and initial approach to the adult patient withundifferentiated hypotension and shock", section on 'Hemodynamic support' and"Treatment of severe hypovolemia or hypovolemic shock in adults", section on 'Initial rate offluid repletion'.)Blood product transfusionsAnemiaGeneral approach—The decision to initiate blood transfusion must be individualized( algorithm 1). Our approach is to initiate blood transfusion if the hemoglobin is <7 g/dL(<70-g/L) [1,23-26]. For most patients, our goal is to maintain the hemoglobin at a level ≥7g/dL (70 g/L), rather than at a higher level. However, for patients at increased risk of adverseevents in the setting of significant anemia, such as those with coronary artery disease or inthose with evidence of ongoing active bleeding, our goal is to maintain the hemoglobin at alevel of ≥8 g/dL (80 g/L). We do not have an age cutoff for determining which patients shouldhave a goal hemoglobin of ≥8 g/dL (80 g/L), and instead base the decision on the patient'scomorbid conditions. Hemoglobin thresholds for individuals with other features, such asacute coronary syndrome (ACS), are summarized in the table and discussed separately. (See"Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acute MI'.)Using a restrictive transfusion strategy for most hemodynamically stable patients wassupported by a meta-analysis of five randomized trials with a total of 1965 patients withacute upper gastrointestinal bleeding [19]. Patients assigned to a restrictive transfusionstrategy had a lower all-cause mortality than those assigned to a liberal transfusion strategy(absolute risk reduction [ARR] 2.2 percent, relative risk [RR] 0.65, 95% CI 0.44-0.97) andrebleeding (ARR 4.4 percent, RR 0.58, 95% CI 0.40-0.84). While two of the studies used a6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 8/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/22https://www.uptodate.com/contents/sodium-chloride-preparations-saline-and-oral-salt-tablets-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/lactated-ringer-solution-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?sectionName=Hemodynamic%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H87905475&source=see_link#H87905475https://www.uptodate.com/contents/evaluation-of-and-initial-approach-to-the-adult-patient-with-undifferentiated-hypotension-and-shock?sectionName=Hemodynamic%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H87905475&source=see_link#H87905475https://www.uptodate.com/contents/treatment-of-severe-hypovolemia-or-hypovolemic-shock-in-adults?sectionName=INITIAL%20RATE%20OF%20FLUID%20REPLETION&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H580797430&source=see_link#H580797430https://www.uptodate.com/contents/treatment-of-severe-hypovolemia-or-hypovolemic-shock-in-adults?sectionName=INITIAL%20RATE%20OF%20FLUID%20REPLETION&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H580797430&source=see_link#H580797430https://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1,23-26https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20MI&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H812290&source=see_link#H812290https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/19cutoff of 7 g/dL (70 g/L) for a restrictive transfusion strategy and three used a cutoff of 8 g/dL(80 g/L), all of the studies favored a restrictive transfusion strategy. There were nodifferences between patients with cirrhosis and those with non-variceal bleeding. Onsubgroup analysis, there were non-statistically significant trends toward a higher risk ofmortality with a restrictive transfusion strategy among patients with ischemic heart disease(RR 4.4, 95% CI 0.27-22) and a lower risk of mortality among patients without ischemic heartdisease (RR 0.58, 95% CI 0.86-1.3). Rebleeding risk was similar between those with andwithout ischemic heart disease (RR 0.50 and 0.69, respectively).The meta-analysis did not detect a difference between a restrictive and a liberal transfusionstrategy in the risk of myocardial infarction (RR 0.79, 95% CI 0.33-1.89), stroke (RR 0.49, 95%CI 0.12-2.01), or acute kidney injury (RR 0.77, 0.56-1.05), but not all of the included trialsreported these outcomes.Suspected variceal bleeding—It is important to avoid overtransfusion in patientswith suspected variceal bleeding. In patients with variceal bleeding, we transfuse once thehemoglobin is <7 g/dL (<70 g/L), with the goal of increasing the hemoglobin to ≥7 g/dL (70g/L). We do not use a higher transfusion threshold (eg, <9 g/dL [90 g/L]), as transfusion canprecipitate worsening of the bleeding [25,27]. (See "Overview of the management of patientswith variceal bleeding", section on 'Resuscitation and support'.)Active bleeding and hypovolemia—For patients with active/brisk bleeding andhypovolemia, decisions about transfusion are guided by hemodynamic parameters (eg, pulseand blood pressure), the pace of the bleeding, estimated blood loss, and the ability to stopthe bleeding, rather than by serial hemoglobin measurements. Patients who require massivetransfusion (defined by institutional protocols, often >3 units of RBCs in an hour or 10 unitsof RBCs in 24 hours) may also need replacement of coagulation factors and/or platelets. (See"Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acutebleeding' and "Massive blood transfusion", section on 'Approach to volume and bloodreplacement'.)Thrombocytopenia—Patients with critical or life-threatening bleeding and a low plateletcount (<50,000/microL) should be transfused with platelets. Limited data suggest thatproceeding with upper endoscopy in patients with thrombocytopenia is generally safe [28],though whether there is a lower limit below which endoscopy should be delayed is unclear[29]. Our approach is to perform an upper endoscopy if the platelet count is >20,000/microL,though if the patient is suspected to have active bleeding, we attempt to raise the plateletcount to >50,000/microL prior to endoscopy.In the past, platelet transfusions were considered in non-thrombocytopenic or mildlythrombocytopenic patients with life-threatening bleeding who had been taking antiplateletagents such as aspirin or clopidogrel [30]. However, high-quality evidence regarding the6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 9/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/25,27https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?sectionName=Resuscitation%20and%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H5&source=see_link#H5https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?sectionName=Resuscitation%20and%20support&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H5&source=see_link#H5https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/28https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/29https://www.uptodate.com/contents/aspirin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/clopidogrel-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/30benefit of platelet transfusion is lacking, and some evidence suggests that platelettransfusion may be deleterious [31]. Because these cases can be complex, an individualizedapproach based on the complete clinical picture is required. Potential adverse effects ofplatelet transfusion are discussed separately. (See "Platelet transfusion: Indications,ordering, and associated risks", section on 'Complications'.)If the patient is taking antiplatelet medications because of a recent (less than one year)vascular stent placement or acute coronary syndrome, when possible, a cardiologist shouldbe consulted prior to stopping the medications.Managing anticoagulants, antiplatelet agents, and coagulopathiesAnticoagulants and antiplatelet agents—The approach to management ofanticoagulants and antiplatelet agents depends on the medications being used and theirindications, how severe the bleeding is, and how quickly reversal of anticoagulation isneeded. The medications and products that may be used to reverse anticoagulation arediscussed in the tables and separate topic reviews:For most patients, endoscopy should not be delayed because of anticoagulant or antiplateletagent use [1]. Provided the patient is hemodynamically stable, urgent endoscopy can usuallyproceed simultaneously with management of antithrombotic medications. However, forpatients undergoing upper endoscopy, we wait until the INR is <2.5 to perform theendoscopy, if possible [32]. This approach is based on data that suggest endoscopy is safeand endoscopic therapy effective in patients who are mildly to moderately anticoagulated[33].When possible, anticoagulants and antiplatelet agents should be held in patients with acuteupper GI bleeding. In patients with severe, ongoing bleedingwho are taking ananticoagulant, administration of a reversal agent or intravenous prothrombin complexconcentrate may be indicated. However, the thrombotic risk of reversing anticoagulationshould be weighed against the risk of continued bleeding without reversal, and thus thedecision to discontinue medications or administer reversal agents needs to be individualized.For antiplatelet agents, the decision to discontinue may be straightforward (eg, stopping anonsteroidal anti-inflammatory drug in a patient who is taking it for mild joint pain).However, in more complicated cases, consultation with the provider who prescribed theWarfarin ( table 2) (see "Management of warfarin-associated bleeding orsupratherapeutic INR", section on 'Treatment of bleeding')●Direct oral anticoagulants (DOACs) ( table 3) (see "Management of bleeding inpatients receiving direct oral anticoagulants", section on 'Major bleeding')●Heparins (see "Heparin and LMW heparin: Dosing and adverse effects", section on'Reversal')●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 10/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/31https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks?sectionName=COMPLICATIONS&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H382870592&source=see_link#H382870592https://www.uptodate.com/contents/platelet-transfusion-indications-ordering-and-associated-risks?sectionName=COMPLICATIONS&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H382870592&source=see_link#H382870592https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/32https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/33https://www.uptodate.com/contents/warfarin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F89478&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F89478&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/management-of-warfarin-associated-bleeding-or-supratherapeutic-inr?sectionName=TREATMENT%20OF%20BLEEDING&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H6&source=see_link#H6https://www.uptodate.com/contents/management-of-warfarin-associated-bleeding-or-supratherapeutic-inr?sectionName=TREATMENT%20OF%20BLEEDING&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H6&source=see_link#H6https://www.uptodate.com/contents/image?imageKey=HEME%2F96230&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=HEME%2F96230&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants?sectionName=MAJOR%20BLEEDING&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H3105425&source=see_link#H3105425https://www.uptodate.com/contents/management-of-bleeding-in-patients-receiving-direct-oral-anticoagulants?sectionName=MAJOR%20BLEEDING&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H3105425&source=see_link#H3105425https://www.uptodate.com/contents/heparin-and-lmw-heparin-dosing-and-adverse-effects?sectionName=Reversal&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H81746&source=see_link#H81746https://www.uptodate.com/contents/heparin-and-lmw-heparin-dosing-and-adverse-effects?sectionName=Reversal&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H81746&source=see_link#H81746antiplatelet medication should be considered. (See "Management of anticoagulants inpatients undergoing endoscopic procedures", section on 'Urgent procedures' and"Management of antiplatelet agents in patients undergoing endoscopic procedures" and"Gastrointestinal endoscopy in patients with disorders of hemostasis".)When to resume these medications once hemostasis has been achieved will depend on thepatient's risks for thrombosis and recurrent bleeding. (See "Management of anticoagulantsin patients undergoing endoscopic procedures", section on 'Resuming anticoagulants afterhemostasis' and "Overview of the treatment of bleeding peptic ulcers", section on 'Riskfactors for persistent or recurrent bleeding'.)Coagulopathies related to cirrhosis—The management of coagulopathies in patientswith cirrhosis is particularly complicated. In patients with cirrhosis, the INR is not an accuratemeasure of coagulation because it only reflects changes in procoagulant factors, and bothprocoagulant and anticoagulant factors are reduced. These issues are discussed separately.