Case

A 74-year-old man presents with vomiting of blood for two days. He has a history of daily alcohol and tobacco use. Vital signs are: blood pressure, 88/50; heart rate, 120; respiratory rate, 36. He is actively vomiting coffee ground emesis. His abdomen is soft with voluntary guarding. What is the best management of this condition?

Upper gastrointestinal bleeding (UGIB) is a significant problem in the U.S., with 350,000 hospitalizations annually and a mortality rate of five to 10 percent.^1,2 The three most common causes are peptic ulcer disease (often secondary to nonsteroidal anti-inflammatory drug use or Helicobacter pylori infection), esophagogastric varices (often due to cirrhosis with portal hypertension), and erosive esophagitis (often secondary to severe GERD or alcohol use).¹ UGIB will typically manifest as melena, hematemesis, or hematochezia.¹

Rapid assessment of vital signs and degree of bleeding should determine whether a patient is stable or unstable. There are several scoring systems available, such as the Glasgow-Blatchford system, but none of these are superior to physician assessment. Tachycardia, hypotension, tachypnea, mental status, and degree of bleeding are important indicators of stability.

Initial stabilization should be done for all patients. Patients should be assessed for evidence of hypovolemia or active exsanguination. Whatever the underlying cause, the patient should have two large-bore intravenous (IV) lines placed and be put on pulse oximetry and cardiac monitoring. Fluid resuscitation should be initiated. Initial laboratory studies should include CBC, complete metabolic profile, blood type and screening, and coagulation studies. Hemoglobin takes several hours to reflect blood loss and should not be used as the sole indicator of bleeding severity. Repeat measurements of hemoglobin may be helpful in assessing stability.

Unstable Patients

The unstable patient with UGIB should be stabilized initially with airway, breathing, and circulatory support. Active UGIB may lead to altered mental status or airway compromise via aspiration. Intubation may be challenging because of both rapid desaturation and extensive hemorrhage. Pre-oxygenation with nasal cannula or face mask should be provided. Nasal cannula oxygen delivery should be maintained during intubation. Suction should be available. Maintain the head of the bed at 45 degrees and ensure that a bag-valve mask is available if initial attempts at intubation fail. Lower doses of sedatives may be used to minimize hypotension. Video laryngoscopy may be attempted, although visualization may be obscured by active bleeding and direct laryngoscopy may be appropriate. Suction-assisted laryngoscopy and airway decontamination, or SALAD, can also be used—in this technique, a rigid suction catheter can simultaneously act as a tongue lifter or depressor while providing continuous suction.

Circulatory collapse should be treated with packed red blood cells, with a transfusion goal for hemoglobin at 7 g/dL. Over-transfusion should be avoided, particularly in cirrhotic patients, due to the risk of increasing portal venous pressure. Fresh frozen plasma, or FFP, should only be given to cirrhotic patients as part of the massive transfusion protocol in cases of profound hypotension, as “patients with cirrhosis rarely have true enzymatic hypocoagulability, and FFP may worsen bleeding due to over-resuscitation and dilution of coagulation factors.”³ Platelets should be transfused with a goal of 50,000/μL.¹ Anticoagulants may be stopped and reversed, but this decision should weigh the risks of thromboembolism against ongoing bleeding.¹ There is no proven benefit of tranexamic acid in the setting of UGIB.^4,5

Nasogastric tubes have little prognostic or therapeutic value in the setting of UGIB.⁶ Balloon tamponade (i.e., a Sengstaken-Blakemore tube) may be used as a temporizing measure for unstable UGIB but should not delay emergent esophagogastroduodenoscopy (EGD). There are few data on the outcomes of UGIB when balloon tamponade is used as a temporizing measure. However, a 2017 study of 34 patients suggests that balloon tamponade, when used as a bridge to EGD, improves patient mortality, with 59 percent of patients surviving to hospital discharge.⁷

The gold standard for both diagnosis and hemostasis of UGIB is esophagogastroduodenoscopy (EGD). Any delay in this procedure past 24 hours is associated with significantly increased mortality.⁸

Following initial stabilization, unstable patients should be admitted to the intensive care unit for definitive management.

