Upper gastrointestinal bleeding initial resuscitation
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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
Initial resuscitation
In patients with acute Upper GI bleeding who are unstable rapid assessment and resuscitation should be initiated even before diagnostic evaluation. Once hemodynamic stability is achieved, a proper clinical history, physical examination, and initial laboratory findings are crucial not only in determining the likely sources of bleeding but also in directing the appropriate intervention. The hematocrit level is measured soon after the onset of bleeding, but will not accurately reflect the amount of blood loss. Equilibration between the intravascular and extravascular spaces is not complete until 24 to 72 hours after bleeding has occurred. Low mean corpuscular volume, low iron and ferritin levels, and high transferrin and total iron-binding capacity (TIBC) confirm iron deficiency. Blood urea nitrogen (BUN) level may be elevated out of proportion to any increase in the creatinine level in patients with UGIB, secondary to the breakdown of blood proteins to urea by intestinal bacteria. Platelet count and coagulation studies should be checked, especially in patients with known or suspected coagulopathy. Nasogastric lavage should be performed if the presence or source of bleeding is unknown. Upper gastrointestinal endoscopy is the primary diagnostic tool, performed for both diagnosis and treatment of active bleeding. The American Society of Gastrointestinal Endoscopy guidelines recommend that upper endoscopy be performed within 24 hours of presentation in all patients with UGIB. Angiography and tagged erythrocyte scan are rarely needed, but may be used to diagnose (and embolize) active UGIB, particularly in patients who cannot tolerate EGD. Also, upper gastrointestinal tract radiographic studies using barium are generally not advised, as they may obscure visualization during EGD.
Initial Evaluation
- The initial steps in the management of a patient with UGIB is to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed.[1][2][3]
- Any patient with hemodynamic instability or who is actively bleeding should be admitted to the ICU for monitoring and resuscitation
- The patient’s hemodynamic status is of great importance in determining the degree of severity and triage status.
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Criteria for Admission of patient |
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Supportive Therapy
- Supportive care includes administration of supplemental oxygen, IV fluid administration, and monitoring of urine output.
- Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
- The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
- Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
- Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any falls in blood pressure.
Blood transfusion
- Patients with severe bleeding will need to be transfused.
| Indications for transfusion
Based on the patient’s age and presence of comorbid conditions. | |
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| AGE | Target Hematocrit |
| Elderly patient ( >45) | 30% |
| Younger patient (<45) | 25% |
| patients with portal hypertension | 28% |
- Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes
| WORKUP AND INITIAL TREATMENT Initial Resuscitation | |
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| Initial Evaluation |
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| Supportive Therapy |
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| Blood transfusion |
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National Institute for Health and Care Excellence (NICE) guidline
The National Institute for Health and Care Excellence (NICE) guidline on blood product management in upper GI bleeding:
- Platelets should only be given if the patient is actively bleeding or hemodynamically unstable and has a platelet count of <50×109/L.
- Fresh frozen plasma should be given if the fibrinogen level is <1 g/L or the prothrombin time (PT) or activated partial thromboplastin time is >1.5 times normal.
- Prothrombin complex should be provided to those on warfarin and actively bleeding.
- Recombinant factor VIIa should only be used when all of the above measures have failed.
| Acute GI bleeding | |||||||||||||||||||||||||||||||||||||||||||||||
| Initial evaluation and resuscitation | |||||||||||||||||||||||||||||||||||||||||||||||
| Uppe GI endoscopy | |||||||||||||||||||||||||||||||||||||||||||||||
| Source found | Undiagnostic | ||||||||||||||||||||||||||||||||||||||||||||||
| Specific Treatment | |||||||||||||||||||||||||||||||||||||||||||||||
| Unstable | Stable | ||||||||||||||||||||||||||||||||||||||||||||||
| Urgent CT | Repeat Endoscopy/Angiograpghy | ||||||||||||||||||||||||||||||||||||||||||||||
| No source identified | |||||||||||||||||||||||||||||||||||||||||||||||
| Angioembolization | Endoscopic intervention | TIPS | Surgery | ||||||||||||||||||||||||||||||||||||||||||||
| Surgery (Laprotomy) | |||||||||||||||||||||||||||||||||||||||||||||||
| Sclerotherapy | Banding | Injection | Thermocoagulation | Clips | |||||||||||||||||||||||||||||||||||||||||||
References
- ↑ Wassef W (2004). "Upper gastrointestinal bleeding". Curr. Opin. Gastroenterol. 20 (6): 538–45. PMID 15703679.
- ↑ Kovacs TO (2008). "Management of upper gastrointestinal bleeding". Curr Gastroenterol Rep. 10 (6): 535–42. PMID 19006607.
- ↑ Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, Rotondano G, Hucl T, Dinis-Ribeiro M, Marmo R, Racz I, Arezzo A, Hoffmann RT, Lesur G, de Franchis R, Aabakken L, Veitch A, Radaelli F, Salgueiro P, Cardoso R, Maia L, Zullo A, Cipolletta L, Hassan C (2015). "Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline". Endoscopy. 47 (10): a1–46. doi:10.1055/s-0034-1393172. PMID 26417980.