Endoscopic and Pharmacologic Management of Upper GI Bleeding

  • David M. RichardsEmail author
  • Sajini Thekkel
  • William A. Ross
Reference work entry


Upper gastrointestinal bleeding can occur from multiple sources. Broadly, upper gastrointestinal bleeding can be divided into variceal and nonvariceal etiologies. The suspected source of bleeding will drive the initial resuscitation and management. Adequate resuscitation, management of the patients prior medications, initiating medications to affect gastric pH, initiating vasoactive drugs, or administering antibiotics all occur prior to endoscopy. Endoscopy is important in the diagnosis and management of upper gastrointestinal bleeding. Pharmacologic agents are useful during the endoscopy to help achieve hemostasis. Finally, once hemostasis is achieved, decisions must be made regarding reinitiation of previous mediations like antithrombotics and which medications can be used acutely and chronically to reduce the risk of rebleeding and mortality from upper gastrointestinal bleeding.


Upper gastrointestinal bleeding Nonvariceal Variceal Proton pump inhibitors Antithrombotic Antiplatelet Anticoagulation Octreotide Vasoactive drugs Epinephrine Hemospray 


  1. 1.
    ASGE Standards of Practice Committee, Acosta RD, Abraham NS, Chandrasekhara V, Chathadi KV, Early DS, et al. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc. 2016;83(1):3–16. Scholar
  2. 2.
    ASGE Technology Committee, Bhat YM, Banerjee S, Barth BA, Chauhan SS, Gottlieb KT, et al. Tissue adhesives: cyanoacrylate glue and fibrin sealant. Gastrointest Endosc. 2013;78(2):209–15. Scholar
  3. 3.
    Bajaj JS, Ananthakrishnan AN, Hafeezullah M, Zadvornova Y, Dye A, McGinley EL, et al. Clostridium difficile is associated with poor outcomes in patients with cirrhosis: a national and tertiary center perspective. Am J Gastroenterol. 2010;105(1):106–13. Scholar
  4. 4.
    Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FK, Furberg CD, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. Am J Gastroenterol. 2008a;103(11):2890–907. Scholar
  5. 5.
    Bhatt DL, Scheiman J, Abraham NS, Antman EM, Chan FK, Furberg CD, et al. ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical expert consensus documents. J Am Coll Cardiol. 2008b;52(18):1502–17. Scholar
  6. 6.
    Cheung KS, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: risk, prevention and management. World J Gastroenterol. 2017;23(11):1954–63. Scholar
  7. 7.
    Connolly SJ, Milling TJ Jr, Eikelboom JW, Gibson CM, Curnutte JT, Gold A, et al. Andexanet alfa for acute major bleeding associated with factor Xa inhibitors. N Engl J Med. 2016;375(12):1131–41. Scholar
  8. 8.
    Cremers I, Ribeiro S. Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis. Ther Adv Gastroenterol. 2014;7(5):206–16. Scholar
  9. 9.
    Derogar M, Sandblom G, Lundell L, Orsini N, Bottai M, Lu Y, et al. Discontinuation of low-dose aspirin therapy after peptic ulcer bleeding increases risk of death and acute cardiovascular events. Clin Gastroenterol Hepatol. 2013;11(1):38–42. Scholar
  10. 10.
    Feldman M, Friedman LS, Brandt LJ. Sleisenger and Fordtran’s gastrointestinal and liver disease: pathophysiology/diagnosis/management. Philadelphia: Saunders/Elsevier; 2016.Google Scholar
  11. 11.
    Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology. 2017;65(1):310–35. Scholar
  12. 12.
    Ghassemi KA, Kovacs TO, Jensen DM. Gastric acid inhibition in the treatment of peptic ulcer hemorrhage. Curr Gastroenterol Rep. 2009;11(6):462–9. Scholar
  13. 13.
    Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2015;47(10):a1–46. Scholar
  14. 14.
    Harrison MF. The misunderstood coagulopathy of liver disease: a review for the acute setting. West J Emerg Med. 2018;19(5):863–71. Scholar
  15. 15.
    Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute non-variceal upper GI bleeding. Gastrointest Endosc. 2012;75(6):1132–8. Scholar
  16. 16.
    Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, Decker GA, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014;80(2):221–7. Scholar
  17. 17.
    Imperiale TF, Birgisson S. Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Ann Intern Med. 1997;127(12):1062–71. Scholar
  18. 18.
    Kang SH, Yim HJ, Kim SY, Suh SJ, Hyun JJ, Jung SW, et al. Proton pump inhibitor therapy is associated with reduction of early bleeding risk after prophylactic endoscopic variceal band ligation: a retrospective cohort study. Medicine (Baltimore). 2016;95(8):e2903. Scholar
