Circulatory collapse should be treated with packed red blood cells, with a transfusion goal for hemoglobin at 7 g/dL. Over-transfusion should be avoided, particularly in cirrhotic patients, due to the risk of increasing portal venous pressure. Fresh frozen plasma, or FFP, should only be given to cirrhotic patients as part of the massive transfusion protocol in cases of profound hypotension, as “patients with cirrhosis rarely have true enzymatic hypocoagulability, and FFP may worsen bleeding due to over-resuscitation and dilution of coagulation factors.”³ Platelets should be transfused with a goal of 50,000/μL.¹ Anticoagulants may be stopped and reversed, but this decision should weigh the risks of thromboembolism against ongoing bleeding.¹ There is no proven benefit of tranexamic acid in the setting of UGIB.^4,5

Nasogastric tubes have little prognostic or therapeutic value in the setting of UGIB.⁶ Balloon tamponade (i.e., a Sengstaken-Blakemore tube) may be used as a temporizing measure for unstable UGIB but should not delay emergent esophagogastroduodenoscopy (EGD). There are few data on the outcomes of UGIB when balloon tamponade is used as a temporizing measure. However, a 2017 study of 34 patients suggests that balloon tamponade, when used as a bridge to EGD, improves patient mortality, with 59 percent of patients surviving to hospital discharge.⁷

The gold standard for both diagnosis and hemostasis of UGIB is esophagogastroduodenoscopy (EGD). Any delay in this procedure past 24 hours is associated with significantly increased mortality.⁸

Following initial stabilization, unstable patients should be admitted to the intensive care unit for definitive management.

Stable Patients

For both stable and resuscitated patients, high-dose IV proton pump inhibitor therapy (i.e., pantoprazole 80 mg IV bolus and drip) should be initiated.⁹ A loading dose of octreotide 50 mcg IV, followed by 50 mcg/hour, decreases variceal bleeds.³ Although the American Gastroenterological Association (AGA) does not recommend octreotide for the use of non-variceal UBIG, the AGA states that “there should be a low threshold for its use if there is concern for underlying portal hypertension.”¹⁰ Given the difficulty of obtaining history from these patients, we recommend the empiric use of octreotide in the ED for UGIB, consistent with earlier studies.^11,12 Antibiotics, such as ceftriaxone 1 g or cefotaxime 2 g IV is associated with improved survival in UGIB patients with cirrhosis.^1,3 Erythromycin as a prokinetic agent should be considered to improve endoscopic visualization.

For patients with acute variceal bleeds, the vasoactive agent terlipressin is a potential first-line choice of therapy, because of both its safety and its efficacy in reducing mortality.¹³ A 2018 meta-analysis found that terlipressin is comparable with somatostatin, octreotide, and vasopressin in the control of bleeding. Terlipressin should still be used in combination with endoscopic therapy.¹⁴