Upper GI Bleeding: Upper GI Bleeding: Non-Variceal Bleeding Care

0:00Welcome to Board Pearls. This is episode one of two of the Upper GI Bleeding chapter, in the Stomach and Small Bowel Disorders module. This episode is non-variceal upper gastrointestinal, GI, bleeding, from the emergency department to discharge, then the same bleed in patients on blood thinners. A man with a bleeding ulcer shows what happens in the first hour and in what order, when to transfuse, which drugs go in before the scope and which never does, how the ulcer's appearance decides treatment, what happens when he rebleeds, and how the next bleed is prevented. A woman on apixaban and aspirin shows whether to reverse, what to do with the aspirin, and when to restart. A patient on warfarin and one on dabigatran show when reversal is right and which agent to use. And a man with a three-week-old coronary stent shows the hardest antiplatelet decision. The principle in the second half is that two risks compete, the bleeding now and the clot the drug was preventing, and in the weeks after a bleed the clot kills more patients.

1:03Here's the first patient. A sixty-three-year-old man has taken naproxen twice daily for a month for a shoulder injury. Since yesterday he's passed three black, tarry stools, and this morning he fainted in the bathroom. His blood pressure is ninety-six over sixty, and his pulse is one hundred twelve. His hemoglobin is seven point four, down from fourteen last year, and his blood urea nitrogen, BUN, is fifty-eight with a normal creatinine. He takes no anticoagulants.

1:32Melena with syncope, a fast pulse, and a falling hemoglobin in a man on naproxen is an acute upper GI bleed until proven otherwise, most likely from an ulcer caused by the nonsteroidal anti-inflammatory drug, NSAID. Upper GI bleeding is a perfusion problem first, a diagnosis problem second, and an endoscopy problem third. So the first hour follows a fixed order: stabilize him, prepare his stomach for endoscopy, estimate his risk, then scope. Most of what lowers mortality in the first hour doesn't involve an endoscope.

2:04His resuscitation starts with access and monitoring. He gets two large-bore intravenous lines, sixteen to eighteen gauge, or a central line, crystalloid, a type and crossmatch, and a monitored bed, with electrolytes, coagulation, and lactate. A lactate or base deficit over four means he's sicker than his blood pressure suggests. The airway matters too, because it's the leading preventable cause of death in massive upper bleeding. Ongoing hematemesis, altered mental status, or grade three to four encephalopathy in a patient with cirrhosis means intubation is considered. He's alert and not vomiting blood.

2:42Resuscitation includes deciding when to transfuse, and the threshold is restrictive. Transfusion starts below seven grams per deciliter, aiming for seven to nine. In a large randomized trial, that strategy lowered mortality and rebleeding compared with transfusing at nine. The benefit was largest in cirrhosis, where liberal transfusion raises portal pressure and makes varices rebleed, so transfusing a stable patient with cirrhosis to nine or ten is actively harmful.

3:10Some patients are transfused at a higher hemoglobin. The exceptions are active hemorrhage, hemodynamic instability, acute coronary syndrome, with a target of eight to ten, severe thrombocytopenia, cancer patients on active chemotherapy, and chronic transfusion-dependent anemia. Stable coronary disease is a soft reason to transfuse under eight instead of seven. He's above seven but actively bleeding, with a fast pulse and low pressure after fainting, so he gets two units.

3:39Preparing his stomach for the scope means two drugs, and one drug never goes in. An intravenous proton pump inhibitor, PPI, is the first: an eighty-milligram bolus of pantoprazole or esomeprazole followed by eight milligrams an hour. It raises intragastric pH, which reduces high-risk findings at endoscopy and the need for endoscopic treatment. It doesn't reduce rebleeding or death once the ulcer has been treated, and the current American College of Gastroenterology, ACG, guideline couldn't reach a recommendation either way. But it downstages lesions and may help most when endoscopy will be delayed.

4:16The second drug clears the view. Intravenous erythromycin, two hundred fifty milligrams thirty to ninety minutes before endoscopy, stimulates motilin receptors and empties blood and clot from the stomach so the endoscopist can see. It reduces the need for a second-look endoscopy without changing transfusion, surgery, or length of stay. Metoclopramide is the alternative. An electrocardiogram, ECG, comes first in a patient on other QT-prolonging drugs.