  19. 19.
    Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, et al. Diagnosis of gastrointestinal bleeding: a practical guide for clinicians. World J Gastrointest Pathophysiol. 2014;5(4):467–78. Scholar
  20. 20.
    Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107(3):345–60; quiz 361. Scholar
  21. 21.
    Lo GH, Perng DS, Chang CY, Tai CM, Wang HM, Lin HC. Controlled trial of ligation plus vasoconstrictor versus proton pump inhibitor in the control of acute esophageal variceal bleeding. J Gastroenterol Hepatol. 2013;28(4):684–9. Scholar
  22. 22.
    Lo EA, Wilby KJ, Ensom MH. Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review. Ann Pharmacother. 2015;49(2):207–19. Scholar
  23. 23.
    Lu Y, Loffroy R, Lau JY, Barkun A. Multidisciplinary management strategies for acute non-variceal upper gastrointestinal bleeding. Br J Surg. 2014;101(1):e34–50. Scholar
  24. 24.
    Lu Y, Adam V, Teich V, Barkun A. Timing or dosing of intravenous proton pump inhibitors in acute upper gastrointestinal bleeding has low impact on costs. Am J Gastroenterol. 2016;111(10):1389–98. Scholar
  25. 25.
    Muguruma N, Kitamura S, Kimura T, Miyamoto H, Takayama T. Endoscopic management of nonvariceal upper gastrointestinal bleeding: state of the art. Clin Endosc. 2015;48(2):96–101. Scholar
  26. 26.
    Oakland K, Desborough MJ, Murphy MF, Schachter M, Jairath, V. Re-bleeding and mortality after lower gastrointestinal bleeding in patients taking anti-platelets or anti-coagulants. Clin Gastroenterol Hepatol. 2017.
  27. 27.
    Oakland K, Jairath V, Murphy MF. Advances in transfusion medicine: gastrointestinal bleeding. Transfus Med. 2018;28(2):132–9. Scholar
  28. 28.
    Pollack CV Jr, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373(6):511–20. Scholar
  29. 29.
    Robertson M, Majumdar A, Boyapati R, Chung W, Worland T, Terbah R, et al. Risk stratification in acute upper GI bleeding: comparison of the AIMS65 score with the Glasgow-Blatchford and Rockall scoring systems. Gastrointest Endosc. 2016;83(6):1151–60. Scholar
  30. 30.
    Shim CN, Chung HS, Park JC, Shin SK, Lee SK, Lee YC, et al. Is endoscopic therapy safe for upper gastrointestinal bleeding in anticoagulated patients with supratherapeutic international normalized ratios? Am J Ther. 2016;23(4):e995–e1003. Scholar
  31. 31.
    Shingina A, Barkun AN, Razzaghi A, Martel M, Bardou M, Gralnek I, et al. Systematic review: the presenting international normalised ratio (INR) as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding. Aliment Pharmacol Ther. 2011;33(9):1010–8. Scholar
  32. 32.
    Short NJ, Connors JM. New oral anticoagulants and the cancer patient. Oncologist. 2014;19(1):82–93. Scholar
  33. 33.
    Strate LL, Gralnek IM. ACG clinical guideline: management of patients with acute lower gastrointestinal bleeding. Am J Gastroenterol. 2016;111(5):755. Scholar
  34. 34.
    Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut. 2015;64(11):1680–704. Scholar
  35. 35.
    Udayachalerm S, Rattanasiri S, Angkananard T, Attia J, Sansanayudh N, Thakkinstian A. The reversal of bleeding caused by new oral anticoagulants (NOACs): a systematic review and meta-analysis. Clin Appl Thromb Hemost. 2018.
  36. 36.
    Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(1):11–21. Scholar
  37. 37.
    Weersink RA, Bouma M, Burger DM, Drenth JPH, Harkes-Idzinga SF, Hunfeld NGM, et al. Safe use of proton pump inhibitors in patients with cirrhosis. Br J Clin Pharmacol. 2018;84(8):1806–20. Scholar
  38. 38.
    Wuerth BA, Rockey DC. Changing epidemiology of upper gastrointestinal hemorrhage in the last decade: a nationwide analysis. Dig Dis Sci. 2018;63(5):1286–93. Scholar
  39. 39.
    Zakko L, Rustagi T, Douglas M, Laine L. No benefit from platelet transfusion for gastrointestinal bleeding in patients taking antiplatelet agents. Clin Gastroenterol Hepatol. 2017;15(1):46–52. Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • David M. Richards
    • 2
    Email author
  • Sajini Thekkel
    • 1
  • William A. Ross
    • 2
  1. 1.Division of Anesthesiology, Critical Care and Pain MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Gastroenterology, Hepatology & Nutrition, Division of Internal MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA

Personalised recommendations