As always, an assessment of airway, breathing, and circulation is the topmost priority. Protection of the airway with intubation may be needed to avoid respiratory compromise from potential aspiration of blood and gastric contents, especially in patients with active bleeding and altered mental status (6). All patients who present with signs and symptoms of UGIB should be evaluated immediately for hemodynamic stability and managed accordingly by rapid intravascular volume replacement with isotonic crystalloid fluids (7). It has been demonstrated that early and aggressive resuscitation reduces mortality in UGIB (8). After initial hemodynamic resuscitation patient risk stratification based on clinical, laboratory and endoscopic features is recommended by the International Consensus Upper Gastrointestinal Bleeding Conference Group (1). Prognostic scales such as Blatchford and Rockall scores are recommended for early stratification of patients into low and high-risk categories for rebleeding and mortality. The Glasgow …show more content…
Recommended timing is based on patient risk factors and resuming warfarin between 7 to 15 days is comparatively safe and effective (26). Aspirin for primary cardiac prophylaxis should be withheld and cardiology consultation is recommended to reevaluate the risks and benefits of restarting aspirin. Discontinuation of low dose aspirin significantly increases risk of death and acute cardiovascular events (27). Aspirin for secondary cardiac prophylaxis should be withheld for 3 days after endoscopy for those with high risk of rebleeding and immediately resumed along with PPI for those with low risk of rebleeding (7, 28). The need for NSAIDs should be carefully evaluated in patients with NSAID associated bleeding ulcers. Those who need NSAIDs, a COX-2 selective NSAID like celecoxib is recommended at the lowest effective dose along with a PPI