4:44The drug that never goes in is tranexamic acid. A large trial settled the question in GI bleeding, and it isn't given before endoscopy, even when coagulopathy is suspected.

4:54Estimating his risk decides where he's managed, using a score built from what's known before the scope. The Glasgow-Blatchford score uses BUN, hemoglobin, systolic blood pressure, pulse, melena, syncope, liver disease, and heart failure. It runs from zero to twenty-three and is the preferred prognostic tool. A score of zero or one identifies very low-risk patients, with a false-negative rate under one percent for needing endoscopic treatment. They can be managed as outpatients, with prompt outpatient endoscopy.

5:27The other scores have narrower uses. AIMS65 is built from an albumin under three, an international normalized ratio, INR, over one point five, altered mental status, a systolic pressure under ninety, and age over sixty-five. It predicts mortality and intensive care unit, ICU, need, with two or more predicting ICU admission, but it isn't recommended for identifying very low-risk patients. Rockall needs the endoscopic findings. The Oakland score is for lower GI bleeding, and the ABC score covers upper or lower bleeding. His Glasgow-Blatchford score is very high, and he's admitted to a monitored bed.

6:08His timing follows his type of bleeding. Non-variceal bleeding is scoped within twenty-four hours. Even in the highest-risk patients, scoping within six hours instead of between six and twenty-four didn't improve rebleeding or mortality, so resuscitation comes first. Suspected variceal bleeding is scoped within twelve hours, because its treatment bundle is time-sensitive. He's resuscitated overnight and scoped at fourteen hours. His endoscopy shows a fifteen-millimeter ulcer on the back wall of the duodenal bulb, with a raised, pigmented visible vessel at its base, not actively bleeding.

6:43He has a bleeding duodenal ulcer, and its appearance decides treatment, because the Forrest classification links appearance to rebleeding risk. Forrest one A is spurting arterial bleeding, which rebleeds in eighty to ninety percent without treatment. One B is oozing without a discrete vessel, at ten to thirty percent. Two A is a non-bleeding visible vessel, a one-to-two-millimeter pigmented bump in the ulcer base where the eroded artery is capped by clot. It rebleeds in fifty to sixty percent without treatment, and dual therapy lowers that durably.

7:14The lower-risk appearances complete the classification. Two B is an adherent clot that won't wash off with vigorous irrigation, at twenty-five to thirty-five percent. Two C is a flat pigmented spot, rebleeding in zero to eight percent. Three is a clean base, at zero to twelve percent, with most series at one to five.

7:33Those rates decide who's treated. One A, one B, and two A need endoscopic treatment. A flat spot and a clean base need none. An adherent clot is debated, and the guideline makes no recommendation. It can be removed with a cold snare and the lesion underneath treated, or left with high-dose intravenous PPI alone. Pooled data favor removal and treatment, though the analysis is heterogeneous, and removing a clot from a deep posterior ulcer can turn a stable lesion into a hard-to-control hemorrhage.

8:04He has a two A visible vessel, and treatment must be dual therapy, because epinephrine alone is inferior and strongly recommended against. Epinephrine diluted one to ten thousand is injected at four points around the lesion, half a milliliter to two milliliters each, for tamponade and vasoconstriction. It's combined with a second method that seals the vessel: bipolar electrocoagulation or a heater probe, absolute ethanol, or hemoclips.

8:30The second method is chosen by the ulcer's base. The ACG strongly recommends the thermal methods and ethanol, and conditionally suggests clips. Thermal methods and clips work about equally well. Clips suit a scarred or thin base, and thermal suits a soft, accessible ulcer. His vessel is injected and coagulated with a bipolar probe.

8:53His ulcer's location adds risk, which raises the stakes of that first treatment. A posterior duodenal bulb ulcer can erode into the gastroduodenal artery, and a lesser curvature gastric ulcer into the left gastric artery, and those two locations rebleed most. Ulcers over two centimeters, instability at presentation, and active bleeding at endoscopy also predict failure. So those lesions get dual therapy at the first procedure, with interventional radiology and surgery consulted early.