(See "Hemostatic abnormalities in patients with liver disease", section on 'Bleeding'.)Other bleeding disorders—For individuals with other bleeding disorders, consultationwith hematology (the patient's primary hematologist if possible) is prudent. They can adviseregarding specific products, dosing, and monitoring based on the individual's specificdisorder and medical history.Dilutional coagulopathy—Patients who require massive transfusion (defined byinstitutional protocols, often >3 units RBCs in an hour or 10 units RBCs in 24 hours) may alsoneed replacement of coagulation factors and/or platelets. (See "Indications and hemoglobinthresholds for RBC transfusion in adults", section on 'Acute bleeding' and "Massive bloodtransfusion", section on 'Approach to volume and blood replacement'.)MedicationsAcid suppression—Patients admitted to the hospital with acute upper GI bleeding aretypically treated with a proton pump inhibitor (PPI). The optimal approach to PPIadministration prior to endoscopy is unclear. Options include giving an IV PPI every 12 hoursor starting a continuous infusion. Our approach is to give a high-dose bolus (eg,esomeprazole 80 mg) to patients with signs of active bleeding (eg, hematemesis,hemodynamic instability).Typically, we try to perform endoscopy on patients with suspected ongoing active bleedingafter resuscitation within 12 hours. If endoscopy is performed after 12 hours, a second doseof an IV PPI should be given 12 hours later (eg, esomeprazole 40 mg). For patients who mayhave stopped bleeding (eg, patients who are hemodynamically stable with melena), we givean IV PPI every 12 hours (eg, esomeprazole 40 mg). Subsequent dosing will then depend onthe endoscopic findings. Oral formulations (eg, esomeprazole 40 mg orally twice daily) are a6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&source… 11/51https://www.uptodate.com/contents/management-of-anticoagulants-in-patients-undergoing-endoscopic-procedures?sectionName=URGENT%20PROCEDURES&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H12&source=see_link#H12https://www.uptodate.com/contents/management-of-anticoagulants-in-patients-undergoing-endoscopic-procedures?sectionName=URGENT%20PROCEDURES&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H12&source=see_link#H12https://www.uptodate.com/contents/management-of-antiplatelet-agents-in-patients-undergoing-endoscopic-procedures?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/gastrointestinal-endoscopy-in-patients-with-disorders-of-hemostasis?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/management-of-anticoagulants-in-patients-undergoing-endoscopic-procedures?sectionName=Resuming%20anticoagulants%20after%20hemostasis&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H15&source=see_link#H15https://www.uptodate.com/contents/management-of-anticoagulants-in-patients-undergoing-endoscopic-procedures?sectionName=Resuming%20anticoagulants%20after%20hemostasis&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H15&source=see_link#H15https://www.uptodate.com/contents/management-of-anticoagulants-in-patients-undergoing-endoscopic-procedures?sectionName=Resuming%20anticoagulants%20after%20hemostasis&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H15&source=see_link#H15https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Risk%20factors%20for%20persistent%20or%20recurrent%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H97407782&source=see_link#H97407782https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Risk%20factors%20for%20persistent%20or%20recurrent%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H97407782&source=see_link#H97407782https://www.uptodate.com/contents/hemostatic-abnormalities-in-patients-with-liver-disease?sectionName=BLEEDING&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H61498824&source=see_link#H61498824https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2https://www.uptodate.com/contents/esomeprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/esomeprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkreasonable alternative if IV formulations are not available. Pantoprazole and esomeprazoleare the only intravenous formulations available in the United States, and intravenouslansoprazole has been removed from the world market. (See "Overview of the treatment ofbleeding peptic ulcers", section on 'Acid suppression'.)Several studies have examined the role of acid suppression given before or after endoscopy(with or without therapeutic intervention) [34-45]. In the setting of active upper GI bleedingfrom an ulcer, acid suppressive therapy with H2 receptor antagonists has not been shown tosignificantly lower the rate of ulcer rebleeding [39,42,46]. By contrast, high doseantisecretory therapy with an intravenous infusion of a PPI significantly reduces the rate ofrebleeding compared with standard treatment in patients with bleeding ulcers [47]. Oral andintravenous PPI therapy also decrease the length of hospital stay, rebleeding rate, and needfor blood transfusion in patients with high-risk ulcers treated with endoscopic therapy. (See"Overview of the treatment of bleeding peptic ulcers", section on 'Acid suppression'.)PPIs may also promote hemostasis in patients with lesions other than ulcers. This likelyoccurs because neutralization of gastric acid leads to the stabilization of blood clots [45].Prokinetics—Both erythromycin and metoclopramide have been studied in patients withacute upper GI bleeding [48-57]. The goal of using a prokinetic agent is to improve gastricvisualization at the time of endoscopy by clearing the stomach of blood, clots, and foodresidue. We suggest that erythromycin be used before endoscopy. A reasonable dose is 250mg intravenously over 20 to 30 minutes. Endoscopy is performed 20 to 90 minutes followingcompletion of the erythromycin infusion. Patients receiving erythromycin need to bemonitored for QTc prolongation. In addition, drug-drug interactions should be evaluatedbefore giving erythromycin because it is a cytochrome P450 3A inhibitor ( table 4).Erythromycin promotes gastric emptying based upon its ability to be an agonist of motilinreceptors. Using erythromycin to improve gastric visualization has been studied in severalrandomized controlled trials and meta-analyses [48-56]. The randomized trials were includedin a 2016 meta-analysis that examined the role of pre-endoscopic erythromycin [55]. Themeta-analysis included eight randomized trials with 598 patients with upper gastrointestinalbleeding and compared patients who received erythromycin with those who did not. Patientswho received erythromycin were more likely to have adequate gastric visualization (77 versus51 percent, odds ratio [OR] 4.14; 95% CI 2.01-8.53), were less likely to require second-lookendoscopy (15 versus 26 percent, OR 0.51; 95% CI 0.34-0.77), and had shorter hospital stays(mean difference -1.75 days, 95% CI -2.43 to -1.06). There were no differences in units ofblood transfused, endoscopy duration, or need for emergent surgery between those whor*ceived erythromycin and those who did not. A second meta-analysis also found bettervisualization with the use of erythromycin [56]. In two trials with 195 patients, patients whor*ceived erythromycin scored higher than patients who received placebo on a 16-point6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 12/51https://www.uptodate.com/contents/pantoprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/lansoprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Acid%20suppression&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224540&source=see_link#H57224540https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Acid%20suppression&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224540&source=see_link#H57224540https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/34-45https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/39,42,46https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/47https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Acid%20suppression&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224540&source=see_link#H57224540https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/45https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/metoclopramide-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/48-57https://www.uptodate.com/contents/image?imageKey=DRUG%2F76992&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=DRUG%2F76992&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/48-56https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/55https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/56ordinal scale, with higher scores indicating better visualization (mean difference 3.63 points,95% CI 2.20- 5.05).Some trials have compared pre-endoscopy erythromycin with nasogastric lavage. In onetrial, 253 patients were assigned to receive erythromycin alone, nasogastric lavage alone, ornasogastric lavage plus erythromycin. It found that the quality of visualization did not differsignificantly among the three groups [52]. In addition, there were no differences among thegroups with regard to procedure duration, rebleeding rates, need for second endoscopy,number of transfused units of blood, and mortality. A meta-analysis also failed to show asignificant difference between erythromycin and nasogastric lavage [56]. (See 'Nasogastriclavage' above.)Metoclopramide has also been studied as an approach to improving gastric visualization. Ina randomized trial with 62 patients with active upper GI bleeding, intravenousmetoclopramide (10 mg administered over five minutes) given 30 to 120 minutes prior toendoscopy was similar to placebo with regard to adequate visualization (77 versus 62percent, OR 2.16 [95% CI 0.71-6.58]), but decreased the need for second-look endoscopy (3.2versus 23 percent, OR 0.11 [95% CI 0.01-0.99]) [57]. Among the subset of patients with gastriclesions, metoclopramide increased the rate of adequate visualization (93 versus 50 percent,OR 13 [95% CI 1.32-128.1]). This trial suggests that metoclopramide may be an alternative toerythromycin if erythromycin is not available or is contraindicated.Vasoactive medications—Somatostatin, its analog octreotide, and terlipressin are used inthe treatment of variceal bleeding and may also reduce the risk of bleeding due tononvariceal causes. In patients with suspected variceal bleeding, octreotide is given as anintravenous bolus of 50 mcg, followed by a continuous infusion at a rate of 50 mcg per hour.