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Acute Upper GI Bleeding (UGIB) in Hospitalized Patients: Mastering the Critical First Hours of Hematemesis Management for Hospitalists
In this episode of Hospital Medicine Unplugged, we blitz acute peptic ulcer bleeding—risk fast, resuscitate right, scope within 24 hours, secure hemostasis, run high-dose PPIs, and crush recurrence.
We open with the do-firsts: airway/breathing/circulation, 2 large-bore IVs, orthostatics, urine output, type & cross, and labs (CBC, BMP, INR/LFTs). Risk-stratify with Glasgow–Blatchford (GBS)—≤1 may go outpatient; everyone else is inpatient/urgent care.
Resuscitation that matters: balanced crystalloids, permissive targets while bleeding, and a restrictive transfusion strategy (Hb <7–8 g/dL; <10 g/dL if active CAD). Correct coagulopathy pragmatically; reverse only when it changes decisions.
Pre-endoscopic moves: start IV PPI immediately, consider IV erythromycin 250 mg 30–60 min pre-EGD to clear the field. No tranexamic acid. If cirrhosis/portal hypertension is on the table: prophylactic antibiotics + vasoactive therapy.
Endoscopy: within 24 hours after stabilization; sooner if unstable once perfusing. Treat high-risk stigmata (Forrest Ia/Ib/IIa/IIb):
• Dual-modality is king—epinephrine + thermal or mechanical clips.
• Over-the-scope clips (OTSC) and hemostatic powders are clutch for difficult or diffuse bleeding.
• No therapy for clean base/flat spot; discharge planning starts now.
Post-EGD pharmacotherapy—build the acid-suppression backbone:
• High-dose PPI for 72 h: 80 mg IV bolus → 8 mg/h infusion or 40–80 mg IV/PO BID. These regimens are equivalent.
• Then step down: most get daily PPI; high-risk get BID x 10–14 days, then daily 2–4 weeks.
Monitoring & rebleeding: watch vitals q2–4h, H/H q6–12h for 24–48h, and the stool/NG story. Rebleed? → repeat endoscopy first. If failure or early re-rebleed, transcatheter arterial embolization; surgery if IR/EGD fail.
Etiology plays—prevent the encore:
• H. pylori: test everyone (biopsy/stool/UBT), treat 14 days, confirm eradication off PPI (≥2 weeks) and antibiotics/bismuth (≥4 weeks).
• NSAID/aspirin ulcers: stop the culprit when possible. If needed, switch to COX-2 + daily PPI. For secondary prevention, resume aspirin early after hemostasis.
• Idiopathic ulcers: high-dose PPI 6–8 weeks, scrutinize meds/comorbidities, close follow-up.
Antithrombotics without fear:
• Aspirin for secondary prevention—continue or restart early; mortality benefit outweighs modest rebleed risk.
• Warfarin/DOACs: hold during active bleed; reverse selectively for life-threatening hemorrhage; restart promptly after hemostasis based on thrombotic risk (coordinate with cardiology/hematology).
Nutrition, level of care, disposition: early feeding after control is safe and shortens LOS. Step-down/ICU for major stigmata or instability (first 24 h). Low-risk ulcers can go home early with clear return precautions and a PPI plan.
Medication pitfalls you don’t want to meet: epinephrine monotherapy (never), under-dosed PPIs, premature endoscopy before resuscitation, and stopping secondary-prevention aspirin without a plan.
We close with the systems bundle that sticks:
Triage with GBS + ABCs + IV PPI ± erythromycin;
EGD ≤24 h with dual-modality for high-risk stigmata; OTSC/powders for select cases;
72-hour high-dose PPI (infusion or BID—equivalent), then tailored step-down;
Rebleed pathway: repeat EGD → IR embolization → surgery if needed;
Etiology track: test/treat/confirm H. pylori, NSAID strategy, idiopathic high-dose PPI;
Antithrombotic game-plan: early aspirin for secondary prevention, timely anticoagulant resumption;
Early enteral nutrition, targeted monitoring, and clear discharge instructions.
Fast, hemostasis-focused, and recurrence-proof—stabilize, scope, suppress acid, fix the cause, and never miss a rebleed.