9:21Two tools are kept for bleeding the standard methods can't control. Hemostatic powder, sprayed onto an actively bleeding surface, forms a mechanical barrier that washes off within one to three days. It's a bridge to definitive treatment when bleeding obscures the view, when conventional treatment fails or isn't feasible, or when a tumor oozes. The over-the-scope clip is the rescue for an ulcer that rebleeds after initial treatment, preferred over a third standard attempt or surgery, and some experts allow it as first treatment for selected high-risk lesions.

9:54After hemostasis, the clot has to be protected, and it's stable only when the stomach isn't acidic. Above pH four, stress injury is prevented. Above five, pepsin dissolves clot more slowly. Above six, pepsin is inactivated and platelets aggregate well, and that's the target.

10:12His PPI course is set to hold that pH. After treating a high-risk lesion, he gets high-dose intravenous PPI for seventy-two hours, either an eighty-milligram bolus and eight milligrams per hour, or intermittent intravenous doses of forty milligrams two or three times a day, which work as well. Then he takes an oral PPI twice daily for two weeks, thirty to sixty minutes before breakfast and dinner, then once daily to complete four to eight weeks.

10:41The schedule matters more than the drug. The dose schedule and meal timing matter more than which PPI is used, and intravenous esomeprazole is approved to reduce rebleeding in the first seventy-two hours after therapeutic endoscopy. Vonoprazan, a potassium-competitive acid blocker, is an alternative, particularly when a PPI has failed. A patient with a flat spot or clean base needs only oral PPI and can often go home the same or next day.

11:07On the second day, his hemoglobin drops two grams, and he passes fresh melena. A rebleed goes to a second endoscopy, not surgery, because repeat endoscopic treatment succeeds in about seventy percent. For recurrent ulcer bleeding, the over-the-scope clip is the tool.

11:24If a second endoscopy fails, the next steps are shared. Transcatheter arterial embolization comes next. Surgery, a Graham patch, oversewing, or in selected cases vagotomy and antrectomy, is reserved for failed or unavailable embolization, decided by endoscopist, radiologist, and surgeon together. A routine second-look endoscopy in a patient who hasn't rebled doesn't improve outcomes, so it's kept for suspected rebleeding or an inadequate first exam. His repeat endoscopy places an over-the-scope clip, and he stays stable.

11:59Once he's stable, the focus turns to preventing the next bleed, starting with H. pylori, the single most important step. Eradication cuts rebleeding at a year to under five percent, a larger absolute reduction than any other preventive step. Biopsy-based tests at the index endoscopy are reasonable, but blood in the stomach lowers their sensitivity, so a positive result stands and a negative may be false.

12:25Serology helps in exactly this setting. The pretest probability after an ulcer bleed is high, so a positive serology can be trusted. Otherwise a breath test or stool antigen follows after two weeks off PPI. His biopsy test was negative, but his serology is positive. He's treated with bismuth quadruple therapy or a vonoprazan-based regimen. Cure is confirmed with a breath test or stool antigen at least four weeks after the antibiotics and two weeks off PPI.

12:54His naproxen stops, because it caused the ulcer. If he needed an anti-inflammatory, it would be celecoxib at the lowest effective dose with a PPI, because that pairing rebleeds less than celecoxib alone or a non-selective NSAID with a PPI. Primary-prevention aspirin would stop.

13:13His ulcer's location decides whether he needs another scope. A gastric ulcer is re-scoped at six to twelve weeks, because a gastric cancer can look like a benign ulcer. That's especially true for one not adequately biopsied, one over two centimeters, one in an unusual location, one without an NSAID or H. pylori explanation, or one in a patient with a family history of gastric cancer. A duodenal ulcer like his doesn't need routine follow-up endoscopy.

13:42The second patient bleeds on two drugs that prevent clots. A seventy-eight-year-old woman with atrial fibrillation takes apixaban five milligrams twice daily. She also takes aspirin eighty-one milligrams daily because of a coronary stent placed four years ago. She's passed black stools for a day. Her last apixaban dose was six hours ago. Her blood pressure is one hundred ten over seventy after a liter of fluid, her pulse ninety-six, and her hemoglobin eight point one. Her creatinine clearance is fifty-five.

