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__NOTOC__
__NOTOC__
{{Upper gastrointestinal bleeding}}
{{Upper gastrointestinal bleeding}}
{{CMG}}
{{CMG}} ; {{AE}} {{ADG}}


==Overview==
==Overview==
Upper gastrointestinal bleeding is a medical emergency and requires prompt treatment. According to the American Society of Gastroenterology guidelines, the recommended medications include PPI's, octreotide and antibiotics. Pharmacotherapy is only used as an adjuvant therapy for all patients with UGIB.


==Medical Treatment==
==Medical Therapy==
Upper gastrointestinal bleeding is an medical emergency and requires prompt treatment. Pharmacotherapy is recommended as an adjuvant among all patients with UGIB. [[Proton pump inhibitor|PPIs]] or, less commonly [[antihistamines]] are generally prescribed for patients with suspected or confirmed bleeding due to [[Peptic ulcer disease|peptic ulcer disease,]] stress ulcers, or erosive gastritis. [[Octreotide]] , a somatostatin analog that decreases portal blood flow, is often administered as a continuous drip to [[Cirrhosis|cirrhotic]] patients with active variceal bleeding. [[Antibiotic]] medications , such as a [[Fluoroquinolones|fluoroquinolone]] or an extended-spectrum [[cephalosporin]], are also recommended to patients with cirrhosis experiencing UGIB. Administration of [[antibiotics]] have been demonstrated to significantly reduce [[bacterial infections]], all-cause mortality, bacterial infection mortality, rebleeding, and hospital length of stay. In patients with a large volume of blood in the stomach from any source, [[erythromycin]] may increase the rate of gastric emptying.<ref name="pmid16834764">{{cite journal |vauthors=Arabi Y, Al Knawy B, Barkun AN, Bardou M |title=Pro/con debate: octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin? |journal=Crit Care |volume=10 |issue=4 |pages=218 |year=2006 |pmid=16834764 |pmc=1750992 |doi=10.1186/cc4958 |url=}}</ref><ref name="pmid23997925">{{cite journal |vauthors=Brooks J, Warburton R, Beales IL |title=Prevention of upper gastrointestinal haemorrhage: current controversies and clinical guidance |journal=Ther Adv Chronic Dis |volume=4 |issue=5 |pages=206–22 |year=2013 |pmid=23997925 |pmc=3752180 |doi=10.1177/2040622313492188 |url=}}</ref><ref name="pmid25400991">{{cite journal |vauthors=Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE |title=Diagnosis of gastrointestinal bleeding: A practical guide fr clinicians |journal=World J Gastrointest Pathophysiol |volume=5 |issue=4 |pages=467–78 |year=2014 |pmid=25400991 |pmc=4231512 |doi=10.4291/wjgp.v5.i4.467 |url=}}</ref><ref name="pmid22385878">{{cite journal |vauthors=Struijk M, Postma DF, van Tuyl SA, van de Ree MA |title=Optimal drug therapy after aspirin-induced upper gastrointestinal bleeding |journal=Eur. J. Intern. Med. |volume=23 |issue=3 |pages=227–30 |year=2012 |pmid=22385878 |doi=10.1016/j.ejim.2011.10.004 |url=}}</ref>
===Upper gastrointestinal bleeding===
*'''Upper gastrointestinal bleeding secondary to peptic ulcer disease, stress ulcers, or erosive gastritis.'''
** '''Preferred regimen (1)''': [[Esomeprazole]] 40 mg PO q24h
** '''Preferred regimen (2)''': [[Lansoprazole]] 30 mg PO q24h
** '''Preferred regimen (3)''': [[Pantoprazole]] 40 mg PO oq24h 
*** Note: It is reasonable that patients with UGIB be treated with an intravenous [[PPI]] at presentation until endoscopy confirms the cause of bleeding.
*** Note: Contraindicated in patients with [[PPI]] [[hypersensitivity]] ([[esomeprazole]], [[pantoprazole]])
** '''Alternative regimen (1)''': [[Cimetidine]] 37.5 to 50 mg/hr IV continuous (total daily dosage 900-1,200 mg).
** '''Alternative regimen (2)''': [[Ranitidine]] 50 mg IV q8h '''(or)''' 6.25 mg/hr  continuous IV infusion (total daily dosage 150 mg).
** '''Alternative regimen (3)''': [[Famotidine]] 20 mg IV q12h '''or''' 10 mg IV initially, followed by 1.7 mg/hr by continuous IV infusion (total daily dosage 40 mg).
*** Note: Goal is to maintain intragastric [[pH]] above 4.0.
*'''Upper gastrointestinal bleeding secondary to esophageal varices or other lesions caused by portal hypertension.'''
** '''Preferred regimen (1)''': [[Octreotide]] 50 μg bolus followed by a continuous intravenous drip at 50 μg/hr for 72 hours.
*'''Upper gastrointestinal bleeding in patients with cirrhosis.'''
** '''Preferred regimen (1)''': [[Ciprofloxacin]] 400 mg IV q8h.
** '''Preferred regimen (2)''': [[Cefepime]] 2g iv q12h.
** '''Preferred regimen (3)''': [[Erythromycin]] 250 mg iv once 20 minutes prior to [[endoscopy]].
*** Note: Because of its [[Prokinetic|prokinetic action]], [[erythromycin]] is administered before [[endoscopy]] in patients who have a large volume of blood in the [[esophagus]] or [[stomach]].
===Proton pump inhibitors===
*[[Proton pump inhibitor|PPIs]] are usually first drug of choice in patients with UGIB, but an [[H2 receptor antagonists]] are administered if [[Proton pump inhibitor|PPIs]] are contraindicated or otherwise not preferred therapy.<ref name="pmid26034370">{{cite journal |vauthors=Zhang YS, Li Q, He BS, Liu R, Li ZJ |title=Proton pump inhibitors therapy vs H2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: A meta-analysis |journal=World J. Gastroenterol. |volume=21 |issue=20 |pages=6341–51 |year=2015 |pmid=26034370 |pmc=4445112 |doi=10.3748/wjg.v21.i20.6341 |url=}}</ref>
*An [[PH|acidic pH]] slows [[blood clotting]] therefore, elevating intragastric pH above 4.0 may facilitate [[platelet aggregation]].
*There is conflicting evidence regarding [[efficacy]] of [[clopidogrel]], an anti-clotting medication, with concomitant use with a [[PPI]].
*The [[FDA]] has issued safety information regarding patients who take both [[omeprazole]] and [[clopidogrel]], warning that such patients may experience decreased efficacy of [[clopidogrel]], and thus may have an increased risk of cardiovascular events. <ref name="pmid26727382">{{cite journal |vauthors=Guérin A, Mody R, Carter V, Ayas C, Patel H, Lasch K, Wu E |title=Changes in Practice Patterns of Clopidogrel in Combination with Proton Pump Inhibitors after an FDA Safety Communication |journal=PLoS ONE |volume=11 |issue=1 |pages=e0145504 |year=2016 |pmid=26727382 |pmc=4699636 |doi=10.1371/journal.pone.0145504 |url=}}</ref>
*Ingestion of [[Proton pump inhibitor|PPIs]] within 4 weeks prior to performing urease or breath tests for H.pylori detection may lead to false-negative results.