(See "Methods to achieve hemostasis in patients with acute variceal hemorrhage", section on'Somatostatin and its analogs'.)Octreotide is not recommended for routine use in patients with acute nonvariceal upper GIbleeding, but it can be used as adjunctive therapy in some cases. Its role is generally limitedto settings in which endoscopy is unavailable or as a means to help stabilize patients beforedefinitive therapy can be performed. (See "Overview of the treatment of bleeding pepticulcers", section on 'Somatostatin and octreotide'.)Antibiotics for patients with cirrhosis—Bacterial infections are present in up to 20percent of patients with cirrhosis who are hospitalized with gastrointestinal bleeding; up toan additional 50 percent develop an infection while hospitalized. Such patients haveincreased mortality.Multiple trials evaluating the effectiveness of prophylactic antibiotics in cirrhotic patientshospitalized for GI bleeding suggest an overall reduction in infectious complications and6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 13/51https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/52https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/56https://www.uptodate.com/contents/metoclopramide-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/57https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/octreotide-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/terlipressin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=Somatostatin%20and%20its%20analogs&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H62477672&source=see_link#H62477672https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=Somatostatin%20and%20its%20analogs&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H62477672&source=see_link#H62477672https://www.uptodate.com/contents/octreotide-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Somatostatin%20and%20octreotide&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224611&source=see_link#H57224611https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Somatostatin%20and%20octreotide&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224611&source=see_link#H57224611possibly decreased mortality. Antibiotics may also reduce the risk of recurrent bleeding inhospitalized patients who bled from esophageal varices. A reasonable conclusion from thesedata is that patients with cirrhosis who present with acute upper GI bleeding (from varices orother causes) should be given prophylactic antibiotics, preferably before endoscopy(although effectiveness has also been demonstrated when given after endoscopy). (See"Overview of the management of patients with variceal bleeding".)Ineffective treatments—Tranexamic acid is an antifibrinolytic agent that has beenstudied in patients with upper GI bleeding and does not appear to be beneficial [58,59]. Ameta-analysis that included eight randomized trials of tranexamic acid in patients with upperGI bleeding found a benefit with regard to mortality but not with regard to bleeding, surgery,or transfusion requirements [58]. However, when only studies that used antiulcer drugsand/or endoscopic therapy were included, there was no beneficial effect.In a subsequent randomized trial with 12,009 patients with GI bleeding (most of whom hadevidence of upper GI bleeding), use of tranexamic acid did not reduce the risk of death dueto bleeding within five days (4 percent with tranexamic acid, 4 percent with placebo) [59].Tranexamic acid use was associated with an increase in venous thromboembolic events(deep vein thrombosis, pulmonary embolism) and seizures compared with placebo (relativerisks of 1.85 and 1.73, respectively).The randomized trial and meta-analysis suggest that there is no role for tranexamic acid inthe treatment of upper GI bleeding.ConsultationsGastroenterology – Gastroenterological consultation should be obtained in all patientswith suspected clinically significant acute upper GI bleeding.●Transfusion medicine (if available) – The transfusion medicine service or clinicalpathology/blood bank physician should be alerted if the patient may require a massivetransfusion protocol so they can ensure that adequate blood products are available.●Hematology – Hematology consultation can help if emergency reversal ofanticoagulation is indicated and/or if abnormal clotting tests are unexplained.●Surgery/interventional radiology – The decision to obtain surgical and interventionalradiology consultations prior to endoscopy should be based upon the likelihood ofpersistent or recurrent bleeding, or risks/complications stemming from endoscopictherapy (perforation, precipitation of massive bleeding).●Clinician who prescribed an anticoagulant or antiplatelet agent (if relevant) – If ananticoagulantor antiplatelet agent needs to be discontinued and/or reversed due to●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 14/51https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/tranexamic-acid-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/58,59https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/58https://www.uptodate.com/contents/tranexamic-acid-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/59https://www.uptodate.com/contents/tranexamic-acid-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkAs a general rule, we obtain surgical and interventional radiology consultation if endoscopictherapy is unlikely to be successful, if the patient is deemed to be at high risk for rebleedingor complications associated with endoscopy, or if there is concern that the patient may havean aorto-enteric fistula. In addition, a surgeon and an interventional radiologist should bepromptly notified of all patients with severe acute upper GI bleeding, such as thosepresenting with hemodynamic instability that fails to respond to resuscitation [60].DIAGNOSTIC STUDIESAn algorithm providing an overview of the diagnostic approach to patients with suspectedupper gastrointestinal bleeding is provided ( algorithm 2).Upper endoscopy—Upper endoscopy is the diagnostic modality of choice for acute upperGI bleeding ( algorithm 2) [61,62]. Endoscopy has a high sensitivity and specificity forlocating and identifying bleeding lesions in the upper GI tract. In addition, once a bleedinglesion has been identified, therapeutic endoscopy can achieve acute hemostasis and preventrecurrent bleeding in most patients. Early endoscopy (within 24 hours) is recommended formost patients with acute upper GI bleeding. For patients with suspected variceal bleeding,we perform endoscopy within 12 hours of presentation. (See 'Early endoscopy' below and"Methods to achieve hemostasis in patients with acute variceal hemorrhage", section on'Initial management' and "Overview of the treatment of bleeding peptic ulcers", section on'Endoscopic therapy' and "Methods to achieve hemostasis in patients with acute varicealhemorrhage", section on 'Management of esophageal varices'.)Endoscopic findings in patients with bleeding peptic ulcers are described using the modifiedForrest classification [63]. Findings include spurting hemorrhage (class Ia) ( picture 1),oozing hemorrhage (class Ib), a nonbleeding visible vessel (class IIa) ( picture 2), anadherent clot (class IIb) ( picture 3), a flat pigmented spot (class IIc) ( picture 4), and aclean ulcer base (class III) ( picture 4). The endoscopic appearance helps determine whichlesions require endoscopic therapy. (See "Overview of the treatment of bleeding pepticulcers", section on 'Endoscopic therapy'.)It may be helpful to give a prokinetic agent such as erythromycin or to irrigate the stomachprior to endoscopy to help remove residual blood and other gastric contents. However,despite prokinetic administration or irrigation, the stomach can be obscured with blood,potentially making it difficult to establish a clear diagnosis and/or perform therapeuticmaneuvers. In patients in whom blood obscures the source of bleeding, a second endoscopymay be required to establish a diagnosis and to potentially apply therapy, but routineserious or life-threatening bleeding, the clinician who prescribed the medication shouldbe contacted to discuss plans for resuming it.6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 15/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/60https://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/61,62https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=Initial%20management&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H15&source=see_link#H15https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=Initial%20management&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H15&source=see_link#H15https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=ENDOSCOPIC%20THERAPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H4&source=see_link#H4https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=ENDOSCOPIC%20THERAPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H4&source=see_link#H4https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=MANAGEMENT%20OF%20ESOPHAGEAL%20VARICES&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H61879176&source=see_link#H61879176https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=MANAGEMENT%20OF%20ESOPHAGEAL%20VARICES&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H61879176&source=see_link#H61879176https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/63https://www.uptodate.com/contents/image?imageKey=GAST%2F61646&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F61646&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F54960&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F54960&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F76246&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F76246&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=ENDOSCOPIC%20THERAPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H4&source=see_link#H4https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=ENDOSCOPIC%20THERAPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H4&source=see_link#H4https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linksecond-look endoscopy is not recommended. (See 'Nasogastric lavage' above and "Overviewof the treatment of bleeding peptic ulcers", section on 'Second-look endoscopy'.)Early endoscopy—Our approach is to perform upper endoscopy within 24 hours for mostpatients with upper GI bleeding, but only after adequate resuscitation has been provided.For patients with suspected variceal bleeding, we perform endoscopy within 12 hours ofpresentation.Studies have reached variable conclusions when determining whether the application ofearly endoscopy (typically within 24 hours) for risk stratification and treatment reducesresource utilization or affects patient outcomes [64-75]. Some studies have demonstratedreduced resource utilization and improved outcomes from early endoscopy [68,69,71,73-75],while other studies, including a randomized trial, did not [65,66,70].Retrospective studies have suggested that emergency