Managing Upper GI Bleeds

Upper gastrointestinal (GI) bleeding is common and associated with a mortality rate of up to 11%.1 Upper GI bleeds are often caused by peptic ulcers (also called gastric ulcers; located in the stomach) or duodenal ulcers (located in the duodenum [the beginning of the small intestine]).8 Use the chart below to answer questions about how to manage patients admitted to the hospital with an upper GI bleed.

Abbreviations: GI = gastrointestinal; IV = intravenous; COX-2 = cyclo-oxygenase-2; NSAID = nonsteroidal anti-inflammatory drug; PPI = proton pump inhibitor.

Question/Topic

Answer/Pertinent Information

What are symptoms of upper GI bleeding?

 

  • Symptoms of upper GI bleeding can include:8,9
    • melena (i.e., black stool, often sticky or tar like) or large amounts of red blood in stool
    • hematemesis (i.e., bloody vomit [can be bright red vomit or vomit that looks more like coffee grounds])
    • feeling lightheaded or dizzy
    • having difficulty breathing
    • chest or abdominal pain
    • severe upper GI bleeding can present with symptoms of shock (e.g., hypotension, tachycardia, not urinating or infrequent urination, unconsciousness)

 

What are risk factors for upper GI bleeding?

 

  • Helicobacter pylori infection (increased risk for peptic ulcers) is a major risk factor for upper GI bleeding.
  • Taking any of the following medications can increase a patient’s risk for an upper GI bleed:4,7
  • Other risk factors for upper GI bleed include:
    • previous GI bleed
    • older age
    • concomitant use of alcohol or steroids at doses greater than prednisone 10 mg/day WITH aspirin or NSAIDs
  • Risk factors for adverse outcomes associated with upper GI bleeding include:4,5
    • active bleeding at the time of endoscopy
    • older age
    • multiple chronic medical comorbidities

 

What are causes of upper GI bleeding?

 

  • Common causes of upper GI bleeding can include:9
    • peptic or duodenal ulcers
    • esophageal tears (e.g., Mallory-Weiss tears)
    • esophageal varices (abnormal, enlarged veins in the esophagus)
    • esophagitis (inflammation in the esophagus, often caused by gastroesophageal reflux disease [GERD])

 

Which patients with an upper GI bleed can be managed in the outpatient setting?

 

  • Can consider outpatient management for patients WITHOUT melena, syncope, liver disease, or cardiac failure with the following clinical features:5
    • systolic blood pressure (SBP): ≥110 mmHg
    • heart rate (HR): <100 beats per minute
    • hemoglobin: ≥13 g/dL (male) or ≥12 g/dL (female)
    • blood urea nitrogen (BUN): <18.2 mg/dL
  • Use a scoring system (e.g., Glasgow-Blatchford Bleeding Score [GBS]; https://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs) to stratify patients according to risk.1,5
    • GBS ≤1: low risk of rebleeding. Can usually be managed WITHOUT an admission or endoscopy.1,5

 

How should proton pump inhibitors be used to treat upper GI bleeding?

 

 

 

 

 

  • If possible, start PPIs about 24 hours before endoscopy. Starting PPIs before endoscopy does NOT reduce rebleeding. However, it may reduce length of stay and may lead to fewer interventions during endoscopy (e.g., hemoclips, sclerotherapy, heater probe thermocoagulation) [Evidence Level B-2].1,6 The use of PPIs should not delay endoscopy.1
  • Start PPIs with an IV loading dose (e.g., esomeprazole 80 mg). There are not data to show PPI loading doses improve outcomes. But, loading doses seem to raise the pH faster compared to intermittent IV doses.2 Achieving a pH ≥6 seems to stabilize clotting and help with platelet aggregation.2,3,6
  • After the loading dose, many experts recommend PPI continuous infusions (e.g., esomeprazole 8 mg/hour).1,5 However, can consider giving PPIs as intermittent IV doses. Giving PPIs with intermittent IV doses (e.g., esomeprazole 40 mg IV every 12 hours) compared to a continuous infusion seems no different with respect to rebleeding, length of stay, mortality, and time pH is maintained >6 [Evidence Level A-1].2
  • Transition patients from IV to oral PPI dosing once they are stable and tolerating oral intake.2
  • The length of time patients should receive a drip or twice-daily PPI depends if they had an intervention during endoscopy.
    • For patients who do NOT have an endoscopic intervention, change PPI dosing to once daily.5
    • For patients who HAVE an endoscopic intervention, continue the PPI infusion or twice-daily PPI dosing for at least three days.2 Can consider continuing twice-daily PPI dosing for up to 14 days before switching to once daily.1 Limited data suggest continuing twice-daily PPI dosing may reduce rebleeding risk compared to once-daily PPI dosing.1
  • See our chart, Proton Pump Inhibitors: Appropriate Use and Safety Concerns, for the appropriate length of once-daily PPI therapy based on diagnosis (e.g., eight weeks for peptic ulcer), tapering off PPIs, and to understand potential risks associated with PPIs.
  • See our chart, Managing NSAID Risks, to answer questions about GI risks with NSAID use and when to use a PPI to reduce bleeding risk in patients who require treatment with traditional NSAIDs (e.g., ibuprofen) or a COX-2 inhibitor.
  • Can consider long-term PPI therapy to reduce bleeding risk in patients who require long-term anticoagulation or single or dual antiplatelet therapy.1

 

What is the role of endoscopy in the management of upper GI bleeding?

