American Journal of Emergency Medicine 81 (2024) 116–123

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Emergency medicine updates: Upper gastrointestinal bleeding

Brit Long, MD a,⁎, Michael Gottlieb, MD b
a
SAUSHEC, Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
b
Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Upper gastrointestinal bleeding (UGIB) is a condition commonly seen in the emergency department
Received 15 March 2024 (ED). Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the diag-
Received in revised form 20 April 2024 nosis and management of this disease.
Accepted 27 April 2024 Objective: This paper evaluates key evidence-based updates concerning UGIB for the emergency clinician.
Discussion: UGIB most frequently presents with hematemesis. There are numerous causes, with the most com-
Keywords:
mon peptic ulcer disease, though variceal bleeding in particular can be severe. Nasogastric tube lavage for diag-
Gastroenterology
GI
nosis is not recommended based on the current evidence. A hemoglobin transfusion threshold of 7 g/dL is
Gastrointestinal recommended (8 g/dL in those with myocardial ischemia), but patients with severe bleeding and hemodynamic
Upper gastrointestinal bleeding instability require emergent transfusion regardless of their level. Medications that may be used in UGIB include
Bleeding proton pump inhibitors, prokinetic agents, and vasoactive medications. Antibiotics are recommended for those
Hemorrhage with cirrhosis and suspected variceal bleeding. Endoscopy is the diagnostic and therapeutic modality of choice
Endoscopy and should be performed within 24 h of presentation in non-variceal bleeding after resuscitation, though patients
Resuscitation with variceal bleeding may require endoscopy within 12 h. Transcatheter arterial embolization or surgical inter-
Varices
vention may be necessary. Intubation should be avoided if possible. If intubation is necessary, several consider-
Ulcer
ations are required, including resuscitation prior to induction, utilizing preoxygenation and appropriate
Transfusion
suction, and administering a prokinetic agent. There are a variety of tools available for risk stratification, including
the Glasgow Blatchford Score.
Conclusions: An understanding of literature updates can improve the ED care of patients with UGIB.
Published by Elsevier Inc.

1. Introduction varices in particular can be severe [1-4,8-11]. There are multiple risk fac-
tors for developing a new UGIB, including prior UGIB, anticoagulant use,
Acute upper gastrointestinal bleeding (UGIB), defined as bleeding nonsteroidal anti-inflammatory drug (NSAID) use, older age, Helicobacter
above the ligament of Treitz (i.e., esophagus, stomach, proximal small pylori infection, and renal disease [2,7,9-12,16]. Patients can present with
intestine), is a common reason for presentation to the emergency a spectrum of symptoms, ranging from mild hematemesis to syncope and
department (ED) [1-5]. UGIB has an incidence of 48–160 per 100,000 airway compromise resulting from severe hemorrhage. However,
persons and over 250,000 admissions annually, with men affected hematemesis with fresh blood or clots is highly suggestive of moderate
more commonly than women [1-11]. It is more common than lower to severe bleeding [9-11,14]. Patients may also present with melena,
GI bleeding, accounting for approximately 75% of all acute GI bleeding coffee-ground emesis, or even hematochezia in those with severe UGIB
patients [1,2,4,11-16]. UGIB is also associated with a sixfold increased [9-11,13,14]. The following questions will highlight several key updates
rate of admission and higher mortality (2–15%) compared to lower GI in the diagnosis and management of UGIB, but this paper is not intended
bleeding [1,2,4,12-16]. to serve as a review of the condition in its entirety.
There are a variety of UGIB etiologies, including esophagitis, esopha-
geal varices, peptic ulcer disease, gastritis, duodenitis, Mallory-Weiss 2. Discussion
tear, and vascular malformations (Table 1). Bleeding from a peptic ulcer
is most common overall (40–50%), but bleeding in those with esophageal 2.1. Is nasogastric tube lavage recommended to determine the source of
bleeding?

Nasogastric tube (NGT) lavage has been previously utilized to assist

⁎ Corresponding author at: 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, USA.
E-mail address: Brit.long@yahoo.com (B. Long).
in differentiating an upper versus lower source of GI bleeding. NGT

https://doi.org/10.1016/j.ajem.2024.04.052
0735-6757/Published by Elsevier Inc.
B. Long and M. Gottlieb American Journal of Emergency Medicine 81 (2024) 116–123

Table 1
Etiologies of upper gastrointestinal bleeding.

