Upper gastrointestinal bleeding resident survival guide: Difference between revisions

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{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>
{{familytree | | | | | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>❑ Blood in [[vomiting]]<br> ❑ Coffee ground emesis<br>❑ Black and tarry stools<br>❑ Frank blood in stools<br>❑ Maroon colored stool<br>❑ [[Abdominal pain]]<br>❑ [[Altered mental status]]<br>❑ [[Dizziness]]<br>❑ [[Syncope]]<br>❑ [[Palpitations]]<br>
---- ❑ Blood in [[vomiting]]<br> ❑ Coffee ground emesis<br>❑ Black and tarry stools<br>❑ Frank blood in stools<br>❑ Maroon colored stool<br>❑ [[Abdominal pain]]<br>❑ [[Altered mental status]]<br>❑ [[Dizziness]]<br>❑ [[Syncope]]<br>❑ [[Palpitations]]<br>
----
----
'''Inquire about the past medical history:'''<br> ❑ Previous GI bleed <br>❑ [[Anticoagulants]] use <br> ❑ [[NSAIDs]] use <br> ❑ Alcohol intake <br> ❑ Other comorbities  </div>}}
'''Inquire about the past medical history:'''<br> ❑ Previous GI bleed <br>❑ [[Anticoagulants]] use <br> ❑ [[NSAIDs]] use <br> ❑ Alcohol intake <br> ❑ Other comorbities  </div>}}
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{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 41em; width: 27em; padding:1em;">'''Examine the patient:'''<br>
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 41em; width: 27em; padding:1em;">'''Examine the patient:'''<br>
'''Abdominal examination'''
'''Abdominal examination'''
----
❑ [[Abdominal tenderness]]<br>❑ Involuntary [[guarding]]<br>
❑ [[Abdominal tenderness]]<br>❑ Involuntary [[guarding]]<br>
❑ Bowel sounds<br>
❑ Bowel sounds<br>
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----
----
❑ '''Signs of hypovolemia:<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>'''<br>
❑ '''Signs of hypovolemia:<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>'''<br>
----
<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th>'''Severity of blood loss'''</th><th>'''Signs'''</th></tr>
<tr class="v-firstrow"><th>'''Severity of blood loss'''</th><th>'''Signs'''</th></tr>
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{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Order tests:'''<br>
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Order tests:'''<br>
----
❑ [[Blood type]] and [[cross-match]]<br>❑ [[CBC]]<br>❑ [[Platelet count]]<br>❑ [[Prothrombin time]] and [[INR]]<br> ❑ [[Liver enzymes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[Electrolytes]]<br>❑ Order [[EKG]] and [[cardiac enzymes]] to rule out [[myocardial infarction]] in elderly patients </div>}}
❑ [[Blood type]] and [[cross-match]]<br>❑ [[CBC]]<br>❑ [[Platelet count]]<br>❑ [[Prothrombin time]] and [[INR]]<br> ❑ [[Liver enzymes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[Electrolytes]]<br>
----❑ Order [[EKG]] and [[cardiac enzymes]] to rule out [[myocardial infarction]] in elderly patients </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Initiate initial supportive measures:'''<br>
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Initiate initial supportive measures:'''<br>
----
❑ Ensure normal [[breathing]] and clear [[airway]]<br>
❑ Ensure normal [[breathing]] and clear [[airway]]<br>
:❑ Consider [[intubation]] in patients with ongoing massive bleeding<br>
:❑ Consider [[intubation]] in patients with ongoing massive bleeding<br>
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❑ Ensure fluid resuscitation<br>
❑ Ensure fluid resuscitation<br>
   