endoscopy (within 12 hours) may beassociated with poor outcomes [70,72], possibly due to inadequate resuscitation in patientsundergoing emergency endoscopy. However, a randomized trial with 516 patients withupper GI bleeding who were at increased risk for death or further bleeding (Glasgow-Blatchford score ≥12) did not find a difference in outcomes between those who underwent"urgent" endoscopy (within six hours of gastroenterology consultation) and "early"endoscopy (between 6 and 24 hours after gastroenterology consultation), though there wasa trend toward worse outcomes in the urgent endoscopy group [64]. Outcomes examined inthe study included 30-day mortality (8.9 versus 6.6 percent with urgent and early endoscopy,respectively; hazard ratio 1.35; 95% CI 0.72 to 2.54) and further bleeding within 30 days (10.9versus 7.8 percent; hazard ratio 1.45; 95% CI 0.83 to 2.58). Of note, because there was a lagbetween presentation and gastroenterology consultation, the patients in the urgentendoscopy group underwent endoscopy a mean of 10 hours after presentation and those inthe early endoscopy group underwent endoscopy a mean of 25 hours after presentation(with 55 percent undergoing endoscopy >24 hours after presentation). In addition, patientswith hemodynamic instability who could not be stabilized were excluded from the study, sothe results may not apply to this group of patients.Risks of endoscopy—Risks of upper endoscopy include pulmonary aspiration, adversereactions to medications used to achieve conscious sedation, GI perforation, and increasingbleeding while attempting therapeutic intervention.While patients need to be hemodynamically stable prior to undergoing endoscopy, datasuggest that patients do not need to have a normal hematocrit in order to safely undergoendoscopy [76]. In addition, endoscopy appears to be safe in patients who are mildly tomoderately anticoagulated [33]. In a retrospective study of 920 patients with upper GIbleeding undergoing upper endoscopy, patients with low hematocrits (<30 percent) weresimilar to those with high hematocrits (>30 percent) with regard to cardiovascular6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 16/51https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Second-look%20endoscopy&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H6550756&source=see_link#H6550756https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Second-look%20endoscopy&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H6550756&source=see_link#H6550756https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/64-75https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/68,69,71,73-75https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/65,66,70https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/70,72https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/64https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/76https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/33complications and mortality [76]. In another retrospective study with 233 patients with upperGI bleeding who received endoscopic therapy, an elevated INR was not associated with anincreased risk of rebleeding, transfusion requirement, surgery, length of stay, or mortality[33]. The INR was between 1.3 and 2.7 in 95 percent of the patients, so the results of thestudy may only apply to patients who are mildly to moderately anticoagulated.The risks versus benefits of upper endoscopy should be considered in high-risk patients,such as those who have had a recent myocardial infarction. In one study, for example, 200patients who underwent endoscopy within 30 days after myocardial infarction (MI) werecompared with 200 controls matched for age, sex, and endoscopic indication [77].Complications (including fatal ventricular tachycardia, near respiratory arrest, and mildhypotension) occurred more often in patients who had a recent MI (8 versus 2 percent).Complications occurred more often (21 versus 2 percent) in patients who were very ill(Apache II score >16 or hypotension prior to endoscopy). However, such patients are atincreased risk for complications even without endoscopy and may be particularly vulnerableto complications from continued bleeding without endoscopy. (See "Predictive scoringsystems in the intensive care unit".)Other diagnostic tests—Other diagnostic tests for acute upper GI bleeding include CTangiography (CTA using an overt GI bleeding protocol) and angiography, which can detectactive bleeding [78,79], deep small bowel enteroscopy, and rarely, intraoperative enteroscopy( algorithm 2). Upper GI barium studies are contraindicated in the setting of acute upperGI bleeding because they will interfere with subsequent endoscopy, angiography, or surgery[61]. There is also interest in using wireless capsule endoscopy for patients who havepresented to the emergency department with suspected upper GI bleeding. An esophagealcapsule (which has a recording time of 20 minutes) can be given in the emergencydepartment and reviewed immediately for evidence of bleeding. Confirming the presence ofblood in the stomach or duodenum may aid with patient triage and identify patients morelikely to benefit from early endoscopy [80-84]. Small bowel capsule endoscopy has also beenemployed to help localize bleeding in patients with acute gastrointestinal bleeding withouthematemesis. (See "Angiographic control of nonvariceal gastrointestinal bleeding in adults"and "Evaluation of suspected small bowel bleeding (formerly obscure gastrointestinalbleeding)" and "Wireless video capsule endoscopy", section on 'Esophageal capsuleendoscopy' and "Wireless video capsule endoscopy", section on 'Indications' and "Wirelessvideo capsule endoscopy", section on 'Acute gastrointestinal bleeding'.)A colonoscopy is generally required for patients with hematochezia and a negative upperendoscopy unless an alternative source for the bleeding has been identified.In addition,patients with melena and a negative upper endoscopy frequently undergo colonoscopy torule out a colonic source for the bleeding, as right-sided lesions may present with melena. Ina study that included 1743 colonoscopies performed for the evaluation of melena following a6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 17/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/76https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/33https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/77https://www.uptodate.com/contents/predictive-scoring-systems-in-the-intensive-care-unit?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/predictive-scoring-systems-in-the-intensive-care-unit?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/78,79https://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F105093&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/barium-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/61https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/80-84https://www.uptodate.com/contents/angiographic-control-of-nonvariceal-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/evaluation-of-suspected-small-bowel-bleeding-formerly-obscure-gastrointestinal-bleeding?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/evaluation-of-suspected-small-bowel-bleeding-formerly-obscure-gastrointestinal-bleeding?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/wireless-video-capsule-endoscopy?sectionName=ESOPHAGEAL%20CAPSULE%20ENDOSCOPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2518035504&source=see_link#H2518035504https://www.uptodate.com/contents/wireless-video-capsule-endoscopy?sectionName=ESOPHAGEAL%20CAPSULE%20ENDOSCOPY&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2518035504&source=see_link#H2518035504https://www.uptodate.com/contents/wireless-video-capsule-endoscopy?sectionName=Indications&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H4&source=see_link#H4https://www.uptodate.com/contents/wireless-video-capsule-endoscopy?sectionName=Acute%20gastrointestinal%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H3844329040&source=see_link#H3844329040https://www.uptodate.com/contents/wireless-video-capsule-endoscopy?sectionName=Acute%20gastrointestinal%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H3844329040&source=see_link#H3844329040non-diagnostic upper endoscopy, a suspected bleeding source was identified in 5 percent ofpatients, a rate that was higher than that seen in 194,979 average-risk screening controls (1percent) [85]. Despite the relatively low yield in patients with melena, we routinely perform acolonoscopy in patients with melena and a negative upper endoscopy, as well as in patientswith hematochezia. (See "Approach to acute lower gastrointestinal bleeding in adults",section on 'Colonoscopy'.)RISK STRATIFICATIONEndoscopic, clinical, and laboratory features may be useful for risk stratification of patientswho present with acute upper GI bleeding ( table 5 and picture 1 and picture 2 andpicture 3 and picture 4) [86-95], and the use of risk stratification tools is recommendedby the International Consensus Group [1]. Factors associated with rebleeding identified in ameta-analysis included [96]:An increase in the blood urea nitrogen (BUN) level at 24 hours compared with baseline maybe another predictor of poor outcomes. A study of 357 patients with acute nonvariceal upperGI bleeding found that an increase in the BUN at 24 hours was a predictor of a compositeoutcome that included rebleeding and mortality [97]. The authors speculate that theassociation of poor outcomes with an increase in BUN may be the result of inadequateresuscitation.Several investigators have developed decision rules and predictive models that permitidentification of patients who are at low risk for recurrent or life-threatening hemorrhage[98]. Such patients may be suitable for early hospital discharge or even outpatient care. Theeffectiveness of such rules has been evaluated in a variety of clinical settings, with moststudies suggesting that patients deemed to be low-risk can safely be discharged early ortreated as outpatients [66,86-92,98-105]. In addition, this approach is associated withreduced resource utilization compared with universal hospitalization of patients with acuteupper GI bleeding.Risk scores—Two commonly cited scoring systems are the Rockall score and the Blatchfordscore. The International Consensus Group suggests using a Glasgow Blatchford score (GBS)Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rategreater than 100 beats per minute)●Hemoglobin less than 10 g/L●Active bleeding at the time of endoscopy●Large ulcer size (greater than 1 to 3 cm in various studies)●Ulcer location (posterior duodenal bulb or high lesser gastric curvature)●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 18/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/85https://www.uptodate.com/contents/approach-to-acute-lower-gastrointestinal-bleeding-in-adults?sectionName=Colonoscopy&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H25592670&source=see_link#H25592670https://www.uptodate.com/contents/approach-to-acute-lower-gastrointestinal-bleeding-in-adults?sectionName=Colonoscopy&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H25592670&source=see_link#H25592670https://www.uptodate.com/contents/image?imageKey=GAST%2F78607&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F78607&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F61646&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F61646&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F54960&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F54960&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F76246&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F76246&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F52497&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/86-95https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/96https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/97https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/98https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/66,86-92,98-105of ≤1 to identify patients who are very low risk for rebleeding or mortality and who can beconsidered for outpatient management [1].AIMS65 is another scoring system that uses data available prior to endoscopy (serumalbumin, INR, presence of altered mental status, systolic blood pressure, and age), but it isless sensitive than the Blatchford and preendoscopic Rockall scores for identifying low-riskpatients [107,109]. A newer score, the Age, Blood tests and Comorbidities score, wasdeveloped to predict mortality in patients with upper GI bleeding and lower GI bleeding[110]. Initial data from the validation cohort, which included 4019 patients with upper GIbleeding and 2336 patients with lower GI bleeding suggests good performance for the score(AUROC 0.81 to 0.84).Implementation—The data presented above suggest that risk stratification is feasible andpermits identification of patients who can be managed safely without hospitalization.However, for these systems to be successful, the risk stratification system must be tieddirectly to decisions regarding patient discharge. None of the published risk scores has yetbeen adopted widely.The Rockall score which is calculated after endoscopy is based upon age, the presenceof shock, comorbidity, diagnosis, and endoscopic stigmata of recent hemorrhage(calculator 1) [86]. In one validation study, only 32 of 744 patients (4 percent) whoscored 2 or less (out of a maximum of 11) rebled and only one died.●On the other hand, in a later study of 247 patients who underwent endoscopic therapyfor bleeding peptic ulcers, the model performed poorly when predicting recurrentbleeding, underscoring the need for validation of this model [106].The GBS, unlike the Rockall score, does not take endoscopic data into account and thuscan be calculated when the patient first presents (calculator 2) [91]. The score is basedupon the blood urea nitrogen, hemoglobin, systolic blood pressure, pulse, and thepresence of melena, syncope, hepatic disease, and/or cardiac failure. The score rangesfrom zero to 23 and the risk of requiring endoscopic intervention increases withincreasing score. One meta-analysis found that a Blatchford score of zero wasassociated with a low likelihood of the need for urgent endoscopic intervention(likelihood ratio 0.02, 95% confidence interval [CI] 0-0.05) [6]. A second study with 3012patients found that a score ≤1 could be used to identify a low-risk cohort [107].●A simpler version of the score, known as the modified GBS, is calculated using only theblood urea nitrogen, hemoglobin, systolic blood pressure, and pulse. The score rangesfrom 0 to 16. A prospective study of the modified score found that it performed as wellas the full GBS and that it outperformed the Rockall score with regard to predicting theneed for clinical intervention, rebleeding, and mortality [108].6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 19/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/1https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/107,109https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/110https://www.uptodate.com/contents/calculator-rockall-score-for-upper-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/86https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/106https://www.uptodate.com/contents/calculator-blatchford-score-for-gastrointestinal-bleeding-in-adults-conventional-and-si-units?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/91https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/6https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/107https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/108As a general rule, we discharge patients following endoscopy if they have a likely bleedingsource identified on upper endoscopy that is not associated with a high risk of rebleedingprovided they:High-risk bleeding sources include variceal bleeding, active bleeding, bleeding from aDieulafoy's lesion, or an ulcer bleeding with high-risk stigmata ( table 5).Prior to endoscopy, we will discharge patients with a GBS of 0-1 provided they have nosignificant comorbidities, have stable vital signs, have a normal hemoglobin level, do not livefar from medical care, and have a mechanism for prompt outpatient gastroenterologyevaluation/endoscopy (ie, within three days). We discharge the patient on a proton pumpinhibitor (eg, omeprazole or esomeprazole 20 mg once daily, pantoprazole 40 mg once daily).Ultimately, the decision to discharge the patient also depends on individual-patient factors,such as reliability for follow-up and confidence of the endoscopists in the diagnosis.If patients do not meet the above criteria we admit them to a monitored setting or intensivecare unit (depending upon the severity of bleeding, comorbidities, and stability of vital signs).Most patients who have received endoscopic treatment for high-risk stigmata should behospitalized for 72 hours to monitor for rebleeding, since most rebleeding occurs during thistime [111].TREATMENTThe treatment of patients with upper GI bleeding is discussed separately:Have no comorbidities●Have stable vital signs●Have a normal hemoglobin level●(See "Overview of the treatment of bleeding peptic ulcers".)●(See "Methods to achieve hemostasis in patients with acute variceal hemorrhage".)●(See "Angiodysplasia of the gastrointestinal tract", section on 'Treatment'.)●(See "Portal hypertensive gastropathy", section on 'Management'.)●(See "Causes of upper gastrointestinal bleeding in adults", section on 'Vascular lesions'.)●(See "Causes of upper gastrointestinal bleeding in adults", section on 'Aortoentericfistulas'.)●(See "Causes of upper gastrointestinal bleeding in adults", section on 'Uppergastrointestinal tumors'.)●(See "Argon plasma coagulation in the management of gastrointestinal hemorrhage".)●(See "Angiographic control of nonvariceal gastrointestinal bleeding in adults".)●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 20/51https://www.uptodate.com/contents/image?imageKey=GAST%2F78607&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=GAST%2F78607&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/omeprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/esomeprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/pantoprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/111https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/angiodysplasia-of-the-gastrointestinal-tract?sectionName=TREATMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H21&source=see_link#H21https://www.uptodate.com/contents/portal-hypertensive-gastropathy?sectionName=MANAGEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H60159209&source=see_link#H60159209https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?sectionName=Vascular%20lesions&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H78373134&source=see_link#H78373134https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?sectionName=Aortoenteric%20fistulas&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H78374387&source=see_link#H78374387https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?sectionName=Aortoenteric%20fistulas&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H78374387&source=see_link#H78374387https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?sectionName=Upper%20gastrointestinal%20tumors&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H78373245&source=see_link#H78373245https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?sectionName=Upper%20gastrointestinal%20tumors&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H78373245&source=see_link#H78373245https://www.uptodate.com/contents/argon-plasma-coagulation-in-the-management-of-gastrointestinal-hemorrhage?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/angiographic-control-of-nonvariceal-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkSOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines from selected countries and regionsaround the world are provided separately. (See "Society guideline links: Gastrointestinalbleeding in adults".)INFORMATION FOR PATIENTSUpToDate offers two types of patient education materials, "The Basics" and "Beyond theBasics." The Basics patient education pieces are written in plain language, at the 5 to 6grade reading level, and they answer the four or five key questions a patient might haveabout a given condition. These articles are best for patients who want a general overviewand who prefer short, easy-to-read materials. Beyond the Basics patient education pieces arelonger, more sophisticated, and more detailed. These articles are written at the 10 to 12grade reading level and are best for patients who want in-depth information and arecomfortable with some medical jargon.Here are the patient education articles that are relevant to this topic. We encourage you toprint or e-mail these topics to your patients. (You can also locate patient education articleson a variety of subjects by searching on "patient info" and the keyword(s) of interest.)SUMMARY AND RECOMMENDATIONSth thth thBasics topics (see "Patient education: Upper endoscopy (The Basics)" and "Patienteducation: GI bleed (The Basics)")●Beyond the Basics topics (see "Patient education: Upper endoscopy (Beyond theBasics)" and "Patient education: Peptic ulcer disease (Beyond the Basics)")●Rapid overview – A table outlining the emergency management of acute severe uppergastrointestinal bleeding is provided ( table 1). (See 'Introduction' above.)●History and examination – The history and physical examination can help identifypotential sources of the upper GI bleed, assess the severity of the bleed, and identifycomorbid conditions that may influence the patient's subsequent management. (See'Initial evaluation' above.)●The presence of abdominal pain, especially if severe and associated with reboundtenderness or involuntary guarding, raises concern for perforation. If any signs of anacute abdomen are present, further evaluation to exclude a perforation is requiredprior to endoscopy. (See 'Physical examination' above.)6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 21/51https://www.uptodate.com/contents/society-guideline-links-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/society-guideline-links-gastrointestinal-bleeding-in-adults?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/upper-endoscopy-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/gi-bleed-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/gi-bleed-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/upper-endoscopy-beyond-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/upper-endoscopy-beyond-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/peptic-ulcer-disease-beyond-the-basics?