In this episode of Hospital Medicine Unplugged, we blitz acute peptic ulcer bleeding—risk fast, resuscitate right, scope within 24 hours, secure hemostasis, run high-dose PPIs, and crush recurrence.

We open with the do-firsts: airway/breathing/circulation, 2 large-bore IVs, orthostatics, urine output, type & cross, and labs (CBC, BMP, INR/LFTs). Risk-stratify with Glasgow–Blatchford (GBS)—≤1 may go outpatient; everyone else is inpatient/urgent care.

Resuscitation that matters: balanced crystalloids, permissive targets while bleeding, and a restrictive transfusion strategy (Hb <7–8 g/dL; <10 g/dL if active CAD). Correct coagulopathy pragmatically; reverse only when it changes decisions.

Pre-endoscopic moves: start IV PPI immediately, consider IV erythromycin 250 mg 30–60 min pre-EGD to clear the field. No tranexamic acid. If cirrhosis/portal hypertension is on the table: prophylactic antibiotics + vasoactive therapy.

Endoscopy: within 24 hours after stabilization; sooner if unstable once perfusing. Treat high-risk stigmata (Forrest Ia/Ib/IIa/IIb):
• Dual-modality is king—epinephrine + thermal or mechanical clips.
• Over-the-scope clips (OTSC) and hemostatic powders are clutch for difficult or diffuse bleeding.
• No therapy for clean base/flat spot; discharge planning starts now.

Post-EGD pharmacotherapy—build the acid-suppression backbone:
• High-dose PPI for 72 h: 80 mg IV bolus → 8 mg/h infusion or 40–80 mg IV/PO BID. These regimens are equivalent.
• Then step down: most get daily PPI; high-risk get BID x 10–14 days, then daily 2–4 weeks.

Monitoring & rebleeding: watch vitals q2–4h, H/H q6–12h for 24–48h, and the stool/NG story. Rebleed? → repeat endoscopy first. If failure or early re-rebleed, transcatheter arterial embolization; surgery if IR/EGD fail.

Etiology plays—prevent the encore:
• H. pylori: test everyone (biopsy/stool/UBT), treat 14 days, confirm eradication off PPI (≥2 weeks) and antibiotics/bismuth (≥4 weeks).
• NSAID/aspirin ulcers: stop the culprit when possible. If needed, switch to COX-2 + daily PPI. For secondary prevention, resume aspirin early after hemostasis.
• Idiopathic ulcers: high-dose PPI 6–8 weeks, scrutinize meds/comorbidities, close follow-up.

Antithrombotics without fear:
• Aspirin for secondary prevention—continue or restart early; mortality benefit outweighs modest rebleed risk.
• Warfarin/DOACs: hold during active bleed; reverse selectively for life-threatening hemorrhage; restart promptly after hemostasis based on thrombotic risk (coordinate with cardiology/hematology).

Nutrition, level of care, disposition: early feeding after control is safe and shortens LOS. Step-down/ICU for major stigmata or instability (first 24 h). Low-risk ulcers can go home early with clear return precautions and a PPI plan.

Medication pitfalls you don’t want to meet: epinephrine monotherapy (never), under-dosed PPIs, premature endoscopy before resuscitation, and stopping secondary-prevention aspirin without a plan.

We close with the systems bundle that sticks:

1. Triage with GBS + ABCs + IV PPI ± erythromycin;

2. EGD ≤24 h with dual-modality for high-risk stigmata; OTSC/powders for select cases;

3. 72-hour high-dose PPI (infusion or BID—equivalent), then tailored step-down;

4. Rebleed pathway: repeat EGD → IR embolization → surgery if needed;

5. Etiology track: test/treat/confirm H. pylori, NSAID strategy, idiopathic high-dose PPI;

6. Antithrombotic game-plan: early aspirin for secondary prevention, timely anticoagulant resumption;

7. Early enteral nutrition, targeted monitoring, and clear discharge instructions.

Fast, hemostasis-focused, and recurrence-proof—stabilize, scope, suppress acid, fix the cause, and never miss a rebleed.