Upper GI Bleed: Risk Scores, PPI/Octreotide & Endoscopy Timing

Hematemesis, melena, or brisk hematochezia from an upper source demands fast stabilization, early risk stratification, and targeted therapy while arranging timely endoscopy. This is a pragmatic ED-to-endoscopy playbook.

Step 1 — Stabilize (Airway, Breathing, Circulation)

• Airway: assess mental status/aspiration. Intubate only if failure to protect airway or ongoing massive hematemesis; avoid routine prophylactic intubation.
• Breathing: pulse oximetry; supplemental O₂ as needed.
• Circulation: 2 large-bore IVs, cardiac monitor, lactate. Draw CBC, CMP, type & cross, PT/INR, PTT.
• Transfusion: restrictive strategy—RBC threshold generally Hgb ≤7 g/dL (≤8 g/dL if active ischemia/CAD or persistent shock). Transfuse platelets if severe thrombocytopenia or on antiplatelets with ongoing bleed.
• Fluids: balanced crystalloids while arranging blood products if unstable.
• Correct coagulopathy: reverse warfarin with 4-factor PCC + IV vitamin K; consider specific antidotes for DOACs (e.g., idarucizumab for dabigatran; andexanet alfa or PCC for factor Xa inhibitors per local protocol).
• HALT-IT reminder: tranexamic acid is not recommended in GI bleed given lack of benefit and increased adverse events.

Step 2 — Risk Stratify

• Pre-endoscopy: Glasgow-Blatchford Score (GBS) predicts need for intervention; 0 (or 0–1 in some pathways) → possible safe discharge with close follow-up.
• Post-endoscopy: Rockall score (clinical + endoscopic) estimates rebleed/mortality risk and guides disposition.

Step 3 — Empiric Pharmacotherapy (start before scope)

Non-variceal bleed suspected (peptic ulcer, erosive disease)

• PPI: e.g., IV pantoprazole 80 mg bolus then 8 mg/h infusion for 72 h or high-dose IV/PO intermittent regimens per local protocol.
• Hold NSAIDs; evaluate H. pylori later and eradicate if positive.

Variceal bleed suspected (cirrhosis, stigmata)

• Octreotide (or somatostatin/terlipressin where used): 50 mcg IV bolus, then 50 mcg/h infusion.
• Antibiotics: prophylaxis for all suspected variceal bleeds, e.g., ceftriaxone 1 g IV daily (typical 5–7 days).
• Continue PPIs until endoscopy clarifies etiology; PPIs do not treat varices but may cover concurrent ulcers.

Step 4 — Endoscopy Timing & Goals

• Timing: perform upper endoscopy within 24 hours for most; within 12 hours if suspected variceal bleeding or ongoing hemodynamic instability after resuscitation.
• Non-variceal therapy: epinephrine injection plus a second modality (thermal or mechanical clips); post-therapy high-dose PPI as above.
• Variceal therapy: endoscopic band ligation preferred for esophageal varices; consider sclerotherapy if banding not feasible. Initiate secondary prevention plan (nonselective beta-blocker) once stable.

Transfusion & Adjuncts

• Platelets: consider if <50K with active bleeding or on antiplatelets and life-threatening bleed.
• Plasma/PCC: reverse coagulopathy rapidly for procedures; individualize using viscoelastic testing if available.
• Prokinetic (e.g., erythromycin 250 mg IV) 30–90 min pre-endoscopy can improve visualization in active hematemesis.

Antithrombotics: Pause & Restart

• Aspirin for secondary prevention: if held, restart within 3–5 days after hemostasis (earlier in high CV risk).
• P2Y12 inhibitors/dual therapy: coordinate with cardiology; weigh stent thrombosis risk vs rebleed risk.
• Anticoagulants: resume after hemostasis based on thrombotic risk—often within 3–7 days; earlier in high-risk AF/VTE with secure endoscopic control.

If Bleeding Persists or Rebleeds

• Repeat endoscopy with advanced hemostatic options (powders, over-the-scope clips).
• Consider TIPS for refractory variceal hemorrhage after vasoactive therapy and banding fail.
• For non-variceal refractory bleeding, consult interventional radiology for angiographic embolization; surgery if IR unavailable or unsuccessful.

Disposition

• Low-risk (GBS 0–1), stable, no comorbidities: outpatient plan may be reasonable with early follow-up.
• Most others: admit to monitored unit; ICU for hemodynamic instability, large transfusion needs, or high-risk comorbidity.

Patient FAQs

“Why can’t I eat yet?” An empty stomach improves endoscopic visualization and safety during urgent procedures.

“Do PPIs fix bleeding varices?” No—PPIs treat acid-related lesions. Varices need octreotide + banding and antibiotics.

References & Notes

Practical UGI bleed pathway: stabilize, restrictive transfusion, GBS/Rockall scoring, early PPI for non-variceal, octreotide + antibiotics for suspected variceal, and endoscopy within 24 h (sooner if high risk). Local protocols vary—follow institutional guidance. Educational only.