Upper Gastrointestinal Bleeding

in Adults: Evaluation and

Management
Thad Wilkins, MD, MBA, Brittany Wheeler, PharmD, MPH, BCACP, Mary Carpenter, PharmD, BCACP
American Acafemy of Family Physicians

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Upper GI Bleed
• Definition  hemorrhage from the mouth to the
ligament of Treitz
• Incidence  48 - 160 cases /100,000 individuals
• Risk factors
Anticoagulant use
High dose NSAID use
Older age

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Specific Risk Factors and
Management Considerations

Peptic ulcer disease

• 80%  NSAID use, H. pylori infection
• Treatment should be offered to all individuals
testing positive for H. pylori infection
Erosive disorder
• Esophagitis, gastritis, duodenitis
• A meta analysis  PPI more effective than
histamine-2 receptor antagonists for cumulative
healing rates at eight weeks
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Specific Risk Factors and
Management Considerations

Mallory-Weiss Syndrome
• A mucosal tear at the distal esophagus
• Frequently heals spontaneously
• Mortality was higher in patients older than 65 or
with multiple comorbid
Medications Associated With Upper GI Bleeding
Antiplatelet therapy
• 37% increased risk of GI bleeding

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Specific Risk Factors and
Management Considerations

Medications Associated With Upper GI Bleeding

Antiplatelet therapy
GI-bleeding risk
100%
93%
80%
60%
40%
36%
20%
0%
Aspirin Aspirin + CPG

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Specific Risk Factors and
Management Considerations

Medications Associated With Upper GI Bleeding

Antiplatelet therapy
• 2018 consensus
Addition of PPI
A single antiplatelet with a history of
• 42% decrease risk
upper GI bleeding
of GI-bleed
• 17% increase
PPI major adverse
cardiovascular
event
Dual antiplatelet agent with multiple risk
factor for upper GI bleeding
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Specific Risk Factors and
Management Considerations

Medications Associated With Upper GI Bleeding

Anticoagulant therapy
• Warfarin  incidence of GI bleed 1-4%
• Non–vitamin K oral anticoagulants  similar stroke
prevention effect with major bleed reduction
NSAID
• Celecoxib less peptic ulcer disease/peptic ulcer
bleeding

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Specific Risk Factors and
Management Considerations

Medications Associated With Upper GI Bleeding

NSAID
• Celecoxib less peptic ulcer disease/peptic ulcer
bleeding
• Gastroprotective agent (PPI, AH2) should be
considered to the patients with high risk of bleeding
• Patients should be tested for H. pylori before
initiating long-term (at least four weeks) NSAID use

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Specific Risk Factors and
Management Considerations

Medications Associated With Upper GI Bleeding

SSRI (Selective Serotonin Reuptake Inhibitor)
• Increased the risk of upper GI bleeding by 55%
• Continue SSRI use unless the patient has had a
previous bleed and is on concomitant medications
that also increase bleeding

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Specific Risk Factors and
Management Considerations
Review of Antithrombotics and Gastrointestinal Bleeding

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Specific Risk Factors and
Management Considerations
Review of Antithrombotics and Gastrointestinal Bleeding

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Specific Risk Factors and
Management Considerations
Review of Antithrombotics and Gastrointestinal Bleeding

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Specific Risk Factors and
Management Considerations
Review of Antithrombotics and Gastrointestinal Bleeding

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Clinical presentation
Clinical manifestation History taking
• Abdominal pain • prior upper GI bleeding
• Lightheadedness • History of coagulopathy,
• Dizziness and use of
• Syncope antithrombotics, NSAIDs,
• Hematemesis SSRIs
• Melena

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Clinical presentation
Physical exam
• Hemodynamic
• Rebound tendernes
• Stool color exam

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Initial Evaluation, Stabilization
Severity
Identify possible source
Identify possible source
Guide to management decision

Laboratory Laboratory
• Complete blood count • Liver test
• Basic metabolic panel • Type and crossmatch
• Coagulation panel
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Initial Evaluation, Stabilization
Management
• significant bleeding  place two large-bore
peripheral intravenous catheters and a bolus of
normal saline or lactated Ringer solution 
correct hypovolemia, and maintain BP
• The Glasgow-Blatchford bleeding score 
endoscopy or surgery
 score ≤ 1 predicts survival without the need
for intervention

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Initial Evaluation, Stabilization
Transfusion and coagulopathy
• Upper GI bleeding with Hb <7 g/dL (70 g per L)
• platelet transfusion if platelet counts <50.000/uL
• INR >2.5 should be corrected before endoscopy

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Treatment
Endoscopy
• Patients with hemodynamic instability

Epinephrine injection
Bipolar electrocoagulation probes
Bipolar electrocoagulation probes
Heater probes
Endoclips

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Treatment
Arterial Embolization and Surgery
Endoscopy Fail Arterial embolization Fail Surgery

Proton pump inhibitor

• Should be started upon presentation with upper
GI bleeding

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Treatment
Proton pump inhibitor
• Oral may be preferred  cost effectiveness
• High-dose PPI (esomeprazole, 80 mg/day) for the
first 72 hours post-endoscopy
• Once-daily PPI should be continued for 4-8 weeks
in patients with peptic ulcer bleeding

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Rebleeding and Follow-up
Strategies
Rebleeding
• Repeat endscopy
When to restart antithrombotic therapy

Warfarin Non–vitamin K Apixaban

OAC
resumed 7-15
Switch to Dose
days after a
apixaban reduction
bleeding event
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Rebleeding and Follow-up
Strategies
Rebleeding
• Repeat endscopy
When to restart antithrombotic therapy

Aspirin
Low rebleeding risk Moderate-high risk
• immediate • within 3 days
resumption

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Rebleeding and Follow-up
Strategies
H. pylori eradication
• Choice of therapy should be individualized
• A test of cure at least 4 weeks after the
completion of antibiotics and 1-2weeks after
completion of PPI therapy

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thankyou