View all episodes
By Roger Musa, MDIn this episode of Hospital Medicine Unplugged, we blitz acute peptic ulcer bleeding—risk fast, resuscitate right, scope within 24 hours, secure hemostasis, run high-dose PPIs, and crush recurrence.
We open with the do-firsts: airway/breathing/circulation, 2 large-bore IVs, orthostatics, urine output, type & cross, and labs (CBC, BMP, INR/LFTs). Risk-stratify with Glasgow–Blatchford (GBS)—≤1 may go outpatient; everyone else is inpatient/urgent care.
Resuscitation that matters: balanced crystalloids, permissive targets while bleeding, and a restrictive transfusion strategy (Hb <7–8 g/dL; <10 g/dL if active CAD). Correct coagulopathy pragmatically; reverse only when it changes decisions.
Pre-endoscopic moves: start IV PPI immediately, consider IV erythromycin 250 mg 30–60 min pre-EGD to clear the field. No tranexamic acid. If cirrhosis/portal hypertension is on the table: prophylactic antibiotics + vasoactive therapy.
Endoscopy: within 24 hours after stabilization; sooner if unstable once perfusing. Treat high-risk stigmata (Forrest Ia/Ib/IIa/IIb):
• Dual-modality is king—epinephrine + thermal or mechanical clips.
• Over-the-scope clips (OTSC) and hemostatic powders are clutch for difficult or diffuse bleeding.
• No therapy for clean base/flat spot; discharge planning starts now.
Post-EGD pharmacotherapy—build the acid-suppression backbone:
• High-dose PPI for 72 h: 80 mg IV bolus → 8 mg/h infusion or 40–80 mg IV/PO BID. These regimens are equivalent.
• Then step down: most get daily PPI; high-risk get BID x 10–14 days, then daily 2–4 weeks.
Monitoring & rebleeding: watch vitals q2–4h, H/H q6–12h for 24–48h, and the stool/NG story. Rebleed? → repeat endoscopy first. If failure or early re-rebleed, transcatheter arterial embolization; surgery if IR/EGD fail.
Etiology plays—prevent the encore:
• H. pylori: test everyone (biopsy/stool/UBT), treat 14 days, confirm eradication off PPI (≥2 weeks) and antibiotics/bismuth (≥4 weeks).
• NSAID/aspirin ulcers: stop the culprit when possible. If needed, switch to COX-2 + daily PPI. For secondary prevention, resume aspirin early after hemostasis.
• Idiopathic ulcers: high-dose PPI 6–8 weeks, scrutinize meds/comorbidities, close follow-up.
Antithrombotics without fear:
• Aspirin for secondary prevention—continue or restart early; mortality benefit outweighs modest rebleed risk.
• Warfarin/DOACs: hold during active bleed; reverse selectively for life-threatening hemorrhage; restart promptly after hemostasis based on thrombotic risk (coordinate with cardiology/hematology).
Nutrition, level of care, disposition: early feeding after control is safe and shortens LOS. Step-down/ICU for major stigmata or instability (first 24 h). Low-risk ulcers can go home early with clear return precautions and a PPI plan.
Medication pitfalls you don’t want to meet: epinephrine monotherapy (never), under-dosed PPIs, premature endoscopy before resuscitation, and stopping secondary-prevention aspirin without a plan.
We close with the systems bundle that sticks:
Triage with GBS + ABCs + IV PPI ± erythromycin;
EGD ≤24 h with dual-modality for high-risk stigmata; OTSC/powders for select cases;
72-hour high-dose PPI (infusion or BID—equivalent), then tailored step-down;
Rebleed pathway: repeat EGD → IR embolization → surgery if needed;
Etiology track: test/treat/confirm H. pylori, NSAID strategy, idiopathic high-dose PPI;
Antithrombotic game-plan: early aspirin for secondary prevention, timely anticoagulant resumption;
Early enteral nutrition, targeted monitoring, and clear discharge instructions.
Fast, hemostasis-focused, and recurrence-proof—stabilize, scope, suppress acid, fix the cause, and never miss a rebleed.