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=EM%2F72195&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkLaboratory testing – Laboratory tests that should be obtained in patients with acuteupper GI bleeding include a complete blood count, serum chemistries, liver tests, andcoagulation studies. In addition, we suggest ruling out a myocardial infarction in olderadult patients and those with known cardiovascular disease who have severe bleeding,especially if there has been hemodynamic instability. (See 'Laboratory data' above.)●Risk stratification and triage – We suggest incorporation of a validated risk score forupper gastrointestinal bleeding into routine clinical practice to facilitate optimal triagedecisions. Patients with a Glasgow Blatchford Score (GBS) of 0-1 may be considered forout-patient management. Others should be admitted to a monitored bed or intensivecare unit depending upon the severity of bleeding. (See 'Risk scores' above and 'Triage'above.)●Pre-endoscopic management – Prior to endoscopy, patients should receive generalsupportive measures, including:●Provision of supplemental oxygen by nasal cannula•Nothing per mouth•Two large caliber (18 gauge or larger) peripheral catheters or a central venous line•Nasogastric lavage is NOT a routine part of the management of acute upper GIbleeding. (See 'Nasogastric lavage' above.)Pharmacologic therapy – Medications that should be started prior to endoscopyinclude a proton pump inhibitor, erythromycin, antibiotics (for patients with cirrhosis),and somatostatin or one of its analogs (for patients with suspected variceal bleeding).●We suggest thatpatients admitted to the hospital with acute upper GI bleedingreceive an IV proton pump inhibitor (PPI) (Grade 2B). The optimal approach to PPIadministration prior to endoscopy is unclear. Our approach is to give a high-dosebolus (eg, esomeprazole 80 mg) to patients with signs of active bleeding (eg,hematemesis, hemodynamic instability). If endoscopy is delayed beyond 12 hours, asecond dose of an IV PPI should be given (eg, esomeprazole 40 mg). For patientswho may have stopped bleeding (eg, patients who are hemodynamically stable withmelena), we give an IV PPI every 12 hours (eg, esomeprazole 40 mg). Subsequentdosing will then depend on the endoscopic findings. (See 'Acid suppression' aboveand "Overview of the treatment of bleeding peptic ulcers", section on 'Acidsuppression'.)•We suggest that erythromycin be given prior to endoscopy to help improvevisualization (Grade 2C). A reasonable dose is 250 mg intravenously over 20 to 30minutes. Endoscopy is performed 20 to 90 minutes following completion of theerythromycin infusion. Patients receiving erythromycin need to be monitored for6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 22/51https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/grade/5?title=Grade%202B&topicKey=GAST%2F2548https://www.uptodate.com/contents/esomeprazole-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Acid%20suppression&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224540&source=see_link#H57224540https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?sectionName=Acid%20suppression&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H57224540&source=see_link#H57224540https://www.uptodate.com/contents/erythromycin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/grade/6?title=Grade%202C&topicKey=GAST%2F2548QTc prolongation. In addition, drug-drug interactions should be evaluated beforegiving erythromycin because it is a cytochrome P450 3A inhibitor ( table 4). (See'Prokinetics' above.)Patients with cirrhosis who present with acute upper GI bleeding (from varices orother causes) should be given prophylactic antibiotics.•Somatostatin, its analog octreotide, or terlipressin should be started if varicealbleeding is suspected.•Blood transfusion – Transfusion is guided by the hemoglobin level and the presence ofcomorbid conditions:●The decision to initiate blood transfusion must be individualized ( algorithm 1).Our approach is to initiate blood transfusion if the hemoglobin is <7 g/dL (70 g/L) formost patients. Higher transfusion thresholds may be indicated for patients atincreased risk of adverse events in the setting of significant anemia or those withcoronary artery disease. (See "Indications and hemoglobin thresholds for RBCtransfusion in adults", section on 'Overview of our approach'.)•It is important to avoid overtransfusion in patients with suspected variceal bleedingbecause transfusion can precipitate worsening of the bleeding; the bloodtransfusion goal for variceal bleeding is <7 g/dL (70 g/L). (See "Overview of themanagement of patients with variceal bleeding", section on 'Blood products'.)•For patients with active/brisk bleeding and hypovolemia, decisions abouttransfusion are guided by hemodynamic parameters (eg, pulse and blood pressure),the pace of the bleeding, estimated blood loss, and the ability to stop the bleeding,rather than by serial hemoglobin measurements. (See "Indications and hemoglobinthresholds for RBC transfusion in adults", section on 'Acute bleeding' and "Massiveblood transfusion", section on 'Approach to volume and blood replacement'.)•Anticoagulants, antiplatelet agents, and coagulopathies – The approach tomanagement of anticoagulants and antiplatelet agents depends on the specificmedications being used, the reason they are being used, and how quickly reversal ofanticoagulation is needed. Management of coagulopathy depends on the underlyingetiology. Hematology input may be advisable. (See 'Managing anticoagulants,antiplatelet agents, and coagulopathies' above and 'Consultations' above.)●Endoscopy – We recommend upper endoscopy within 24 hours for the evaluation andmanagement of patients admitted with acute upper GI bleeding. For patients withsuspected variceal bleeding, we perform endoscopy within 12 hours of presentation.●6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 23/51https://www.uptodate.com/contents/image?imageKey=DRUG%2F76992&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=DRUG%2F76992&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/octreotide-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/terlipressin-drug-information?search=gastrointestinal%20bleeding&topicRef=2548&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/image?imageKey=HEME%2F131907&topicKey=GAST%2F2548&search=gastrointestinal%20bleeding&rank=1%7E150&source=see_linkhttps://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=OVERVIEW%20OF%20OUR%20APPROACH&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H430736130&source=see_link#H430736130https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=OVERVIEW%20OF%20OUR%20APPROACH&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H430736130&source=see_link#H430736130https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?sectionName=Blood%20products&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H1333342822&source=see_link#H1333342822https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding?sectionName=Blood%20products&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H1333342822&source=see_link#H1333342822https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/indications-and-hemoglobin-thresholds-for-rbc-transfusion-in-adults?sectionName=Acute%20bleeding&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H606681&source=see_link#H606681https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2https://www.uptodate.com/contents/massive-blood-transfusion?sectionName=APPROACH%20TO%20VOLUME%20AND%20BLOOD%20REPLACEMENT&search=gastrointestinal%20bleeding&topicRef=2548&anchor=H2&source=see_link#H2ACKNOWLEDGMENTWe are saddened by the death of Mark Feldman, MD, who passed away in March 2024.UpToDate gratefully acknowledges Dr. Feldman's role as Section Editor on this topic and hisdedicated and longstanding involvement with the UpToDate program.Use of UpToDate is subject to the Terms of Use.REFERENCES1. 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Association between an increase in blood ureanitrogen at24hours and worse outcomes in acute nonvariceal upperGIbleeding.Gastrointest Endosc 2017; 86:1022.98. Das A, Wong RC. Prediction of outcome of acute GI hemorrhage: a review of risk scoresand predictive models. Gastrointest Endosc 2004; 60:85.99. Brullet E, Campo R, Calvet X, et al. A randomized study of the safety of outpatient carefor patients with bleeding peptic ulcer treated by endoscopic injection. GastrointestEndosc 2004; 60:15.100. Gralnek IM, Dulai GS. Incremental value of upper endoscopy for triage of patients withacute non-variceal upper-GI hemorrhage. Gastrointest Endosc 2004; 60:9.101. Longstreth GF, Feitelberg SP. Successful outpatient management of acute uppergastrointestinal hemorrhage: use of practice guidelines in a large patient series.Gastrointest Endosc 1998; 47:219.102. Lee JG, Turnipseed S, Romano PS, et al. Endoscopy-based triage significantly reduceshospitalization rates and costs of treating upper GI bleeding: a randomized controlledtrial. Gastrointest Endosc 1999; 50:755.103. Imperiale TF, Dominitz JA, Provenzale DT, et al. Predicting poor outcome from acuteupper gastrointestinal hemorrhage. Arch Intern Med 2007; 167:1291.104. Das A, Ben-Menachem T, Farooq FT, et al. Artificial neural network as a predictiveinstrument in patients with acute nonvariceal upper gastrointestinal hemorrhage.Gastroenterology 2008; 134:65.105. Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of patients with low-riskupper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.Lancet 2009; 373:42.106. Church NI, Dallal HJ, Masson J, et al. Validity of the Rockall scoring system afterendoscopic therapy for bleeding peptic ulcer: a prospective cohort study. 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Stanley AJ, Laine L, Dalton HR, et al. Comparison of risk scoring systems for patientspresenting with upper gastrointestinal bleeding: international multicentre prospectivestudy. BMJ 2017; 356:i6432.108. Cheng DW, Lu YW, Teller T, et al. A modified Glasgow Blatchford Score improves riskstratification in upper gastrointestinal bleed: a prospective comparison of scoringsystems. Aliment Pharmacol Ther 2012; 36:782.109. Ramaekers R, Mukarram M, Smith CA, Thiruganasambandamoorthy V. The PredictiveValue of Preendoscopic Risk Scores to Predict Adverse Outcomes in EmergencyDepartment Patients With Upper Gastrointestinal Bleeding: A Systematic Review. AcadEmerg Med 2016; 23:1218.110. Laursen SB, Oakland K, Laine L, et al. ABC score: a new risk score that accurately predictsmortality in acute upper and lower gastrointestinal bleeding: an internationalmulticentre study. Gut 2021; 70:707.111. Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations onthe management of patients with nonvariceal upper gastrointestinal bleeding. AnnIntern Med 2010; 152:101.Topic 2548 Version 97.