14:13She has an upper GI bleed on an anticoagulant and an antiplatelet, and the first decision is whether to reverse her apixaban. The rule is to reverse only what needs reversing, choosing the reversal by mechanism. Apixaban is a factor ten A inhibitor, like rivaroxaban and edoxaban.

14:31Her drug class no longer has a targeted antidote. Andexanet alfa was withdrawn in the United States in December twenty twenty-five after postmarketing data showed excess thrombotic events, and guidelines had already advised against routine use in GI bleeding. These drugs have short half-lives, so their effect fades within a day or two, and most bleeding on them is managed by holding the drug and supporting the patient. For life-threatening bleeding, four-factor prothrombin complex concentrate is the practical option, off label, with uncertain evidence.

15:01Her drug has already been taken and the bleeding is happening, so the question is whether the time since her last dose makes specific reversal worthwhile. Reduced kidney function lengthens the effect of each of these drugs. She's stable after fluids, so apixaban is held and not reversed. She gets the same care as the first patient: restrictive transfusion, an intravenous PPI and erythromycin, and endoscopy within twenty-four hours.

15:26What happens to her aspirin depends on why she takes it. Aspirin for secondary prevention, for coronary disease, a stent, or prior stroke, shouldn't be stopped unless bleeding is life-threatening. If it's held, it restarts the day endoscopic hemostasis is confirmed, with a PPI, and at the latest within seven days, because the cardiovascular event rate when it's held even briefly isn't negligible. Aspirin for primary prevention, in someone with no cardiovascular disease, has modest benefit, reduced further by recent trials, and after a GI bleed it's usually stopped for good.

16:02Hers is for a stent, so it continues. Had she taken it only for primary prevention, the same drug at the same dose would be stopped. Her endoscopy shows a gastric ulcer with a non-bleeding visible vessel, treated with epinephrine and clips, followed by seventy-two hours of high-dose intravenous PPI.

16:19When her apixaban restarts is where the competing risks matter most. Restarting within about seven days of hemostasis lowers mortality compared with longer holds, and most rebleeding risk falls before that point. Late deaths in anticoagulated patients after a GI bleed come mainly from thrombosis, not rebleeding. For atrial fibrillation with a definitively treated lesion, restarting within one to three days is common, accounting for a direct oral anticoagulant's half-life and kidney function.

16:49She restarts apixaban on day three, because waiting three weeks for a clinic visit would expose her to the thrombosis the drug was preventing. She continues aspirin and a PPI and is tested for H. pylori.

17:02Two other drugs affect her bleeding risk over the long term. Patients on dual antiplatelet therapy with PPI protection keep the PPI for as long as the antiplatelets continue. Selective serotonin reuptake inhibitors, SSRIs, raise upper GI bleeding risk modestly on their own, through platelet serotonin, by roughly sixty percent to double. The risk is greater with NSAIDs, antiplatelets, or anticoagulants, and a PPI likely offsets part of it.

17:31The third patient shows that warfarin changes the reversal decision. A patient on warfarin with an INR of four point two, hematemesis, and a blood pressure of eighty-five has a major bleed, and here reversal is right. The reversal is four-factor prothrombin complex concentrate, not fresh frozen plasma. It corrects the INR within about thirty minutes rather than hours, in a small volume that matters in an elderly patient with heart disease. It supplies factors two, seven, nine, and ten, plus proteins C and S.

18:06The guideline details shape how it's used. Guidelines suggest the concentrate over plasma and against routine plasma, which is used only if the concentrate isn't available. Vitamin K, five to ten milligrams intravenously, is often added to keep the INR corrected after the concentrate wears off, though the joint guideline conditionally suggests against routine vitamin K here. Warfarin restarts within about seven days, often after one to three, once the lesion is treated.

18:35Dabigatran, a direct thrombin inhibitor, has its own answer in a life-threatening bleed. Its reversal agent is idarucizumab, a humanized antibody fragment that binds dabigatran about three hundred fifty times more tightly than thrombin, neutralizing free and thrombin-bound drug within minutes. The dose is five grams intravenously, as two consecutive two-and-a-half-gram infusions. Guidelines are cautious about routine use in GI bleeding because of cost and limited evidence, but for life-threatening bleeding it's the targeted choice.