Emergency treatment for upper GI bleeds includes aggressive replacement of volume with [[intravenous]] solutions, and [[blood]] products if required. As patients with [[esophageal varices]] typically have coagulopathy, [[fresh frozen plasma|plasma]] products may have to be administered.  Vitals signs are continuously monitored.
===Octreotide===
*[[Octreotide]] is generally limited to settings in which endoscopy is unavailable or as a means to help stabilize patients before definitive therapy can be performed.<ref name="pmid15647641">{{cite journal |vauthors=Yang JF, Wu XJ, Li JS, Cao JM, Han JM |title=Effect of somatostatin versus octreotide on portal haemodynamics in patients with cirrhosis and portal hypertension |journal=Eur J Gastroenterol Hepatol |volume=17 |issue=1 |pages=53–7 |year=2005 |pmid=15647641 |doi= |url=}}</ref>
*[[Octreotide]] is recommended as an adjunct to [[Endoscopy|endoscopic]] and [[Proton pump inhibitor|PPI]] therapy.
*[[Octreotide]] reduces portal venous blood flow and arterial flow to the [[stomach]] and the duodenum while preserving renal arterial flow.
*[[Somatostatin]] or [[octreotide]] also reduces the risk of continued [[bleeding]] from causes other than [[varices]] and are also used in management of non-variceal UGIB.


