Upper GI Bleeding Management (ACG 2021)

Algorithm Steps

1. ▶

   Start

   START: Suspected UGIB

   Hematemesis, melena, or coffee-ground emesis

   1. ●

      Action

      Initial Resuscitation

      Stabilize before risk stratification

      • 2 large-bore IVs (≥18G)
      • Type and screen/crossmatch
      • CBC, BMP, coags, LFTs
      • NPO status
      • Continuous monitoring
      1. ◆

         Decision

         Hemodynamically Stable?

         Assess vital signs and perfusion

         • UNSTABLE: SBP <90, HR >100, orthostatic changes, signs of shock
         • STABLE: Normal vitals, no orthostatic changes
         1. ⚠

            Warning

            Aggressive Resuscitation

            Hemodynamic instability

            • Crystalloid bolus
            • Blood transfusion (target Hgb ≥7, or ≥8 if CAD)
            • Consider massive transfusion protocol if ongoing bleeding
            • Correct coagulopathy (FFP if INR >1.5, platelets if <50K)
            • Early GI and surgical consult
            1. ●

               Action

               IV PPI Therapy

               Start before endoscopy

               • IV PPI bolus: Pantoprazole 80mg or equivalent
               • Followed by continuous infusion 8mg/hr (for high-risk stigmata)
               • OR intermittent high-dose (80mg q12h) if low-risk stigmata
               • Continue until endoscopy determines risk
               1. ●

                  Action

                  Consider Erythromycin

                  Prokinetic before EGD

                  • Erythromycin 250mg IV 20-90 min before EGD
                  • Improves visualization
                  • Reduces need for repeat endoscopy
                  • Conditional recommendation
                  1. ◆

                     Decision

                     EGD Timing

                     Based on stability and risk

                     • URGENT (<12 hr): Hemodynamically unstable, ongoing bleeding
                     • EARLY (12-24 hr): High-risk patients (GBS ≥12, liver disease)
                     • STANDARD (<24 hr): All other admitted patients
                     1. ●

                        Action

                        Upper Endoscopy (EGD)

                        Diagnostic and therapeutic

                        • Identify bleeding source
                        • Forrest classification for ulcers
                        • Endoscopic therapy if high-risk stigmata
                        • Combination therapy preferred (epinephrine + thermal/clip)
                        1. ◆

                           Decision

                           Forrest Classification

                           Ulcer stigmata risk

                           • HIGH-RISK (treat): Ia (spurting), Ib (oozing), IIa (visible vessel), IIb (adherent clot)
                           • LOW-RISK (no treatment): IIc (flat spot), III (clean base)
                           1. ●

                              Action

                              High-Risk Stigmata

                              Endoscopic therapy required

                              • Combination therapy: Epinephrine injection + thermal/clips
                              • High-dose IV PPI infusion x 72 hours post-EGD
                              • NPO initially, advance diet as tolerated
                              • Monitor for rebleeding
                              1. ⚠

                                 Warning

                                 Rebleeding?

                                 Signs of recurrent hemorrhage

                                 • Hematemesis or melena recurrence
                                 • Hemoglobin drop >2g despite transfusion
                                 • Hemodynamic instability
                                 1. ●

                                    Action

                                    Repeat EGD vs IR/Surgery

                                    Manage rebleeding

                                    • Repeat EGD for second attempt at hemostasis
                                    • Interventional radiology (angioembolization) if EGD fails
                                    • Surgery if IR unavailable or fails
                                 2. ✓

                                    Outcome

                                    Discharge Planning

                                    After successful management

                                    • Test and treat H. pylori if ulcer
                                    • Review and stop NSAIDs if possible
                                    • PPI for 8-12 weeks (longer if on anticoagulation)
                                    • GI follow-up
                                    • Discuss anticoagulation/antiplatelet resumption with cardiology
                           2. ●

                              Action

                              Low-Risk Stigmata

                              Medical management

                              • No endoscopic therapy needed for IIc/III
                              • Oral PPI daily
                              • Early feeding (within 24 hr)
                              • Early discharge if stable
         2. ●

            Action

            Risk Stratification

            Calculate Glasgow-Blatchford Score (GBS)

            • BUN, Hemoglobin, SBP, HR, Melena, Syncope, Liver disease, Heart failure
            • GBS = 0-1: Very low risk, may consider outpatient management
            • GBS ≥1: Admit for inpatient management
            1. ◆

               Decision

               GBS 0-1?

               Very low risk patients

               1. ✓

                  Outcome

                  Consider Outpatient EGD

                  GBS 0-1 may be discharged

                  • Oral PPI twice daily
                  • EGD within 24-72 hours as outpatient
                  • Clear return precautions
                  • Reliable patient with good support