Etiology Features Risk factors

Duodenal/gastric ulcer Hematemesis, melena, hematochezia, upper abdominal pain, pain Infection (H. pylori, CMV, HSV), NSAID use, stress ulcer, idiopathic
with eating (worse with eating – gastric, improved with eating –
duodenal)
Esophagitis Hematemesis, melena, hematochezia, dysphagia, odynophagia, GERD, medications (e.g., doxycycline/tetracycline, clindamycin, NSAIDs,
retrosternal pain bisphosphonates, potassium chloride, iron, quinidine), infections (HSV, CMV,
HIV, Candida)
Gastritis/duodenitis Hematemesis, melena, dyspepsia Excessive alcohol, H. pylori, NSAIDs, radiation, stress, anticoagulant use
Esophageal or ectopic Hematemesis, melena, hematochezia, portal hypertension Cirrhosis, portal vein thrombosis, portal hypertension
varices (splenomegaly, ascites), altered mental status, may be
hemodynamically unstable.
Portal hypertensive Hematemesis, melena, hematochezia, portal hypertension Cirrhosis, portal vein thrombosis, portal hypertension
gastropathy (splenomegaly, ascites)
Angiodysplasia Hematemesis, melena, hematochezia End stage renal disease, aortic stenosis, left ventricular assist device, von
Willebrand disease, hereditary hemorrhagic telangiectasia, radiation
Dieulafoy's lesion Hematemesis, melena, hematochezia Unknown etiology; may be associated with cardiovascular disease,
hypertension, NSAIDs, kidney disease, diabetes, alcohol
Gastric antral vascular Hematemesis, melena, hematochezia, stigmata of liver disease Cirrhosis, kidney disease, diabetes, systemic sclerosis, bone marrow
ectasia transplantation
Blue rubber bleb nevus Hematemesis, melena, hematochezia, venous
syndrome malformation/hemangioma of other systems (skin, liver, muscles,
central nervous system)
Mallory-Weiss syndrome Hematemesis after increased intraabdominal pressure, melena, Vomiting/retching, straining with lifting or bowel movement, coughing,
hematochezia, epigastric and/or back pain seizures, blunt abdominal trauma, hiatal hernia
Foreign body ingestion Hematemesis, melena, hematochezia, dysphagia/odynophagia, Psychiatric disorders, altered mental status, loose dentures
neck or abdominal pain, choking, hypersalivation
Post-surgical anastomotic Hematemesis, melena, hematochezia, epigastric pain, náusea, Billroth II surgery, gastric by-pass surgery, H. pylori infection, NSAIDs,
bleeding vomiting smoking
Post-polypectomy, Hematemesis, melena, hematochezia, epigastric pain, history of Large lesions
endoscopic resection or instrumentation (up to 3 weeks prior to symptoms)
sphincterotomy
Cameron lesions Hematemesis, melena, hematochezia Hiatal hernia, reflux esophagitis
Aortoenteric fistula Hematemesis, melena, hematochezia, may have herald bleed Aortitis, prosthetic aortic graft, aortic aneurysm, penetrating ulcer or tumor,
followed by massive bleeding, fever, back pain, sepsis, pulsatile, trauma, radiation, foreign body perforation
abdominal pass
Upper GI tumor Hematemesis, melena, hematochezia, weight loss, anorexia, Benign (leiomyoma, lipoma, polyp) or malignant (adenocarcinoma, GI
epigastric pain, early satiety, nausea/vomiting, palpable mass, stromal tumor, lymphoma, Kaposi sarcoma, carcinoid, melanoma,
dysphagia metastatic)
Hemosuccus pancreaticus Hematemesis, melena, hematochezia, abdominal pain similar to Pancreatitis, arterial aneurysm, tumor, iatrogenic, infection, congenital
pancreatitis, jaundice, weight loss anomaly
Hemobilia Hematemesis, melena, hematochezia, biliary colic, jaundice, sepsis History of liver/biliary injury or instrumentation

CMV – cytomegalovirus, EBV – Epstein Barr virus, GERD – gastroesophageal reflux disease, HIV – human immunodeficiency virus, HSV – herpes simplex virus, NSAIDs – nonsteroidal
anti-inflammatory drugs.