Early [[esophagogastroduodenoscopy|endoscopy]] is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:
===Antibiotics===
*[[Fluoroquinolones]] have been found to significantly reduces [[bacterial infections]], bacterial infection mortality, rebleeding events, and hospitalization length in patients with cirrhosis and UGIB.<ref name="pmid14999693">{{cite journal |vauthors=Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY, Lee SD |title=Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial |journal=Hepatology |volume=39 |issue=3 |pages=746–53 |year=2004 |pmid=14999693 |doi=10.1002/hep.20126 |url=}}</ref>
*[[Erythromycin]], when given just prior to endoscopy, may also increase gastric emptying in patients who are likely to have a large volume of [[blood]] in their [[stomach]] and thus improve the visualization of [[lesions]].
==Follow Up==
*All patients should be monitored for continued or rebleeding.
*Rebleeding is often first detected by recurrent signs of overt [[hemorrhage]] such as [[melena]] or [[hematemesis]], or by [[hemodynamic instability]].
*In patients with evidence of rebleeding, a second endoscopic therapy generally is recommended.
**In case if bleeding still persists even with a second [[endoscopic]] therapy, surgical or radiologic intervention is considered.
*Length of stay in the hospital should be based on the stability of the patient as well as the endoscopic findings of the source.
*Patients with low-risk lesions can be discharged early from the hospital.
{| border="1" cellpadding="5" cellspacing="0" align="center" |class="wikitable"
! colspan="2" style="background:#efefef;" |'''Blatchford score'''
|-
| colspan="2" |The score is zero if the following criteria are fulfilled:
* Urea Nitrogen < 18.2 mg/dl


*[[Injection (medicine)|injection]] of [[adrenaline]] or other [[sclerotherapy]]
* Absence of [[melena]], [[cardiac failure]], [[syncope]] and [[liver disease]]
*electrocautery
* [[Hemoglobin]] ≥ 13 g/dL (12 g/dL for women)
*endoscopic clipping
* [[Systolic blood pressure]] ≥ 110 mmHg
*or banding of [[esophageal varices|varices]]
* Pulse <100/min
 
|-
Stigmata of high risk include active bleeding, oozing, visible vessels and red spots.  Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.
| rowspan="2" |Interpretation
 
|Score of '''0''' discharged
 
|-
Pharmacotherapy includes the following:
|Score '''>0''' is sent for endoscopic treatment
* [[Proton pump inhibitors]] (PPIs), which reduce [[gastric acid]] production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage.  These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
|}
* [[Octreotide]] is a [[somatostatin]] analog believed to shunt blood away from the splanchnic circulation.  It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage.  It is the somatostatin analog most commonly used in North America.
*Following endoscopic variceal ligation for [[Esophageal varices|esophageal variceal hemorrhage]], repeat EGD should be performed in 2 to 3 weeks when the banding ulcers have healed. At that time, additional banding may be performed to ensure that the [[varices]] have been obliterated
* [[Terlipressin]] is a [[somatostatin]] analog most commonly used in Europe for variceal upper GI hemorrhage.
*Following [[Gastric ulcer perforated|gastric ulcer hemorrhage]], repeat endoscopy in 6 to 8 weeks should be considered to confirm ulcer healing and to exclude the possibility of a [[Gastric malignancy|malignant gastric ulcer.]]
* Antibiotics are prescribed in upper GI bleeds associated with [[portal hypertension]]
*Routine endoscopic follow-up is not required for [[Duodenal ulcer|duodenal ulcers]]. Lifelong therapy with [[Proton pump inhibitor|PPIs]] may be warranted in patients who are at a high risk for recurrence for ulcers, or who have experienced [[Peptic ulcer|peptic ulcer hemorrhage]].
 
If ''[[Helicobacter pylori]]'' is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.
 
===Refractory bleeding===
Refractory cases of upper GI hemorrhage may require:
* Repeat [[endoscopy|esophagogastroduodenoscopy]]
* Anti-fibrinolytics, such as [[tranexamic acid]]
* [[Angiography]] to identify and possibly occlude the feeder vessel
* Recombinant [[Factor VII]] is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage
* [[Balloon tamponade]]
* [[Surgery]], to oversew or remove the area of hemorrhage
 
Certain causes of upper GI hemorrhage (including [[gastric ulcer]]s require repeat [[endoscopy]] after the episode of bleeding to ascertain healing of the causative lesion.


