Perform urgent endoscopy (e.g., within 24 hours of presentation) after fluid resuscitation and stabilization in patients with upper gastrointestinal bleeding and hemodynamic instability. Prospective study comparing risk assessment tools expert opinion/clinical review The Glasgow-Blatchford bleeding score is recommended for risk stratification in upper gastrointestinal bleeding to predict a composite of various clinical interventions and mortality. Deciding when to restart antithrombotic therapy after upper GI bleeding is difficult because of lack of sufficient data. Guidelines recommend high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy because this is when rebleeding risk is highest. Proton pump inhibitors should be initiated upon presentation with upper GI bleeding. A common strategy in patients with failed endoscopic hemostasis is to attempt transcatheter arterial embolization, then proceed to surgery if hemostasis is not obtained. Patients with hemodynamic instability and signs of upper GI bleeding should be offered urgent endoscopy, performed within 24 hours of presentation. Clinical prediction guides (e.g., Glasgow-Blatchford bleeding score) are necessary for upper GI bleeding risk stratification and to determine therapy. A bolus of normal saline or lactated Ringer solution should be rapidly infused to correct hypovolemia and to maintain blood pressure, and blood should be transfused when hemoglobin is less than 8 g per dL. Laboratory tests should include a complete blood count, basic metabolic panel, coagulation panel, liver tests, and type and screen. Physical examination includes assessment of hemodynamic stability, presence of abdominal pain or rebound tenderness, and examination of stool color. Signs and symptoms of upper GI bleeding may include abdominal pain, lightheadedness, dizziness, syncope, hematemesis, and melena. Causes of upper GI bleeding include peptic ulcer bleeding, gastritis, esophagitis, variceal bleeding, Mallory-Weiss syndrome, and cancer. Common risk factors for upper GI bleeding include prior upper GI bleeding, anticoagulant use, high-dose nonsteroidal anti-inflammatory drug use, and older age. Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz.
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