   
'''Blatchford score = 0 ?'''<br>
'''Does the patient have a Blatchford score of  0 ?'''<br>
----
Blatchford Score = 0 if:<br>
----
❑ [[Urea Nitrogen]] < 18.2 mg/dl<br>❑ [[Hemoglobin]] < 13.2 g/dL (12 g/dL for women)<br>❑ [[Systolic blood pressure]] > 110 mmHg<br>❑ [[Pulse]] <100/min<br>❑ Absence of [[melena]], [[cardiac failure]], [[syncope]] and [[liver disease]]
❑ [[Urea Nitrogen]] < 18.2 mg/dl<br>❑ [[Hemoglobin]] < 13.2 g/dL (12 g/dL for women)<br>❑ [[Systolic blood pressure]] > 110 mmHg<br>❑ [[Pulse]] <100/min<br>❑ Absence of [[melena]], [[cardiac failure]], [[syncope]] and [[liver disease]]
</div>}}
</div>}}

Revision as of 00:40, 28 January 2014

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

Definition

Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to ligament of Treitz.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe upper GI bleed is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Initial Management

Shown below is an algorithm summarizing the approach to upper GI bleed.

 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Blood in vomiting
❑ Coffee ground emesis
❑ Black and tarry stools
❑ Frank blood in stools
❑ Maroon colored stool
Abdominal pain
Altered mental status
Dizziness
Syncope
Palpitations

Inquire about the past medical history:
❑ Previous GI bleed
Anticoagulants use
NSAIDs use
❑ Alcohol intake
❑ Other comorbities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Abdominal examinationAbdominal tenderness
❑ Involuntary guarding
❑ Bowel sounds

❑ Hyperactive: Suggests UGIB
❑ Hypoactive: Suggests mesenteric ischemia or ileus

Signs of liver failure
Rectal exam to assess the stool color
Guaiac test
Blood pressure
Pulse


Signs of hypovolemia:[1]

Severity of blood lossSigns
Mild to moderate Resting tachycardia
15% blood lossOrthostatic hypotension
40% blood lossHypotension
ShockCold clammy extremities,
Weak and thready pulse
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order tests:
Blood type and cross-match
CBC
Platelet count
Prothrombin time and INR
Liver enzymes
BUN
Creatinine
Electrolytes
❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate initial supportive measures:

❑ Ensure normal breathing and clear airway

❑ Consider intubation in patients with ongoing massive bleeding
❑ Assess the hemodynamic status
❑ Monitor vital signs
Cardiac monitoring
❑ Assess mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk assessment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient and/or massive active bleeding
and/or altered mental status
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Resuscitate the patient:[1]
❑ Keep patient NPO
❑ Insert 2 large bore IV lines
❑ Administer supplemental oxygen
❑ Ensure fluid resuscitation
❑ Administer 500 ml of NS during first 30 min and simultaneously send blood sample for cross-matching
❑ Consider increasing fluid administration if blood pressure fails to rise

❑ Consider blood transfusion in patients with Hb < 7 g/dL
❑ Admit to ICUand monitor:

❑ Cardiac status
Pulse oximetry
Urine output
❑ Request a surgical consult
 

❑ Ensure fluid resuscitation

Does the patient have a Blatchford score of 0 ?
Urea Nitrogen < 18.2 mg/dl
Hemoglobin < 13.2 g/dL (12 g/dL for women)
Systolic blood pressure > 110 mmHg
Pulse <100/min
❑ Absence of melena, cardiac failure, syncope and liver disease

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Discharge from emergency room without endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Prepare patient for early endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Endoscopic Management

 
 
 
 
Medications before endoscopy:

❑ Administer IV infusion of erythromycin (250 mg 30 minutes prior to the endoscopy)
❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/hour infusion)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EGD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Variceal bleed
Click here for the detailed management
 
Non variceal bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Active spurting
❑ Oozing blood
❑ Non-bleeding visible vessel
 
Adherent Clot
 
❑ Clean base ulcer
❑ Flat pigmented spot
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopic therapy:
* Thermal therapy with bipolar electrocoagulation PLUS sclerosant injection (e.g absolute alcohol)
* Epinephrin injection PLUS thermal therapy or sclerotherapy or clips
* Clips

❑IV PPI therapy

* 80 mg bolus followed by 8 mg/hr infusion for 72 hours
 
❑ Consider endoscopic therapy in patients with clot resistant to irrigation
❑ IV PPI therapy
 
❑ No endoscopic therapy
❑ Oral PPI therapy (once daily)
❑ Regular diet after endoscopy

Early prompt discharge after endoscopy in following patients:


❑ Hemodynamic stability
❑ No other comorbdity
❑ Easy access to hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Hospital admission for 3 days
❑ Clear liquids can be fed soon after endoscopy
❑ Discharge after 3 days if no re-bleeding occurs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If re-bleeding occurs clinically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat endoscopy with hemostatic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding could not be controlled?
 