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 32/51https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/106https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/107https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/107https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/107https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/108https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/108https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/108https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/109https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/109https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/109https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/109https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/110https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/110https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/110https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/111https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/111https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/abstract/111GRAPHICSUpper GI bleeding in adults: Rapid overview of emergency managementMajor causes*Peptic ulcer, esophagogastric varices, arteriovenous malformation, tumor, esophageal (Mallory-Weiss) tearClinical featuresHistoryUse of: NSAIDs, aspirin, anticoagulants, antiplatelet agentsAlcohol abuse, previous GI bleed, liver disease, coagulopathySymptoms and signs: Abdominal pain, hematemesis or "coffee ground" emesis, passingmelena/tarry stool (stool may be frankly bloody or maroon with massive or brisk upper GIbleeding)ExaminationTachycardia; orthostatic blood pressure changes suggest moderate to severe blood loss;hypotension suggests life-threatening blood loss (hypotension may be late finding in healthyyounger adult)Rectal examination is performed to assess stool color (melena versus hematochezia versusbrown)Significant abdominal tenderness accompanied by signs of peritoneal irritation (eg, involuntaryguarding) suggests perforationDiagnostic testingObtain type and crossmatch for hemodynamic instability, severe bleeding, or high-risk patient;obtain type and screen for hemodynamically stable patient without signs of severe bleedingObtain hemoglobin concentration (note that measurement may be inaccurate with acute severehemorrhage), platelet count, coagulation studies (prothrombin time with INR), liver enzymes (AST,ALT), albumin, BUN, and creatinineNasogastric lavage may be helpful if the source of bleeding is unclear (upper or lower GI tract) or toclean the stomach prior to endoscopyTreatmentClosely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output (nasogastric tube in place)Do NOT give patient anything by mouthEstablish two large bore IV lines (16 gauge or larger)Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD)Treat hypotension initially with rapid, bolus infusions of isotonic crystalloid (eg, 500 to 1000 mL perbolus; use smaller boluses and lower total volumes for patients with compromised cardiac function)6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 33/51Transfusion:For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ration of RBCs,plasma, and platelets, as for trauma patientsFor hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCsFor hemoglobin <8 g/dL (80 g/L) in high-risk patients (eg, older adult, coronary artery disease),transfuse 1 unit RBCs and reassess the patient's clinical conditionFor hemoglobin <7 g/dL (70 g/L) in low-risk patients, transfuse 1 units RBCs and reassess thepatient's clinical conditionAvoid over-transfusion with possible variceal bleedingGive plasma for coagulopathy or after transfusing four units of RBCs; give platelets forthrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or aftertransfusing four units of RBCsObtain immediate consultation with gastroenterologist; obtain surgical and interventional radiologyconsultation for any large-scale bleedingPharmacotherapy for all patients with suspected or known severe bleeding:Give a proton pump inhibitor:Evidence of active bleeding (eg, hematemesis, hemodynamic instability), give esomeprazoleor pantoprazole, 80 mg IVNo evidence of active bleeding, give esomeprazole or pantoprazole, 40 mg IVEndoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40mg IVPharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hourcontinuous IV infusion)Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone)Balloon tamponade may be performed as a temporizing measure for patients with uncontrollablehemorrhage likely due to varices using any of several devices (eg, Sengstaken-Blakemore tube,Minnesota tube); tracheal intubation is necessary if such a device is to be placed; ensure properdevice placement prior to inflation to avoid esophageal ruptureCOPD: chronic obstructive pulmonary disease; GI: gastrointestinal; INR: international normalizedratio; AST: aspartate aminotransferase; ALT: alanine aminotransferase; BUN: blood urea nitrogen; IV:intravenous; RBC: red blood cells.* An important but uncommon cause of gastrointestinal hemorrhage is vascular-enteric fistula,typically aortoduodenal fistula related to erosion of a prosthetic aortic graft.¶ Minimally invasive techniques to control bleeding include sclerotherapy, embolization, and othervascular occlusion techniques. For patients with massive hemorrhage, resuscitative endovascularballoon occlusion of the aorta (REBOA) can be used to limit blood loss and support perfusion of vitalorgans until the sites of bleeding can be directly controlled.Graphic 72195 Version 16.0¶6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 34/51Red blood cell (RBC) transfusion decisions in adultsThe decision to transfuse always incorporates an assessment by the clinician caring for the patient.Thresholds included here are based on data from clinical trials; refer to UpToDate for details. Thisalgorithm does not apply to individuals with hemoglobinopathies (sickle cell disease, transfusion-dependent thalassemia); separate criteria apply to these individuals as discussed in UpToDate. Toconvert hemoglobin to g/L, multiply by 10 (hemoglobin of 7 g/dL = 70 g/L). Refer to UpToDate topicson indications for transfusion for further details and discussions.CAD: coronary artery disease; GI: gastrointestinal; ICU: intensive care unit; RBC: red blood cell.* Assessment includes:Symptoms (and whether attributable to anemia)Clinical status (vital signs, signs of hemodynamic instability, cardiac and respiratoryexamination)Underlying comorbiditiesHemoglobin levelRate of hemoglobin decline and cause (active bleeding versus ongoing hemolysis versusdecreased RBC production)¶ Rarely, an individual with hemoglobin below an accepted threshold may decline transfusion(Jehovah's Witness, healthy young adult); it is important that they understand the risks andalternatives. Rarely, an individual with a hemoglobin above 10 g/dL may warrant transfusion, such asif there are clear symptoms attributable to anemia and the cause of anemia cannot otherwise berapidly treated.6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 35/51Δ Rapidly declining hemoglobin includes rapid bleeding associated with hemodynamic instability or afall in hemoglobin of ≥2 g/dL per day.Graphic 131907 Version 4.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 36/51Emergency reversal of anticoagulation from warfarin for life-threateninghemorrhage in adults: Suggested approaches based upon available resourceA. If 4-factor prothrombin complex concentrate (4F PCC) is available (preferredapproach):1. Give 4F PCC 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion ofthe infusion. If INR is not ≤1.5, give additional 4F PCC (refer to topic or drug reference fordetails).2. Give vitamin K 10 mg IV over 10 to 20 minutes.B. If 3-factor prothrombin complex concentrate (3F PCC) is available but 4F PCC isnot available:1. Give 3F PCC 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion ofthe infusion. If INR is not ≤1.5, give additional 3F PCC (refer to topic or drug reference fordetails).2. Give Factor VIIa 20 mcg/kg IV or give FFP 2 units IV by rapid infusion. Factor VIIa may bepreferred if volume overload is a concern.3. Give vitamin K 10 mg IV over 10 to 20 minutes.C. If neither 3F PCC nor 4F PCC is available:1. Give FFP 2 units IV by rapid infusion. Check INR 15 minutes after completion of infusion. If INR≥1.5, administer 2 additional units of FFP IV rapid infusion. Repeat process until INR ≤1.5. Maywish to administer loop diuretic between FFP infusions if volume overload is a concern.2. Give vitamin K 10 mg IV over 10 to 20 minutes.These products and doses are for use in life-threatening bleeding only. Evidence of life-threateningbleeding and over-anticoagulation with a vitamin K antagonist (eg, warfarin) are required.Anaphylaxis and transfusion reactions can occur.It may be reasonable to thaw 4 units of FFP while awaiting the PT/INR. The transfusion service maysubstitute other plasma products for FFP (eg, Plasma Frozen Within 24 Hours After Phlebotomy[PF24]); these products are considered clinically interchangeable. PCC will reverse anticoagulationwithin minutes of administration; FFP administration can take hours due to the volume required;vitamin K effect takes 12 to 24 hours, but administration of vitamin K is needed to counteract the longhalf-life of warfarin. Subsequent monitoring of the PT/INR is needed to guide further therapy. Refer totopics on warfarin reversal in individual situations for further management.3F PCC: PCC containing factors II, IX, and X and only trace factor VII; 4F PCC: PCC containingcoagulation factors II, VII, IX, X, protein S and protein C; FEIBA: factor eight inhibitor bypassing agent;FFP: fresh frozen plasma; INR: international normalized ratio; PCC: unactivated prothrombin complexconcentrate; PT: prothrombin time.* Before use, check product label to confirm factor types (3 versus 4 factor) and concentration.Activated complexes and single-factor IX products (ie, FEIBA, AlphaNine, Mononine, Immunine,BeneFix) are not used for warfarin reversal.* ¶* ¶6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 37/51¶ PCC doses shown are those suggested for initial treatment of emergency conditions. Subsequenttreatment is based on INR and patient weight if available. Refer to topic and drug reference includedwith UpToDate for INR-based dosing.Graphic 89478 Version 12.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 38/51Direct oral anticoagulant-associated bleeding reversal strategiesType of bleeding Agent Possible interventionsLife-threatening orimminently fatalbleeding (eg,intracranial,retroperitoneal,compartmentsyndrome, massivegastrointestinal)Dabigatran (Pradaxa) IdarucizumabActivated PCC* (eg, FEIBA)Antifibrinolytic agent (eg, tranexamic acid,epsilon-aminocaproic acid)Anticoagulant discontinuationOral activated charcoal (if last dose within priotwo hours)HemodialysisRBC transfusions if needed for anemiaPlatelet transfusions if needed forthrombocytopenia or impaired plateletfunction (eg, due to aspirin)Surgical/endoscopic intervention if appropriateRivaroxaban (Xarelto),apixaban (Eliquis),edoxaban (Lixiana)Andexanet alfa (AndexXa) or a 4-factorunactivated PCC (eg, Kcentra)Antifibrinolytic agent (eg, tranexamic acid,epsilon-aminocaproic acid)Anticoagulant discontinuationOral activated charcoal (if last dose recentenough)RBC transfusions if needed for anemiaPlatelet transfusions if needed forthrombocytopenia or impaired plateletfunction (eg, due to aspirin)Surgical/endoscopic intervention if appropriateMinor bleeding (eg,epistaxis,uncomplicated softtissue bleeding, minor[slow] gastrointestinalbleeding)Dabigatran (Pradaxa) Local hemostatic measuresPossible anticoagulant discontinuationHalf-life (normal renal function ): 12 to 17hoursPossible antifibrinolytic agent (eg, tranexamicacid, epsilon-aminocaproic acid)Rivaroxaban (Xarelto),apixaban (Eliquis),edoxaban (Lixiana)Local hemostatic measuresPossible anticoagulant discontinuationHalf-lives (normal renal function ):Rivaroxaban 5 to 9 hoursApixaban 8 to 15 hoursEdoxaban 6 to 11 hoursPossible antifibrinolytic agent (eg, tranexamicacid, epsilon-aminocaproic acid)¶¶6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 39/51The table describes measures that may be used to manage bleeding associated with DOACs. Clinicaljudgment is essential in all cases of DOAC-associated bleeding in order to assess the risks of bleedingand weigh these against the risks of thrombosis if anticoagulation is discontinued or reversed. Referto UpToDate topics on the use of direct thrombin inhibitors and direct factor Xa inhibitors andmanagement of DOAC-associated bleeding for further details and dosing. The onset of all of theagents discussed herein is approximately 2 to 4 hours.PCC: prothrombin complex concentrate; FEIBA: factor eight inhibitor bypassing activity; RBC: redblood cell; DOAC: direct oral anticoagulant.