Practical Management of Non-Variceal Upper GI Bleeding

Risk Stratification and Initial Management

• Use the Blatchford score to identify low-risk patients who may not require hospitalization or urgent endoscopy.

• Most patients with a Blatchford score of 0 or 1 can be safely managed as outpatients.

• Routine use of nasogastric tubes is not recommended; they offer limited diagnostic value and can be uncomfortable.

Transfusion and Resuscitation

• Restrictive transfusion strategies (thresholds of 70–80 g/L) are associated with better outcomes and lower mortality, except in patients with active cardiovascular disease.

• Adequate resuscitation with balanced solutions is essential before endoscopy, especially in sicker patients.

Timing of Endoscopy

• Early endoscopy (within 24 hours) is recommended for most patients, but the sickest patients should not be scoped until they are adequately resuscitated.

• Randomized trials show no benefit to urgent endoscopy (<6 hours) over early endoscopy (within 24 hours) in terms of mortality or rebleeding.

• The timing clock starts at the patient’s initial presentation, even if transferred from another facility.

Anticoagulation and Antiplatelet Management

• For most patients, endoscopy can proceed without reversing anticoagulation or stopping antiplatelet agents.

• Aspirin for secondary prevention should be continued; dual antiplatelet therapy can be restarted 3–5 days after hemostasis.

• Reversal agents are reserved for rare, life-threatening bleeds.

Endoscopic Therapy and Refractory Bleeding

• Combination therapy (injection plus thermal or mechanical) is preferred for high-risk lesions.

• Hemostatic powders are effective for acute and malignant bleeding, providing rapid control and allowing for staged management.

• Over-the-scope clips are valuable for refractory or recurrent bleeding but require experience and careful patient selection.

Practical Pearls

• Second-look endoscopy is not routinely recommended but may be considered if initial hemostasis is uncertain.

• Iron replacement and H. pylori testing/treatment are important for secondary prevention.

• Remain humble and individualize care—complex cases may require multidisciplinary input.

In conclusion, Dr. Barkun’s expert review equips clinicians with the latest evidence and practical strategies for managing non-variceal upper GI bleeding. Emphasis is placed on risk assessment, appropriate timing, and the judicious use of endoscopic and adjunctive therapies to optimize patient outcomes.