In this episode of Hospital Medicine Unplugged, we take on acute peptic ulcer bleeding (PUB)—triage fast, stabilize smart, scope early, seal the vessel, and lock in acid suppression + secondary prevention.

We start at the door with risk stratification: use the Glasgow–Blatchford Score (GBS)—≤1 means very-low risk and potential outpatient management; everyone else gets admitted and prepped for urgent endoscopy. Pull CBC, chemistries, INR, type & cross.

Resuscitation that helps, not harms: large-bore IVs, balanced crystalloids, and a restrictive transfusion strategy—transfuse at Hgb <7–8 g/dL (consider <10 g/dL in active coronary disease). Aim for hemodynamic stability before the scope. Early enteral feeding once controlled shortens LOS.

Pre-endoscopic moves: start IV PPI immediately; give IV erythromycin pre-scope to clear the stomach (better visualization). Skip tranexamic acid. If the patient has cirrhosis, flip to the variceal bundle (antibiotics + vasoactive agents) while you clarify source.

Endoscopy timing & targets: perform within 24 hours (earlier only after stabilization in the unstable). Treat high-risk stigmata—active bleeding, non-bleeding visible vessel, adherent clot. Use dual-modality therapy (epi injection + thermal or clips) as your default. Deploy OTSC or hemostatic powder for difficult lesions or poor visualization. Clean base/flat spots? No therapy; plan early discharge.

Post-endoscopic pharmacotherapy (the acid wall): run high-dose PPI for 72 hours—either 80 mg IV bolus → 8 mg/h infusion or intermittent high-dose IV/PO (equally effective). Then step down: once-daily PPI for most; BID for 10–14 days in high-risk, then daily 2–4 weeks.

Monitoring & rebleeding rescue: watch closest in the first 72 hours—vitals, H/H every 6–12h, stool color, symptoms. Suspect rebleed? Resuscitate → repeat endoscopy (works ~75%). If bleeding persists, escalate to transcatheter arterial embolization (TAE); surgery if IR/endoscopy fail.

Etiology matters (prevent the sequel):
• H. pylori: test everyone, eradicate if positive, and confirm cure (breath/stool ≥4 wks post-abx; off PPI ≥2 wks). Eradication slashes recurrence to near-zero.
• NSAID/aspirin ulcers: stop NSAIDs; if indispensable, switch to COX-2 + PPI. For secondary-prevention aspirin, resume within 1–7 days post-hemostasis (cardiology input for DAPT).
• Idiopathic ulcers: higher recurrence—longer PPI course (6–8 wks) and tight follow-up.

Antithrombotics without chaos: hold during active bleed, but restart early after hemostasis to avoid thrombotic events—continue/restart aspirin for secondary prevention and reintroduce anticoagulants promptly based on thrombotic risk (multidisciplinary call). Use PCC/vitamin K or specific DOAC reversal only for life-threatening bleeds.

Discharge playbook:
• Low-risk endoscopic findings → early discharge with clear return precautions.
• High-risk stigmata → observe ≥72 h with high-dose PPI, then taper.
• Educate on red flags (melena, hematemesis, syncope), ensure H. pylori test-of-cure, review meds, and consider iron for anemia.

Bottom line: assess risk fast, resuscitate right, endoscope within 24h, use dual-modality hemostasis, and run high-dose PPI for 72h. Then fix the cause (H. pylori, NSAIDs, antithrombotics) to prevent the rematch.