Stable Patients

For both stable and resuscitated patients, high-dose IV proton pump inhibitor therapy (i.e., pantoprazole 80 mg IV bolus and drip) should be initiated.⁹ A loading dose of octreotide 50 mcg IV, followed by 50 mcg/hour, decreases variceal bleeds.³ Although the American Gastroenterological Association (AGA) does not recommend octreotide for the use of non-variceal UBIG, the AGA states that “there should be a low threshold for its use if there is concern for underlying portal hypertension.”¹⁰ Given the difficulty of obtaining history from these patients, we recommend the empiric use of octreotide in the ED for UGIB, consistent with earlier studies.^11,12 Antibiotics, such as ceftriaxone 1 g or cefotaxime 2 g IV is associated with improved survival in UGIB patients with cirrhosis.^1,3 Erythromycin as a prokinetic agent should be considered to improve endoscopic visualization.

For patients with acute variceal bleeds, the vasoactive agent terlipressin is a potential first-line choice of therapy, because of both its safety and its efficacy in reducing mortality.¹³ A 2018 meta-analysis found that terlipressin is comparable with somatostatin, octreotide, and vasopressin in the control of bleeding. Terlipressin should still be used in combination with endoscopic therapy.¹⁴

In clinically stable patients who do not require resuscitation, EGD is less urgent and may be performed within six to 24 hours.⁵ These patients may be admitted for further assessment and work-up.

Dr. Matthew Turner, originally trained at the Medical University of South Carolina, is an EM intern at Hershey Medical Center in Hershey, Pa.

Dr. Marco is the associate editor of ACEP Now.

References

1. Kamboj AK, Hoversten P, Leggett CL. Upper gastrointestinal bleeding: etiologies and management. Mayo Clin Proc. 2019:94(4):697-703.
2. Jeong N, Kim KS, Jung YS, et al. Delayed endoscopy is associated with increased mortality in upper gastrointestinal hemorrhage. Am J Emerg Med. 2019:37(2):277-280.
3. Long B, Koyfman A. The emergency medicine evaluation and management of the patient with cirrhosis. Am J Emerg Med. 2018:36(4):689-698.
4. Roberts I, Shakur-Still H, Afolabi A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): An international randomised, double-blind, placebo-controlled trial. Lancet. 2020:395(10241):1927-1936.
5. Dionne JC, Oczkowski SJW, Hunt BJ, et al. tranexamic acid in gastrointestinal bleeding: A systematic review and meta-analysis. Crit Care Med. 2022;50(3):e313-e319.
6. Palamidessi N, Sinert R, Falzon L, et al. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad Emerg Med. 2010;17(2):126-32.
7. Nadler J, Stankovic N, Uber A, et al. Outcomes in variceal hemorrhage following the use of a balloon tamponade device. Am J Emerg Med. 2017;35(10):1500-1502.
8. Radecki RP, Spiegel RJ. Sleep well, endoscopist: January 2021 Annals of Emergency Medicine journal club. Ann Emerg Med. 2021;77(1):127-128.
9. van Rensburg CJ, Cheer S. Pantoprazole for the treatment of peptic ulcer bleeding and prevention of rebleeding. Clin Med Insights Gastroenterol. 2012;5:51-60.
10. Mullady DK, Wang AY, Waschke KA. AGA clinical practice update on endoscopic therapies for nonvariceal upper gastrointestinal bleeding: expert review. Gastroenterology. 2020;159(3):1120-8.
11. Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: A meta-analysis. Ann Intern Med. 1997;127:1062-1071.
12. Barkun A, Bardou M, Marshall JK, et al. Consensus recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2003;139:843-857.
13. Ioannou GN, Doust J, Rockey DC. Terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther. 2003;17(1):53-64.
14. Zhou X, Tripathi D, Song T, et al. Terlipressin for the treatment of acute variceal bleeding: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2018;97(48):e13437.