 

  • For patients admitted with an acute upper GI bleed, endoscopy should be done within 24 hours of presentation.1,5
    • Some experts suggest performing endoscopy within 12 hours of presentation in patients that remain hemodynamically unstable (tachycardia, hypotension) despite volume resuscitation, with in-hospital bloody emesis/nasogastric aspirate, or with contraindication to the interruption of anticoagulation.5
  • Endoscopic intervention (e.g., hemoclips, sclerotherapy, heater probe thermocoagulation):1
    • should be used for patients with high-risk bleeds (e.g., active bleeding, visible vessel in the ulcer bed).
    • may be considered for ulcers with adherent clots. High-dose PPIs (e.g., drip, 40 mg twice daily) alone may be enough.
    • is NOT indicated for patients with low-risk bleeds (e.g., clean-based ulcer).
  • Endoscopies should NOT be repeated, unless there is evidence of rebleeding.1

 

What other therapies should be used to manage patients with upper GI bleeding?

 

  • Follow hospital fluid resuscitation protocols for patients admitted with an upper GI bleed with hemodynamic instability.1
  • Can consider blood transfusions for patients:1,5
    • withOUT cardiovascular disease to achieve hemoglobin levels of about 7 to 9 g/dL. Higher goals can be used for patients WITH cardiovascular disease (e.g., 9 to 11 g/dL).
    • based on clinical status in patients with significant ongoing blood loss, as hemoglobin levels may not be accurate.
  • See our chart, Decompensated Chronic Liver Failure, for use of other products in difficult-to-control bleeds (e.g., cryoprecipitate, platelet transfusions, and red blood cell transfusions).

 

What medications should NOT be used to treat upper GI bleeding?

 

  • Avoid treating upper GI bleeds with histamine-2 receptor antagonists (H2-blockers; [e.g., ranitidine, famotidine]).1
  • Avoid treating nonvariceal upper GI bleeds with somatostatin or octreotide.1,5 See our chart, Esophageal Variceal Bleeding FAQs, for specifics on prevention and initial treatment options (e.g., endoscopy, octreotide, antibiotics) in patients presenting with an esophageal variceal bleed.

 

 

 

How should chronic use of meds that increase risk for bleeding be used after an upper GI bleed?

 

  • Use our chart, The Truth About Aspirin, to answer questions and clarify misconceptions about aspirin therapy and bleeding risk.
  • After an upper GI bleed, counsel patients who take a PPI with a traditional NSAID or who take a COX-2 inhibitor
    (e.g., celecoxib) to watch for signs and symptoms of bleeding (see row above, “What are symptoms of upper gastrointestinal bleeding?”) as these therapies are associated with a risk for recurrent bleeding.1
  • See our chart, Managing Anticoagulation Patients After a Bleed, for how to best manage patients who require long-term anticoagulation therapy.

 

Levels of Evidence

In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.

Level

Definition

Study Quality

A

Good-quality patient-oriented evidence.*

  1. High-quality RCT
  2. SR/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

C

Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening.

*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).

RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]

Project Leader in preparation of this clinical resource (360121): Beth Bryant, Pharm.D., BCPS, Assistant Editor

References

  1. Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. Ann Intern Med 2019 Oct 22. doi: 10.7326/M19-1975.
  2. Worden JC, Hanna KS. Optimizing proton pump inhibitor therapy for treatment of nonvariceal upper gastrointestinal bleeding. Am J Health Syst Pharm 2017;74:109-16.
  3. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med 2014;174:1755-62.
  4. Stanley AJ, Laine L. Management of acute upper gastrointestinal bleeding. BMJ 2019;364:I536.
  5. Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2015;47:a1-46.
  6. Sreedharan A, Martin J, Leontiadis GI, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding (review). Cochrane Database Syst Rev 2010;(7):CD005415.
  7. American College of Gastroenterology. Understanding ulcers, NSAIDs & GI bleeding: a consumer health guide. http://s3.gi.org/patients/pdfs/UnderstandGIBleednew.pdf. (Accessed December 8, 2019).
  8. American College of Gastroenterology. Peptic ulcer disease. Updated December 2012. https://gi.org/topics/peptic-ulcer-disease/. (Accessed December 4, 2019).
  9. Mayo Clinic. Gastrointestinal bleeding. https://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/symptoms-causes/syc-20372729. (Accessed December 4, 2019).

Cite this document as follows: Clinical Resource, Managing Upper GI Bleeds. Hospital Pharmacist’s Letter/Prescriber’s Letter. January 2020.

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