lavage with red blood or coffee ground appearing material may confirm protocol may be necessary, along with administration of calcium. How-
an UGIB, and it can also suggest continued bleeding from an upper GI ever, in otherwise stable patients, clinicians should use a more conser-
source [9-11,17-25]. However, NGT lavage can be negative if there is vative hemoglobin transfusion threshold of 7 g/dL [9-11]. A threshold
no continued bleeding or if the source of bleeding is distal to the pylorus, of ≥8 g/dL may be utilized in those with existing cardiovascular disease
and it is associated with significant discomfort and risk of epistaxis and [9-11]. This transfusion threshold is recommended by the American
placement failure [10,24]. More recent data suggest NGT lavage does College of Gastroenterology (ACG), the European Society of Gastrointes-
not assist in differentiating UGIB and lower GI bleeding [22,23], and a tinal Endoscopy (ESGE), and the Association for the Advancement of
randomized controlled trial (RCT) found that NGT lavage was not Blood and Biotherapies [9,10,26].
associated with improved prediction of a high risk lesion needing endo- These thresholds are based on several RCTs and systematic reviews.
scopic management [24]. Importantly, data also do not demonstrate a One of the largest RCTs including patients with GI bleeding compared
benefit in patient-centered outcomes with NGT lavage. Prospective 7 g/dL and 9 g/dL hemoglobin transfusion thresholds in 899 patients
and retrospective studies evaluating NGT lavage in those with GI bleed- but excluded those with massive hemorrhage [27]. Authors found re-
ing have not found a difference in mortality, hospital length of stay duced transfusion (49% vs. 86%) and lower mortality (5% vs. 9%) in the
(LOS), need for surgery, or transfusion, though there may be a shorter patients randomized to the 7 g/dL transfusion threshold group. They
time to endoscopy [10,17-25]. Based on the current evidence, NGT also found reduced bleeding (10% vs. 16%), fewer cardiac complications
lavage should not be used routinely to determine a bleeding source, (11% vs. 16%), and fewer transfusion reactions (3% vs. 9%) [27]. A meta-
though it may be used to aspirate material from the stomach to assist analysis including 1965 patients found reduced transfusion (mean
with endoscopy and if endotracheal intubation is necessary difference − 1.73 units), all-cause mortality (relative risk 0.65), and
[10,18,20,21]. rebleeding (relative risk 0.58) using restrictive transfusion threshold
in both variceal and non-variceal UGIB [28]. A 2021 meta-analysis
2.2. When should blood products be administered? evaluating transfusion thresholds for all types of bleeding (GI, surgery,
critical care) found no difference in 30-day mortality with restrictive
Patients with massive hemorrhage and hemodynamic instability transfusion strategy compared to a liberal transfusion strategy (risk
should receive blood product transfusion with whole blood (if avail- ratio 0.99, 95% confidence interval [CI] 0.86–1.15), but there were
able), followed by transfusion of packed red blood cells (pRBCs), plate- fewer pRBC transfusions in the restrictive transfusion strategy [29]. Of
lets, and fresh frozen plasma (FFP) in a 1:1:1 ratio. Massive transfusion note, over resuscitation is not recommended, particularly in patients

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B. Long and M. Gottlieb American Journal of Emergency Medicine 81 (2024) 116–123