19:06Dabigatran has two backup options and its own hold times. It's cleared by dialysis, which helps in kidney failure, where it accumulates, and activated charcoal can bind drug taken within two to three hours. Before a planned high-risk procedure, with normal kidney function, dabigatran is held two to three days, apixaban one to two, and rivaroxaban and edoxaban one. Poor kidney function lengthens each hold.

19:31The last patient is the hardest case, because his stent is new. A sixty-two-year-old man had a drug-eluting coronary stent placed three weeks ago and takes aspirin and ticagrelor. He has a bleeding duodenal ulcer. Stopping antiplatelet drugs in the first month after a stent risks stent thrombosis, which can be fatal. So decisions about his P2Y12 inhibitor, clopidogrel, prasugrel, or ticagrelor, are made case by case with cardiology.

20:00The general rules still guide him. Aspirin alone is preferred while bleeding is active, if the indication allows, and dual therapy restarts as soon as bleeding control is confirmed. Platelet transfusion to counter antiplatelet drugs isn't recommended, because there's no clear reduction in bleeding and a signal of higher mortality. Platelets are given only for a count below fifty thousand or an invasive procedure.

20:23His ulcer is treated endoscopically, and ticagrelor is paused briefly while aspirin continues. Cardiology restarts ticagrelor two days after hemostasis, and he stays on a PPI for as long as he's on dual antiplatelet therapy.

20:39Here are the traps the boards set in these patients. A stable patient isn't transfused to nine or ten, especially with cirrhosis. Tranexamic acid isn't given. Erythromycin isn't skipped before endoscopy. A patient with a Glasgow-Blatchford score of zero or one isn't admitted. And the scope isn't rushed within six hours at the expense of resuscitation.

21:01The endoscopy and prevention traps follow. A visible vessel isn't treated with epinephrine alone, and a clean base isn't treated at all. Intravenous PPI isn't given for low-risk findings. A rebleed doesn't go straight to surgery. And a negative H. pylori biopsy taken during bleeding isn't trusted.

21:19The blood thinner traps close the list. A factor ten A inhibitor isn't reversed in a stable patient, and andexanet isn't an option. Fresh frozen plasma isn't used for warfarin when the concentrate is available. Idarucizumab isn't forgotten for a life-threatening dabigatran bleed. Secondary-prevention aspirin isn't stopped, and primary-prevention aspirin isn't continued. Dual antiplatelet therapy after a recent stent isn't stopped without cardiology, and platelets aren't transfused for antiplatelet effect. And anticoagulation isn't held for weeks after the bleeding has stopped.

21:54So, start to finish. Resuscitate first: large-bore access, restrictive transfusion to seven, an intravenous PPI and erythromycin before endoscopy, and no tranexamic acid. Use the Glasgow-Blatchford score, where zero or one allows outpatient care, and scope non-variceal bleeding within twenty-four hours.

22:14Forrest stigmata set the treatment: dual therapy for active bleeding and visible vessels, nothing for flat spots and clean bases, then seventy-two hours of high-dose intravenous PPI after a high-risk lesion. A rebleed goes to repeat endoscopy, then embolization, then surgery. Prevent the next bleed by treating H. pylori, stopping NSAIDs, and re-scoping gastric ulcers.

22:38On blood thinners, reverse only what needs reversing and restart early, because thrombosis drives late mortality. Warfarin in a major bleed gets four-factor prothrombin complex concentrate. Dabigatran gets idarucizumab for life-threatening bleeding. Factor ten A inhibitors have no targeted agent, so they're held, with prothrombin complex concentrate for life-threatening bleeding.

23:01Continue or promptly restart secondary-prevention aspirin, and stop primary-prevention aspirin. Manage P2Y12 inhibitors with cardiology, don't transfuse platelets for antiplatelet effect, and restart anticoagulation within about seven days.

23:17Episode two is bleeding from varices, then the sources the standard approach misses: Dieulafoy lesions, aortoenteric fistula, vascular lesions, and chronic bleeding.

23:27For the full chapter, the practice vignettes, and the topic-tagged question bank, head to board pearls dot com. You'll find the rest of the series on Apple Podcasts, Spotify, or wherever you listen to podcasts. That brings us to the end of episode one of two of chapter nine, and I'll see you in the next one.