==References==
==References==
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[[Category:Medical emergencies]]
[[Category:Medical emergencies]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Needs patient information]]
 
[[Category:Mature chapter]]
[[Category:Needs overview]]


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Latest revision as of 15:07, 5 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Upper gastrointestinal bleeding is a medical emergency and requires prompt treatment. According to the American Society of Gastroenterology guidelines, the recommended medications include PPI's, octreotide and antibiotics. Pharmacotherapy is only used as an adjuvant therapy for all patients with UGIB.

Medical Therapy

Upper gastrointestinal bleeding is an medical emergency and requires prompt treatment. Pharmacotherapy is recommended as an adjuvant among all patients with UGIB. PPIs or, less commonly antihistamines are generally prescribed for patients with suspected or confirmed bleeding due to peptic ulcer disease, stress ulcers, or erosive gastritis. Octreotide , a somatostatin analog that decreases portal blood flow, is often administered as a continuous drip to cirrhotic patients with active variceal bleeding. Antibiotic medications , such as a fluoroquinolone or an extended-spectrum cephalosporin, are also recommended to patients with cirrhosis experiencing UGIB. Administration of antibiotics have been demonstrated to significantly reduce bacterial infections, all-cause mortality, bacterial infection mortality, rebleeding, and hospital length of stay. In patients with a large volume of blood in the stomach from any source, erythromycin may increase the rate of gastric emptying.[1][2][3][4]

Upper gastrointestinal bleeding

  • Upper gastrointestinal bleeding secondary to peptic ulcer disease, stress ulcers, or erosive gastritis.
    • Preferred regimen (1): Esomeprazole 40 mg PO q24h
    • Preferred regimen (2): Lansoprazole 30 mg PO q24h
    • Preferred regimen (3): Pantoprazole 40 mg PO oq24h
      • Note: It is reasonable that patients with UGIB be treated with an intravenous PPI at presentation until endoscopy confirms the cause of bleeding.
      • Note: Contraindicated in patients with PPI hypersensitivity (esomeprazole, pantoprazole)
    • Alternative regimen (1): Cimetidine 37.5 to 50 mg/hr IV continuous (total daily dosage 900-1,200 mg).
    • Alternative regimen (2): Ranitidine 50 mg IV q8h (or) 6.25 mg/hr continuous IV infusion (total daily dosage 150 mg).
    • Alternative regimen (3): Famotidine 20 mg IV q12h or 10 mg IV initially, followed by 1.7 mg/hr by continuous IV infusion (total daily dosage 40 mg).
      • Note: Goal is to maintain intragastric pH above 4.0.
  • Upper gastrointestinal bleeding secondary to esophageal varices or other lesions caused by portal hypertension.
    • Preferred regimen (1): Octreotide 50 μg bolus followed by a continuous intravenous drip at 50 μg/hr for 72 hours.
  • Upper gastrointestinal bleeding in patients with cirrhosis.

Proton pump inhibitors

  • PPIs are usually first drug of choice in patients with UGIB, but an H2 receptor antagonists are administered if PPIs are contraindicated or otherwise not preferred therapy.[5]
  • An acidic pH slows blood clotting therefore, elevating intragastric pH above 4.0 may facilitate platelet aggregation.
  • There is conflicting evidence regarding efficacy of clopidogrel, an anti-clotting medication, with concomitant use with a PPI.
  • The FDA has issued safety information regarding patients who take both omeprazole and clopidogrel, warning that such patients may experience decreased efficacy of clopidogrel, and thus may have an increased risk of cardiovascular events. [6]
  • Ingestion of PPIs within 4 weeks prior to performing urease or breath tests for H.pylori detection may lead to false-negative results.

Octreotide

  • Octreotide is generally limited to settings in which endoscopy is unavailable or as a means to help stabilize patients before definitive therapy can be performed.[7]
  • Octreotide is recommended as an adjunct to endoscopic and PPI therapy.
  • Octreotide reduces portal venous blood flow and arterial flow to the stomach and the duodenum while preserving renal arterial flow.
  • Somatostatin or octreotide also reduces the risk of continued bleeding from causes other than varices and are also used in management of non-variceal UGIB.