with cirrhosis and suspected variceal bleeding. In these patients, trans- does not make a recommendation for or against pre-endoscopic PPI
fusion should be based on the patient's baseline blood pressures and therapy [9]. However, post-endoscopic PPI therapy may reduce risk of
markers of perfusion (e.g., mental status, capillary refill, heart rate) rebleeding in those with confirmed peptic ulcers and high risk of bleed-
[30,31]. ing [9,51,52]. Thus, the ACG states that PPI therapy may have a benefit in
Patients with severe bleeding or critical illness and a platelet count a minority of patients with UGIB due to peptic ulcer disease and that a
<50,000 cells/mm3 should receive platelet transfusion, though platelet PPI may be given based on indirect evidence [9]. They also state use of
transfusion is not recommended as a reversal option for those who a PPI may be considered in patients who will not undergo endoscopy
are on antiplatelet agents [9,11]. In those receiving anticoagulation or in whom endoscopy will be delayed [9]. The ESGE suggests that
(e.g., warfarin, direct oral anticoagulants [DOACs]), reversal is necessary high-dose PPI administration in those with acute UGIB may be consid-
if there is severe bleeding [9,10]. This should consist of vitamin K and ered to reduce the risk of bleeding stigmata and need for endoscopic
prothrombin complex concentrates (PCC) or FFP for warfarin; for therapy despite the absence of improvement in patient-oriented out-
DOACs this may include either PCC or a DOAC-specific reversal agent comes [10]. The ESGE guidelines also recommend high dose PPI therapy
[32-40]. Data suggest that endoscopy is likely safe for patients with for patients who receive endoscopic hemostasis [10].
thrombocytopenia [41]. The ACG, ESGE, and International Consensus Based on the available evidence, PPIs may assist in those with con-
Group (ICG) all recommend not delaying endoscopy for reversal of firmed peptic ulcer disease after endoscopy by reducing rebleeding
anticoagulation [9-11,32]. and need for surgical intervention or repeat endoscopy, but they are
Tranexamic acid (TXA) is an antifibrinolytic agent that has demon- not associated with improved outcomes in other patients with UGIB. If
strated utility in select conditions associated with hemorrhage a PPI is administered, we recommend pantoprazole or omeprazole
(e.g., trauma) [42-44]. However, in patients with UGIB, TXA is likely 40–80 mg IV every 12 h, rather than 80 mg IV bolus and 8 mg/h IV infu-
not effective based on current literature. The highest quality evidence sion, as bolus dosing does not require the continuous use of an IV access
concerning TXA use in UGIB includes the HALT-IT trial, published in site [48-50,53,54]. Of note, H2-receptor antagonists do not demonstrate
2020 [45]. This RCT included over 12,000 patients with UGIB and efficacy in acute UGIB and are not currently recommended [9-11].
found no reduction in death due to bleeding within 5 days (risk ratio
0.99, 95% CI 0.82–1.18) with TXA administration, but TXA was associ- 2.3.2. Prokinetic agents
ated with increased venous thromboembolic events (VTE) (risk ratio Prokinetic agents (e.g., erythromycin, metoclopramide) promote
1.85, 95% CI 1.15–2.98) and seizures (1.73, 95% CI 1.03–2.93) [45]. gastric emptying and may clear the stomach of blood and clots, thereby
Based on the available evidence, the ACG and ESGE recommend against improving endoscopic visualization and diagnostic yield [9-11]. Several
using TXA in those with UGIB [9,10]. RCTs and meta-analyses have evaluated erythromycin. A 2016 meta-
analysis with 8 RCTs evaluated erythromycin prior to endoscopy in
2.3. What medications should be administered in the ED setting? those with UGIB. Erythromycin improved visualization (OR 4.14, 95%
CI 2.01–8.53, NNT 4), reduced the need for second endoscopy (OR
2.3.1. Proton pump inhibitors 0.51, 95% CI 0.34–0.77, NNT 9), and reduced the hospital LOS
Gastric acid suppression, most commonly with a proton pump in- (−1.75 days; 95% CI -2.43 to −1.06) [55]. However, there was no differ-
hibitor (PPI), is often utilized in those with UGIB. In patients with ence in need for emergent surgery or amount of blood transfused. A