* Use activated PCC only if idarucizumab is unavailable and/or if continued bleeding is reasonablylikely to be fatal within hours.¶ The anticoagulant effect of these agents (especially dabigatran) will dissipate more slowly as renalfunction declines. Severe hepatic failure may also prolong the half-life for apixaban, edoxaban, andrivaroxaban.Graphic 96230 Version 18.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 40/51Cytochrome P450 3A (including 3A4) inhibitors and inducersStrong inhibitors ModerateinhibitorsStrong inducers Moderate inducersAdagrasibAtazanavirCeritinibClarithromycinCobicistat andcobicistat-containingcoformulationsDarunavirIdelalisibIndinavirItraconazoleKetoconazoleLevoketoconazoleLonafarnibLopinavirMifepristoneNefazodoneNelfinavirNirmatrelvir-ritonavirOmbitasvir-paritaprevir-ritonavirOmbitasvir-paritaprevir-ritonavir plusdasabuvirPosaconazoleRitonavir andritonavir-containingcoformulationsSaquinavirTucatinibVoriconazoleAmiodaroneAprepitantBerotralstatCimetidineConivaptanCrizotinibCyclosporineDiltiazemDuvelisibDronedaroneErythromycinFedratinibFluconazoleFosamprenavirFosaprepitantFosnetupitant-palonosetronGrapefruit juiceImatinibIsavuconazole(isavuconazoniumsulfate)LefamulinLetermovirNetupitantNilotinibNirogecestatRibociclibSchisandraVerapamilApalutamideCarbamazepineEncorafenibEnzalutamideFosphenytoinLumacaftorLumacaftor-ivacaftorMitotanePhenobarbitalPhenytoinPrimidoneRifampin(rifampicin)BexaroteneBosentanCenobamateDabrafenibDexamethasoneDipyroneEfavirenzElagolix, estradiol,and norethindronetherapy packEslicarbazepineEtravirineLorlatinibMitapivatModafinilNafcillinPexidartinibRepotrectinibRifabutinRifapentineSotorasibSt. John's wortFor drug interaction purposes, the inhibitors and inducers of CYP3A metabolism listed above canalter serum concentrations of drugs that are dependent upon the CYP3A subfamily of liverenzymes, including CYP3A4, for elimination or activation.*¶¶¶¶Δ◊6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 41/51These classifications are based upon US Food and Drug Administration (FDA) guidance. Othersources may use a different classification system, resulting in some agents being classifieddifferently.Data are for systemic drug forms. Degree of inhibition or induction may be altered by dose,method, and timing of administration.Weak inhibitors and inducers are not listed in this table with exception of a few examples. Clinicallysignificant interactions can occasionally occur due to weak inhibitors and inducers (eg, target drugis highly dependent on CYP3A4 metabolism and has a narrow therapeutic index). Accordingly,specific interactions should be checked using a drug interaction program such as the druginteractions program included within UpToDate.Refer to UpToDate topics on specific agents and indications for further details.CYP: cytochrome P450.* Mifepristone is a significant inhibitor of CYP3A4 when used chronically (eg, for hyperglycemia inpatients with Cushing syndrome), not in single-dose use.¶ Classified as a weak inhibitor of CYP3A4, according to FDA system.Δ Classified as a weak inducer of CYP3A4, according to FDA system.◊ The fixed-dose combination therapy pack taken in the approved regimen has moderate CYP3A4induction effects. When elagolix is used as a single agent, it is a weak CYP3A4 inducer. Norethindroneand estradiol are not CYP3A4 inducers.Data from: UpToDate Lexidrug. More information available at https://online.lexi.com/.References:1. Clinical Drug Interaction Studies — Cytochrome P450 Enzyme- and Transporter-Mediated Drug Interactions Guidancefor Industry ( January 2020) available at: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/clinical-drug-interaction-studies-cytochrome-p450-enzyme-and-transporter-mediated-drug-interactions.2. US Food & Drug Administration. Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers.Available at: FDA.gov website.Graphic 76992 Version 101.0[1,2][1][1]6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 42/51https://www.uptodate.com/drug-interactionshttps://www.uptodate.com/drug-interactionshttps://online.lexi.com/https://www.fda.gov/regulatory-information/search-fda-guidance-documents/clinical-drug-interaction-studies-cytochrome-p450-enzyme-and-transporter-mediated-drug-interactionshttps://www.fda.gov/regulatory-information/search-fda-guidance-documents/clinical-drug-interaction-studies-cytochrome-p450-enzyme-and-transporter-mediated-drug-interactionshttps://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm093664.htmEvaluation of suspected upper gastrointestinal bleeding6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 43/516/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults -UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 44/51GI: gastrointestinal; CT: computed tomographic; CTA: computed tomographic angiography; MR:magnetic resonance.* The presence of both hematemesis and melena suggests that brisk bleeding is present.¶ Bleeding associated with signs such as hypotension, tachycardia, or orthostatic hypotension.Δ Consider evaluation with a side-viewing duodenoscope if there are risk factors for hemobilia orhemosuccus pancreaticus; consider CTA (followed by push enteroscopy if the CTA is negative) inpatients at risk for an aortoenteric fistula. Conventional angiography is typically performed if thepatient remains hemodynamically unstable despite attempts at resuscitation.◊ Patients who present with hematemesis do not need to undergo colonoscopy, since hematemesissuggests the bleeding is proximal to the ligament of Treitz. They should proceed directly to anevaluation for small bowel bleeding if upper endoscopy is negative. Colonoscopy is the next step inthe evaluation ofpatients with melena.§ If the patient becomes hemodynamically unstable following initial resuscitation, conventionalangiography can be performed. Patients who present with hematemesis do not need to undergocolonoscopy and can skip this step in the evaluation because hematemesis suggests the bleeding isproximal to the ligament of Treitz.¥ If the initial endoscopic evaluation was inadequate (eg, fair or poor visualization, failure to reach thececum), repeat examination should be considered before initiating an evaluation for small bowelbleeding. Refer to UpToDate topic review on suspected small bowel bleeding for details.‡ If not already done. If the patient remains hemodynamically stable and does not have evidence ofa*ggressive bleeding (eg, ongoing hematochezia), perform a CTA or push enteroscopy (CTA is the initialtest of choice if there is concern for an aortoenteric fistula). If the patient becomes hemodynamicallyunstable following initial resuscitation or has signs of aggressive bleeding, perform conventionalangiography.† If not already done, angiography or CTA may be obtained. If angiography or CTA has beenperformed and no source is identified, a Meckel's scan should be obtained in younger patients withovert bleeding, unless the only manifestation of bleeding was hematemesis. Surgical exploration isappropriate if no other studies have revealed a source and significant bleeding continues or if there ishigh suspicion for a small bowel neoplasm.** If the deep small bowel enteroscopy was incomplete, a video capsule endoscopy study should beobtained, followed by CT enterography or MR enterographyif the capsule endoscopy is negative.Graphic 105093 Version 4.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 45/51Bleeding gastric ulcerEndoscopy shows an actively bleeding gastric ulcer(Forrest classification Ia) along the lessercurvature.Courtesy of Rome Jutabha, MD and Dennis M Jensen, MD.Graphic 61646 Version 2.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 46/51Duodenal ulcer with visible vesselUpper endoscopy showing a duodenal ulcer with a nonbleeding visible vessel (arrow)in a largecircumferential ulcer(Forrest classification IIa).Courtesy of Rome Jutabha.Graphic 54960 Version 4.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 47/51Gastric ulcer with adherent clotUpper endoscopy showing a gastric ulcer with an adherent clot (Forrest classification IIb).Courtesy of Rome Jutabha, MD.Graphic 76246 Version 1.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 48/51Peptic ulcers at low risk for rebleedingUlcers with a flat pigmented spot (Forrest classification IIc; panel A) or a clean base (Forrestclassification III, panel B) are at low risk for rebleeding and do not need to be treated endoscopically.Courtesy of Rome Jutabha, MD and Dennis M Jensen, MD.Graphic 52497 Version 2.06/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 49/51Endoscopic predictors of recurrent peptic ulcer hemorrhageEndoscopic stigmata ofrecent hemorrhagePrevalence,percentRisk of rebleeding on medicalmanagement, percentActive arterial bleeding (ForrestIa)12% (arterial bleeding+ oozing)55 (arterial bleeding + oozing)Oozing without visible vessel(Forrest Ib) Non-bleeding visible vessel(Forrest IIa)8 43Adherent clot (Forrest IIb) 8 22Flat spot (Forrest IIc) 16 10Clean ulcer base (Forrest III) 55 5References:1. Katschinski B, Logan R, Davies J, et al. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci 1994; 39:706.2. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107:345.Graphic 78607 Version 8.0[1,2]6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 50/51Contributor DisclosuresJohn R Saltzman, MD, FACP, FACG, FASGE, AGAF No relevant financial relationship(s) with ineligiblecompanies to disclose. Loren Laine, MD Consultant/Advisory Boards: Biohaven [Data safetymonitoring board]; Celgene/Bristol Myers Squibb [Data safety monitoring board]; Medtronic[Endoscopic hemostatic therapy]; Phathom Pharmaceuticals [Gastric acid inhibition medication];Prometheus [Data safety monitoring board]. Other Financial Interest: GlaxoSmithKline [Adjudicationpanel to assess GI events in clinical trials]; Intercept [Adjudication committee to assess liver events inclinical trials]; Pfizer [Adjudication committee to adjudicate liver events in clinical trials]. All of therelevant financial relationships listed have been mitigated. Anne C Travis, MD, MSc, FACG, AGAF Norelevant financial relationship(s) with ineligible companies to disclose.Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, theseare addressed by vetting through a multi-level review process, and through requirements forreferences to be provided to support the content. Appropriately referenced content is required of allauthors and must conform to UpToDate standards of evidence.Conflict of interest policy6/6/24, 5:31 AM Approach to acute upper gastrointestinal bleeding in adults - UpToDatehttps://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults/print?search=gastrointestinal+bleeding&sourc… 51/51https://www.uptodate.com/home/conflict-interest-policy