Antibiotics

  • Fluoroquinolones have been found to significantly reduces bacterial infections, bacterial infection mortality, rebleeding events, and hospitalization length in patients with cirrhosis and UGIB.[8]
  • Erythromycin, when given just prior to endoscopy, may also increase gastric emptying in patients who are likely to have a large volume of blood in their stomach and thus improve the visualization of lesions.

Follow Up

  • All patients should be monitored for continued or rebleeding.
  • Rebleeding is often first detected by recurrent signs of overt hemorrhage such as melena or hematemesis, or by hemodynamic instability.
  • In patients with evidence of rebleeding, a second endoscopic therapy generally is recommended.
    • In case if bleeding still persists even with a second endoscopic therapy, surgical or radiologic intervention is considered.
  • Length of stay in the hospital should be based on the stability of the patient as well as the endoscopic findings of the source.
  • Patients with low-risk lesions can be discharged early from the hospital.
Blatchford score
The score is zero if the following criteria are fulfilled:
  • Urea Nitrogen < 18.2 mg/dl
Interpretation Score of 0 discharged
Score >0 is sent for endoscopic treatment
  • Following endoscopic variceal ligation for esophageal variceal hemorrhage, repeat EGD should be performed in 2 to 3 weeks when the banding ulcers have healed. At that time, additional banding may be performed to ensure that the varices have been obliterated
  • Following gastric ulcer hemorrhage, repeat endoscopy in 6 to 8 weeks should be considered to confirm ulcer healing and to exclude the possibility of a malignant gastric ulcer.
  • Routine endoscopic follow-up is not required for duodenal ulcers. Lifelong therapy with PPIs may be warranted in patients who are at a high risk for recurrence for ulcers, or who have experienced peptic ulcer hemorrhage.

References

  1. ↑ Arabi Y, Al Knawy B, Barkun AN, Bardou M (2006). "Pro/con debate: octreotide has an important role in the treatment of gastrointestinal bleeding of unknown origin?". Crit Care. 10 (4): 218. doi:10.1186/cc4958. PMC 1750992. PMID 16834764.
  2. ↑ Brooks J, Warburton R, Beales IL (2013). "Prevention of upper gastrointestinal haemorrhage: current controversies and clinical guidance". Ther Adv Chronic Dis. 4 (5): 206–22. doi:10.1177/2040622313492188. PMC 3752180. PMID 23997925.
  3. ↑ Kim BS, Li BT, Engel A, Samra JS, Clarke S, Norton ID, Li AE (2014). "Diagnosis of gastrointestinal bleeding: A practical guide fr clinicians". World J Gastrointest Pathophysiol. 5 (4): 467–78. doi:10.4291/wjgp.v5.i4.467. PMC 4231512. PMID 25400991.
  4. ↑ Struijk M, Postma DF, van Tuyl SA, van de Ree MA (2012). "Optimal drug therapy after aspirin-induced upper gastrointestinal bleeding". Eur. J. Intern. Med. 23 (3): 227–30. doi:10.1016/j.ejim.2011.10.004. PMID 22385878.
  5. ↑ Zhang YS, Li Q, He BS, Liu R, Li ZJ (2015). "Proton pump inhibitors therapy vs H2 receptor antagonists therapy for upper gastrointestinal bleeding after endoscopy: A meta-analysis". World J. Gastroenterol. 21 (20): 6341–51. doi:10.3748/wjg.v21.i20.6341. PMC 4445112. PMID 26034370.
  6. ↑ Guérin A, Mody R, Carter V, Ayas C, Patel H, Lasch K, Wu E (2016). "Changes in Practice Patterns of Clopidogrel in Combination with Proton Pump Inhibitors after an FDA Safety Communication". PLoS ONE. 11 (1): e0145504. doi:10.1371/journal.pone.0145504. PMC 4699636. PMID 26727382.
  7. ↑ Yang JF, Wu XJ, Li JS, Cao JM, Han JM (2005). "Effect of somatostatin versus octreotide on portal haemodynamics in patients with cirrhosis and portal hypertension". Eur J Gastroenterol Hepatol. 17 (1): 53–7. PMID 15647641.
  8. ↑ Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY, Lee SD (2004). "Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial". Hepatology. 39 (3): 746–53. doi:10.1002/hep.20126. PMID 14999693.


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