UGIB due to peptic ulcer disease, PPIs may neutralize gastric acid and Cochrane review published in 2023 including 11 RCTs found similar
stabilize blood clots, as well as reduce the prevalence of endoscopic results with improved visualization in patients receiving erythromycin
bleeding stigmata [2,4,5,9-11]. However, the evidence concerning PPI (mean difference 3.63 points on 16-point ordinal scale, 95% CI
use in all patients with UGIB is controversial, with no improvement in 2.20–5.05), but no difference in non-serious and serious adverse events,
patient-oriented outcomes. A Cochrane review of 21 RCTs including all-cause mortality, and rebleeding [56]. The 2021 ACG guidelines sug-
patients with endoscopically confirmed peptic ulcer bleeding found gest administering erythromycin prior to endoscopy, while the 2021
PPI therapy reduced rebleeding (number-needed-to-treat [NNT] 15), ESGE guidelines recommend erythromycin only in those with clinically
surgical intervention (NNT 32), and repeat endoscopy (NNT), with no severe or continued, active UGIB prior to endoscopy [9,10]. Erythromy-
reduction in mortality overall [46]. In all patients with undifferentiated cin dosing is 250 mg IV over 5–30 min, with endoscopy 20–90 min fol-
UGIB, a Cochrane review of 6 RCTs evaluating use of PPIs, H2-receptor lowing the infusion [9,10]. Older studies found no consistent, definitive
antagonists, or no treatment prior to endoscopy found no reduction in benefit with metoclopramide 10–20 mg IV, and thus the ACG does not
mortality, risk of rebleeding, or need for surgery [47]. However, authors currently recommend its use to improve visualization prior to endos-
found a reduction in secondary outcomes including stigmata of recent copy [9]. However, one study of 52 patients published in 2019 found im-
hemorrhage (odds ratio [OR] 0.67, 95% CI 0.54–0.84, NNT 11) with PPI proved fundal visualization with metoclopramide in non-ulcer cases of
compared to control and reduced need for endoscopic therapy at the UGIB [57]. An RCT of 68 patients comparing metoclopramide versus pla-
index visit (OR 0.68, 95% CI 0.50–0.93, NNT 33) [47]. cebo found metoclopramide was associated with improved rates of ad-
PPI dosing for UGIB most commonly includes either pantoprazole or equate visualization (OR 13, 95% CI 1.32–128.10) and endoscopic
omeprazole 80 mg intravenous (IV) bolus followed by 8 mg/h or visualized gastroduodenal scores and reduced need for second look
pantoprazole or omeprazole 40–80 mg IV twice per day. Current endoscopy (OR 0.11, 95% CI 0.01–0.99) [58]. Based on the available evi-
evidence suggests no difference in outcomes between these dosing reg- dence, erythromycin or metoclopramide may be administered
imens [48-50]. A Cochrane review published in 2013 including 22 RCTs 20–90 min prior to upper endoscopy in conjunction with GI specialist
evaluated high-dose bolus PPI therapy with continuous infusion com- discussion, as these prokinetic agents may assist in gastric emptying
pared to lower doses administered by continuous infusion, IV bolus, or and improve the diagnostic and therapeutic capabilities of endoscopy.
orally after endoscopy for peptic ulcer bleeding found no difference in However, prokinetic agents should not be administered routinely in
mortality, rebleeding, surgery, hospital LOS, or blood transfusion [48]. all patients with UGIB.
A 2014 meta-analysis including 13 studies comparing continuous infu-
sion PPI versus intermittent dosing in those with UGIB from high-risk 2.3.3. Somatostatin analogues
peptic ulcer after endoscopy found intermittent dosing was noninferior Octreotide is a somatostatin analogue that reduces splanchnic blood
in terms of rebleeding in 7–30 days, mortality, need for intervention, flow and portal pressures and thus is often utilized in patients with
need for blood transfusion, or hospital LOS [49]. variceal UGIB, though the current literature is controversial
Due to the lack of improvement in patient-oriented outcomes such [9,10,30,31,59]. A Cochrane review including 21 RCTs of patients with
as mortality, recurrent hemorrhage, or need for surgery [47], the ACG UGIB from esophageal varices found no reduction in all-cause mortality

