Upper Gastrointestinal Bleeding in Adults: Evaluation and Management

 

Am Fam Physician. 2020 Mar 1;101(5):294-300.

Author disclosure: No relevant financial affiliations.

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and screen. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 8 g per dL. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data.

Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz.1 The incidence of upper GI bleeding varies from 48 to 160 cases per 100,000 individuals.2 Upper GI bleeding mortality in the United States is decreasing. Upper GI bleeding accounts for 300,000 hospitalizations annually with a direct in-hospital economic burden of $3.3 billion.1,2 Patients with significant upper GI bleeding often have hemodynamic compromise and usually present to or are rapidly transported to the emergency department for resuscitation, stabilization, and hospitalization.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

The Glasgow-Blatchford bleeding score is recommended for risk stratification in upper gastrointestinal bleeding to predict a composite of various clinical interventions and mortality.3,26

B

Prospective study comparing risk assessment tools; expert opinion/clinical review

Perform urgent endoscopy (e.g., within 24 hours of presentation) after fluid resuscitation and stabilization in patients with upper gastrointestinal bleeding and hemodynamic instability.30

C

Expert opinion from consensus guideline

Initiation of a proton pump inhibitor should not be delayed before endoscopy and should be started upon presentation with upper gastrointestinal bleeding.33

C

Cochrane review with disease-oriented outcomes

Oral proton pump inhibitors can be used because there was no difference between oral and intravenous proton pump inhibitors in regard to recurrent bleeding, surgery, or mortality.34

A

Consistent evidence from a meta-analysis of nine randomized controlled trials

High-dose proton pump inhibitor treatment is recommended for the first 72 hours post-endoscopy because this is when the rebleeding risk is highest.5

C

Expert opinion from consensus guideline

Repeat endoscopy is recommended in persons with rebleeding.35

B

Evidence from a small randomized controlled trial

Aspirin for secondary cardiovascular prevention should be resumed immediately following endoscopy if the rebleeding risk is low or within three days if the rebleeding risk is moderate to high.5

C

Expert opinion from consensus guideline


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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THAD WILKINS, MD, MBA, FAAFP, is director of academic development and a professor in the Department of Family Medicine at the Medical College of Georgia at Augusta University....

BRITTANY WHEELER, PharmD, MPH, BCACP, is an ambulatory care clinical pharmacist in the Department of Pharmacy at Augusta (Ga.) University Medical Center.

MARY CARPENTER, PharmD, BCACP, is a clinical pharmacist and assistant professor in the Department of Family Medicine at the Medical College of Georgia at Augusta University.

Address correspondence to Thad Wilkins, MD, MBA, Medical College of Georgia at Augusta University, 1120 15th St., HB-4032, Augusta, GA 30912 (email: jwilkins@augusta.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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