Upper GI Bleed

• Resuscitate first: 2 large-bore IVs, type & cross; transfuse restrictively (Hb 70 g/L threshold).
• Erythromycin 250 mg IV 30 min before endoscopy improves views; high-risk stigmata warrant a PPI infusion afterwards.
• Scope within 24 h (urgent if unstable); for variceal bleeding use octreotide + ceftriaxone + bands.
• Rockall/Blatchford scores stratify risk; reverse anticoagulation judiciously.
• Reverse DOACs specifically when bleeding is life-threatening (idarucizumab for dabigatran, andexanet alfa for Xa inhibitors); 4-factor PCC for warfarin.

First Steps in Acute Gastrointestinal (GI) Bleeding

• Resuscitate: place two large-bore IVs or a central line · send blood for typing, CBC, CMP, INR, PTT · infuse isotonic saline or Ringer's lactate (hetastarch is harmful — never use) · transfuse O negative blood if extremely urgent · give oxygen only if hypoxemic
• Factors propagating bleeding: stop anticoagulants (warfarin, heparin) and thrombolytic agents · temporarily withhold antiplatelet therapy after balancing bleeding risk against thrombotic risk, particularly with recent coronary stents or acute coronary syndrome (aspirin, clopidogrel) · stop antithrombotic agents if possible (glycoprotein IIb/IIIa receptor antagonists — abciximab, eptifibatide, tirofiban; direct thrombin inhibitors — argatroban, bivalirudin) · reverse warfarin with 4-factor PCC (weight/INR-based 25–50 IU/kg) + IV vitamin K — FFP only if PCC unavailable; reverse DOACs when life-threatening: idarucizumab (dabigatran), andexanet alfa (Xa inhibitors) · reverse unfractionated heparin with protamine (protamine provides only partial reversal of LMWH)
• Bleeding level: hematemesis or coffee ground emesis points to upper GI bleeding · melena usually means upper GI bleeding but may arise more distally · maroon stool or red blood in the stool typically signals lower GI bleeding · any bleeding with hemodynamic compromise may still be upper GI in origin
• Bleeding etiology: cirrhosis suggests variceal bleeding · hypotension or shock before bleeding suggests ischemic colitis · recent polypectomy suggests postpolypectomy bleeding · prior aortic graft surgery suggests aortoenteric fistula · prior radiation therapy suggests radiation enteritis or proctopathy · prior emesis suggests Mallory–Weiss tear

Managing Acute Upper Gastrointestinal (GI) Bleeding

• Upper GI bleeding signs: blood or coffee grounds in NG tube aspirate · hematemesis (emesis of blood or coffee grounds) · melena · maroon or red blood in stool with hemodynamic compromise
• Variceal versus nonvariceal bleeding? (clinical indicators)
• VARICEAL — clinical clues: history of liver disease/cirrhosis · history of varices/variceal bleeding · ascites · spider angiomata · caput medusa · splenomegaly · hepatic encephalopathy · pancytopenia, low albumin
• Resuscitate first: consider elective intubation for airway protection · balloon tamponade (e.g., Sengstaken–Blakemore tube) only as a temporary bridge (<24 h) until definitive endoscopic therapy or TIPS · blood pressure tends to run low in cirrhotic patients — beware over hydration and fluid overload
• Drug therapy: octreotide bolus then infusion · IV ceftriaxone (preferred) for up to 7 days to prevent bacterial infection/SBP · vasopressin infusion is an alternative but side effects may be limiting; rarely used
• Endoscopic therapy: endoscopic variceal ligation (preferred); sclerotherapy only when band ligation is not feasible · variceal band ligation · glue injection for gastric varices — repeatable if bleeding recurs
• Angiography: consider early (pre-emptive) or rescue TIPS in selected high-risk patients, or when bleeding cannot be controlled endoscopically, for gastric varices from portal hypertension · TIPS placement when endoscopic therapy fails
• Surgery: surgical shunts for portal hypertension · splenectomy for gastric varices due to splenic vein thrombosis
• NONVARICEAL — clinical clues: no liver disease · history of peptic ulcers · history of Helicobacter pylori · history of retching/vomiting · NSAID/aspirin use · chronic renal disease · aortic stenosis (Heyde syndrome) · history of hereditary hemorrhagic telangiectasia
• Resuscitate first → drug therapy: intravenous PPI bolus or infusion OR high-dose oral PPI bid once oral intake is tolerated
• Endoscopic therapy: chosen by stigmata of recent bleeding
• Angiography: when endoscopy fails or bleeding is too brisk for endoscopic localization and therapy
• Surgery: reserved when endoscopic and/or angiographic therapy fails or is unavailable · neoplasms, benign and malignant · isolated vascular abnormalities, e.g., Dieulafoy lesion · aortoenteric fistula → emergent surgery

Managing Peptic Ulcers

• Peptic ulcer disease: gastric and duodenal ulcers · gastric and duodenal erosions · gastritis
• First-line management — PPI acid suppression: 8 wks for most gastric ulcers (longer if large, refractory, or not healed) · 8 wks for duodenal ulcers · 4–6 wks for erosions/gastritis
• Further workup: Helicobacter pylori testing · NSAID/aspirin history
• H. pylori: give eradication therapy · confirm H. pylori eradication in all treated patients
• NSAID/aspirin ulcers: switch to a less toxic NSAID · stop the NSAID if possible · misoprostol for prophylaxis · continuous PPI prophylaxis · if NSAID therapy must continue, use a COX-2 inhibitor plus a PPI
• Idiopathic: retest for H. pylori · scrutinize carefully for NSAID/aspirin use · check fasting serum gastrin when Zollinger–Ellison syndrome is suspected
• Refractory H. pylori (still present after two courses of therapy): culture and sensitivity to guide antibiotic choice · continue PPI only if there is an ongoing indication (e.g., active ulcer or continued NSAID requirement)
• Suspected gastrinoma: secretin stimulation test · gastric output analysis · Ga-68 DOTATATE PET/CT (preferred) ± CT/MRI/EUS for localization · surgery if localized · long-term PPI if refractory
• Repeat upper endoscopy (with biopsy if not healed or suspicious) to confirm healing of gastric ulcers when indicated; when not fully healed, take multiple biopsies to exclude other nonpeptic causes, including malignancy