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or risk of rebleeding; however, there was a reduction in the amount of evaluation within 12 h [9,10,76,77]. In patients with variceal bleeding,
blood products transfused by 0.7 units [59]. It has not demonstrated guidelines recommend endoscopy as soon as possible after resuscitation
any benefit in patients with UGIB from other causes. Thus, while it is [76,77].
not universally recommended for all patients with UGIB, it may be con- These data and guidelines suggest that while endoscopy should be
sidered in situations where the patient is hemodynamically unstable or obtained within 24 h in those with non-variceal UGIB, emergent resus-
if endoscopy is not available, specifically in those with variceal UGIB citation prior to endoscopy is necessary, along with GI consultation in
[9,10]. Dosing of octreotide includes a 50 microgram IV bolus followed the ED [9,10]. In those with variceal bleeding, endoscopy within 12 h
by an infusion of 50 micrograms per hour [30,31]. (or sooner) is recommended after resuscitation [76]. While this
resuscitation is essential, a normal hemoglobin or platelet count is not
2.3.4. Antibiotics necessary prior to endoscopy [78]. The use of antiplatelet agents, antico-
IV antibiotics should be utilized in a select subset of patients with agulants, or a defined international normalized ratio (INR) threshold
UGIB. A Cochrane review of 12 studies (1241 patients) of patients should not be used as contraindications for endoscopy [9,10].
with cirrhosis and UGIB found improved survival and significant reduc-
tion in infections such as nosocomial bacteremia, pneumonia, spontane- 2.5. What are other interventions beyond endoscopy?
ous bacterial peritonitis, and urinary tract infection [60]. Authors found
a NNT of 22 for reduced mortality and a NNT of 4 to prevent infection For patients with UGIB who fail other therapies including
[60]. This effect on mortality was severity-dependent, with more criti- endoscopy, particularly in those with peptic ulcer disease, transcatheter
cally ill patients demonstrating the greatest reduction in mortality arterial embolization (TAE) or surgery may be necessary [2,5,9,10]. A
with antibiotics [60]. There may also be reduced risk of recurrent bleed- meta-analysis including 13 studies comparing TAE versus surgery in pa-
ing in hospitalized patients with cirrhosis and UGIB from esophageal tients with UGIB who failed endoscopy found no difference in mortality
varices [9]. Thus, based on the available evidence, antibiotics such as (OR 0.77, 95% CI 0.50–1.18), but fewer major complications (OR 0.45,
ceftriaxone 1 g IV should be administered in patients with cirrhosis 95% CI 0.30–0.67) and reduced LOS (8 vs. 16 days) in TAE; however,
and UGIB [30,31,60]. there was a higher risk of bleeding with TAE (OR 2.44, 95% CI
1.77–3.36) [79]. Based on these data, TAE is a viable option for control
2.4. When is endoscopy recommended? of UGIB. However, this is based on the local setting and institution. If in-
terventional radiology is available, the emergency clinician should
Upper GI endoscopy is a key diagnostic modality with high sensitiv- consult both interventional radiology and the surgical specialist, as the
ity and specificity for diagnosing the source of bleeding [2,4,5,9-11]. specific modality requires consideration of the hemodynamic status,
Endoscopy is also integral to achieving hemostasis and preventing local expertise, and patient comorbidities. If TAE is an option, computed
rebleeding [2,4,5,9-11]. Thus, consultation with a GI specialist is recom- tomography with angiography is recommended to assist with localiza-
mended for all admitted patients with acute UGIB [2,4,5,9-11]. How- tion of the bleeding [9,10,79-83]. With appropriate localization, TAE is
ever, there are risks of endoscopy including aspiration, GI perforation, successful in approximately 95% of patients [79-83].
increased bleeding, and adverse events to sedation [2,9,10,61-70]. For patients with variceal bleeding who continue bleeding despite
Current data suggest endoscopy within 24 h is associated with reduced medical therapy while waiting endoscopy, a balloon tamponade device
in-hospital mortality, shorter LOS, and reduced costs in those with non- may be utilized [76,84,85]. This can achieve short-term hemorrhage
variceal UGIB [62-65,71-73]. Endoscopy within 12 h has demonstrated control but is associated with complications and risk of rebleeding
conflicting results [9,10,61,74,75]. A 2020 study evaluated endoscopy when the balloon is deflated. There are three balloon tamponade
within 6 h of GI specialist consultation compared with endoscopy devices: Sengstaken-Blakemore tube (with a gastric and esophageal
within 24 h in those with acute UGIB, hemodynamic stability, and Glas- balloon and single gastric suction port), Minnesota tube (gastric and
gow Blatchford score (GBS) ≥ 12 [61]. They found no difference in mor- esophageal balloon with esophageal and gastric suction ports), and
tality, though only a quarter of patients underwent endoscopy within Linton-Nachlas tube (gastric balloon) [84,85]. Balloon tamponade
6 h, and there were no patients who were hemodynamically unstable devices are effective in 30–90% of patients with variceal bleeding [84-
[61]. Another RCT evaluating endoscopy within 12 h compared with 87]. Patients should be intubated prior to balloon placement. Following
after 12 h for those with UGIB due to confirmed bleeding ulcer found placement, the tamponade device can remain in place for 24 h, though
no decrease in bleeding or mortality with endoscopy within 12 h [66]. the gastric balloon will need to be deflated every 12 h to assess for
A large prospective study with 12,601 patients with UGIB associated rebleeding [76]. If bleeding recurs upon deflation, the balloon can be
with peptic ulcers found higher in-hospital and 30-day mortality in pa- reinflated. Importantly, this is only a temporizing measure, and relative
tients undergoing endoscopy within 6 h, particularly in those who were contraindications include recent esophageal or gastric surgery and
hemodynamically unstable or had an American Society of Anesthesiolo- esophageal stricture [84,88]. Transjugular intrahepatic portosystemic
gists score ≥ 3 [69]. The data concerning variceal UGIB differ from pa- shunt (TIPS) is a treatment option for patients with severe, continued
tients with non-variceal UGIB. A meta-analysis of 9 studies found variceal bleeding and functions as a surgical portacaval shunt
patients with variceal UGIB undergoing early endoscopy within 12 h [30,76,89]. This modality has a 90–100% success rate in achieving hemo-
had reduced mortality compared to delayed endoscopy after 12 h, stasis, though it can increase the risk of encephalopathy [30].
with no difference in rebleeding [70].
Importantly, the 2021 ACG guidelines recommend performing 2.6. What airway considerations are necessary in those with UGIB?
endoscopy within 24 h of admission or patient presentation in patients
with non-variceal bleeding who are hemodynamically stable, and the Endotracheal intubation in the patient with UGIB can be challenging
ESGE guidelines and ICG recommend performing endoscopy within and is associated with significant risk. The clinician must be able to man-
24 h but after resuscitation in those with non-variceal bleeding [9-11]. age complications including a view obscured by blood or vomit, the risk
Both the ACG and ESGE guidelines do not recommend urgent of aspiration, hemodynamic instability, comorbidities, and blood or
endoscopy (≤12 h) in patients with non-variceal UGIB, as there is no im- body fluid exposure. Endotracheal intubation should be avoided if pos-
provement in patient-centered outcomes [9,10]. Guidelines stress the sible, as prophylactic intubation in patients with UGIB is associated with
need for resuscitation prior to endoscopy, though the ICG does not greater risk of mortality, pneumonia, hospital LOS, and cost [90-93]. The
make a recommendation before or against endoscopy within 12 h in ESGE recommends against routine endotracheal intubation prior to
those with non-variceal bleeding [9-11]. The guidelines for those with upper endoscopy [10]. However, a select subset of patients will require
variceal bleeding differ as these patients should undergo endoscopic endotracheal intubation, including those with a decreasing level of