Bleeding controlled
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
Arterial embolization
 
IV PPI therapy for 72 hours
Oral therapy thereafter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG) and International consensus.[2][3]

Long Term Prevention of Recurrent Ulcer Bleed

 
 
 
 
 
 
 
 
 
Patient treated for UGIB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approach to long term treatment based on different etiologies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H. Pylori and NSAIDs
 
 
 
Aspirin
 
Idiopathic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Test for H. Pylori
* Endoscopic biopsy based test for H. Pylori
* If biopsy is negative, confirm with a non endoscopic H. Pylori test
 
 
 
Is patient taking aspirin?
 
Continue daily PPI therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with H. Pylori eradication therapy
 
 
 
Assess the indication of aspirin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Document cure of H. Pylori at > 1 month after eradication therapy is stopped with following tests:
* Endoscopy (if done for some other reason)
* Urea breath test
* Stool antigen test
 
Aspirin is being given for an established cardiovascular disease (for secondary prevention)?
 
 
Aspirin is being given for primary prevention?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is patient on NSAID or antithrombotics?
 
Resume aspirin as soon as possible and also start PPI therapy
 
Stop aspirin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stop PPI therapy
 
❑ Stop NSAIDs.

❑ If NSAIDs have to be resumed, use celecoxib plus PPI therapy.

❑ In patients on antithrombotics, continue PPI therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG).[2]


Do's

  • Assess the hemodynamic status immediately upon presentation and start the appropriate resuscitation measures.
  • Rockall score (ranging from 0-7) can be used for risk assessment. Parameters included in rockall score are systolic blood pressure, pulse, age and comorbidities.
  • Administer IV proton pump inhibitors (PPI) therapy before endoscopy to decrease the number of patients with high risk of hemorrhage and patients requiring endoscopic therapy. However, PPI therapy does not affect the outcomes such as recurrent bleeding, surgery or death. If endoscopy is delayed for some reason, IV PPI therapy is indicated to decrease further bleeding.
  • Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb>12.0 mg/dl in women, systolic blood pressure>110 mmHg, pulse<100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.[2]
  • Considered endoscopy among patients with upper GI bleed within 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
  • For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone.
  • For active bleeding on endoscopy, thermal therapy or epinephrine plus a second modality are preferred over clips or sclerosant alone.[2]
  • As for the epinephrine therapy, dilute epinephrine (1:10,000 or 1:20,000 in saline) and inject it in doses of 0.5-2 ml in and around the bleeding site. Continue the injections until the active bleeding stops.

Dont's

  • Do not administer nasogastric lavage in patients with upper GI bleed for diagnosis, prognostic evaluation, visualization or therapeutic effect.[2]
  • Do not administer epinephrine therapy alone. Always combine epinephrine therapy with a second agent.

References

2


Template:WikiDoc Sources

  1. 1.0 1.1 Cappell MS, Friedel D (2008). "Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy". Med Clin North Am. 92 (3): 491–509, xi. doi:10.1016/j.mcna.2008.01.005. PMID 18387374.
  2. 2.0 2.1 2.2 2.3 2.4 Laine L, Jensen DM (2012). "Management of patients with ulcer bleeding". Am J Gastroenterol. 107 (3): 345–60, quiz 361. doi:10.1038/ajg.2011.480. PMID 22310222.
  3. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M; et al. (2010). "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding". Ann Intern Med. 152 (2): 101–13. doi:10.7326/0003-4819-152-2-201001190-00009. PMID 20083829.