On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (On-Demand)

Laine_Nonvariceal UGIB Hemostasis

Pdf Summary

This presentation reviews management of non-variceal upper GI bleeding (UGIB), emphasizing timing of endoscopy, endoscopic hemostatic options, post-procedure care, and antithrombotic management.<br /><br />Key points:<br />- Endoscopy should generally be performed within 24 hours of presentation, but not before initial resuscitation and stabilization. Earlier endoscopy has not clearly improved outcomes and may be harmful in unstable patients.<br />- For low-risk patients, early endoscopy can facilitate discharge; for very high-risk shock patients, urgent endoscopy or interventional radiology may be needed.<br />- Standard endoscopic hemostasis for bleeding ulcers includes thermal therapy (bipolar coagulation, heater probe), clips, and injection therapy. Epinephrine should not be used alone, but only combined with a second modality.<br />- Newer topical hemostatic powders, especially TC-325, can be effective for active bleeding and malignancy-related bleeding, though rebleeding remains common and evidence is still evolving.<br />- Over-the-scope clips may be useful in selected cases of rebleeding or refractory bleeding, but routine first-line use is limited by cost, training needs, and mixed evidence.<br />- After successful hemostasis of high-risk ulcers (Forrest Ia/Ib/IIa/IIb), high-dose PPI therapy for 3 days is strongly recommended, using either continuous infusion or intermittent dosing.<br />- If bleeding recurs, repeat endoscopy is recommended; if endoscopic therapy fails, transcatheter arterial embolization is preferred over surgery.<br />- Antithrombotic therapy should be interrupted as briefly as possible. Aspirin for secondary prevention is usually continued or restarted within 24 hours after hemostasis. Warfarin and DOACs should be resumed once adequate hemostasis is established, balancing bleeding and thrombotic risks.<br /><br />Overall, the “heart is more important than the stomach”: minimize time off antithrombotic therapy while controlling bleeding effectively.

Keywords

non-variceal upper GI bleeding

endoscopy

hemostasis

timing

hemostatic powders

TC-325

proton pump inhibitor

antithrombotic management

transcatheter arterial embolization

rebleeding

endoscopy timing

endoscopic hemostasis

peptic ulcer bleeding

hemostatic clips

epinephrine injection

TC-325 hemostatic powder

high-dose PPI therapy