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Table 2 Table 4
Approach for endotracheal intubation in those with UGIB. GBS scoring system.

• All staff in appropriate PPE (eye protection, mask, gown, gloves) Component Value
• Preoxygenate
Heart rate (bpm)
• Manage any hemodynamic instability prior to induction and prevent further
≥100 1
decline during intubation: multiple points of vascular access, blood product
Systolic blood pressure (mm Hg)
transfusion, peripheral vasopressors
100–109 1
• Place patient head-up at 45 degrees to reduce aspiration risk and improve
90–99 2
laryngeal view
<90 3
• Consider administering a prokinetic agent (e.g., erythromycin 250 mg IV or
Blood urea nitrogen (mg/dL)
metoclopramide 10–20 mg IV) to assist with gastric clearance prior to induction
18.2–22.3 2
and intubation
22.4–28 3
• Consider gastric decompression with an NGT to aspirate gastric contents (not
28–70 4
contraindicated with variceal bleeding) prior to induction and intubation
>70 6
• Have two large bore suction devices prepared and working (e.g., DuCanto
Hemoglobin (g/dL)
catheter, meconium aspirator attached to endotracheal tube)
Male 12.0–13.0 1
• Avoid positive pressure ventilation during induction prior to intubation if possi-
10.0–11.9 3
ble; if necessary use a gentle, slow technique with 6–10 breaths/min
<10.0 6
• Utilize video laryngoscopy with standard geometry blade (e.g., C-MAC); have
Female 10.0–12.0 1
one member of the team watch the screen and assist with suction
<10.0 6
• Consider using suction assisted laryngoscopy airway decontamination with one
Other Markers
suction device placed in esophagus during intubation
Melena 1
NGT, nasogastric tube. Recent syncope 2
History of liver disease 2
Heart failure present 2
consciousness, continued ongoing hematemesis, inability to adequately
control the airway, high risk of continued deterioration, aspiration, and
need for further intervention (e.g., GI tamponade device, endoscopy)
[10]. If intubation is necessary, patients may require a modified ap-
[105]. The ABC score has demonstrated good performance in predicting
proach with several considerations (Table 2). Importantly, the patient
mortality (Table 6) [101,107]. The most recently evaluated score is the
should be resuscitated prior to induction and intubation.
CANUKA scoring system, initially derived in 2019 (Table 7) [106]. A sec-
ond study evaluating the CANUKA score found those with a score < 4
2.7. Which decision tools are effective at risk stratifying patients with UGIB?
had no adverse events, and no patient with a score < 6 died [108]. A
third study found GBS ≤ 1, modified GBS of 0, and CANUKA ≤2 had
Several tools are available seeking to risk stratify patients and poten-
high sensitivity in determining low risk, with no patient deaths [95]. A
tially identify a subset who may be appropriate for discharge, including
2016 systematic review evaluating GBS, Rockall, and AIMS65 scoring
the GBS, AIMS65 score, ABC score, Canada–United Kingdom–Adelaide
systems found the GBS score to have better predictive value in deter-
(CANUKA) score, and the Rockall score [9-11,94-112]. A desirable
mining low risk for 30-day adverse events [109]. Of note, a 2023
score is one that has high sensitivity and minimizes false negatives.
meta-analysis comparing risk scores for UGIB included 38 studies eval-
There are two versions of the Rockall score: pre-endoscopy and
uating the GBS, clinical Rockall score, CANUKA, AIMS64, and ABC score
post-endoscopy [96,97]; however, the pre-endoscopy score is the
and found the GBS score with a threshold of ≤1 was the best discrimina-
most relevant for the emergency clinician and incorporates age, shock,
tor in predicting low risk (including mortality; rebleeding; and need for
and comorbidities (Table 3) [98]. The most commonly used score is
endoscopic, surgical, or radiologic intervention) [112]. Currently, the
the GBS, which has been validated in multiple studies (Table 4). A GBS
ACG, ESGE, and ICG suggest using a GBS score of ≤1 over other scores
of ≤1 is over 98% sensitive in predicting low risk UGIB, and multiple
to identify UGIB patients at very low risk of mortality or rebleeding
studies comparing GBS with other scores suggest GBS is more accurate
and who may be appropriate for outpatient management [9-11].
in determining who is low risk and predicting mortality and need for
Importantly, the clinician should consider other factors and not rely
in-hospital intervention [94,95,98-100,103-105,109-112]. There is a
upon these scores in isolation. Patients with severe or recurrent bleed-
modified version of GBS that removes melena, recent syncope, history
ing, hemodynamic instability, significant comorbidities, suspected
of liver disease, and the presence of heart failure, with several studies
high risk bleeding sources (e.g., varices, ulcer, Dieulafoy's lesion), severe
suggesting similar accuracy between the original and modified versions
comorbidities (e.g., end-stage renal disease, heart failure), or inability to
of GBS [11,110]. The AIMS65 is relatively newer, originally derived in
follow up should be admitted. However, if these are not present and the
2011 to predict mortality, and can also be used prior to endoscopy
patient can be stratified as low risk (e.g., GBS of ≤1), discharge with fol-
(Table 5) [102-104]. One study suggests AIMS65 may be better at
low up can be considered [9,10].
predicting in-hospital mortality, intensive care unit admission, and hos-
pital LOS, while the GBS is better at predicting the need for transfusion
3. Conclusions

Table 3 UGIB is associated with significant morbidity and mortality, with

Rockall score (Pre-endoscopy). most patients admitted. Hematemesis is the most common
Component Value

Age
Table 5
60–79 years 1
AIMS65 score.
≥80 years 2
Shock Component Value
Systolic blood pressure ≥ 100 mmHg, heart rate > 100 1
Systolic blood pressure < 100 mg Hg 2 Albumin <3 g/dL 1
Comorbidities INR > 1.5 1
Any comorbidity except renal/liver failure, malignancy 2 Altered mental status 1
Renal or liver failure, disseminated malignancy 3 Systolic blood pressure ≤ 90 mmHg 1
Age ≥ 65 years 1

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B. Long and M. Gottlieb American Journal of Emergency Medicine 81 (2024) 116–123

Table 6 Visualization, Validation, Supervision, Resources, Conceptualization,

ABC score. Writing – review & editing.
Component Value

Age (years) Declaration of competing interest

60–74 1
≥ 75 2 None.
ASA Class
No author has completed a narrative review on UGIB.
3 1
≥4 3 The authors of this review will not be submitting a manuscript on
Systolic blood pressure (mm Hg) UGIB to another journal until AJEM makes a decision to reject or actually
≥100–119 1 publishes (not just accepts) this manuscript.
≥90–99 2 No AI program was used to construct this review.
<90 3
Blood urea nitrogen
≥28 1 Acknowledgements
Albumin
< 3 mg/dL 2
Serum creatinine (mg/dL) BL and MG conceived the idea for this manuscript and contributed
≥1–1.4 1 substantially to the writing and editing of the review. This manuscript
≥1.5 2 did not utilize any grants, and it has not been presented in abstract form.
Comorbidities This clinical review has not been published, it is not under consideration
Cirrhosis 2
Altered mental status 2
for publication elsewhere, its publication is approved by all authors and
Disseminated malignancy 4 tacitly or explicitly by the responsible authorities where the work was
carried out, and that, if accepted, it will not be published elsewhere in
the same form, in English or in any other language, including electroni-
Table 7
cally without the written consent of the copyright-holder. This review
CANUKA score. does not reflect the views or opinions of the U.S. government, Depart-
ment of Defense, Defense Health Agency, U.S. Army, U.S. Air Force, or
Component Value
SAUSHEC EM Residency Program.
Age (years)
50–64 1
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