Template:Upper GI bleed treatment
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Resuscitation
- Place 2 large bore IVs and monitor airway status
Proton Pump Inhibitor
- Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
- Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing[1]
- Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[2]
- There is a mortality benefit in Asian patients[3]
Erythromycin
- Achieves endoscopy conditions equal to lavage[4]
- 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
IVF
- Crystalloid can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result
PRBC transfusions
- Indications for PRBC transfusions:
- Hemoglobin <7 g/dl
- Continued active bleeding
- Failure to improve perfusion and vital signs after infusion of 2L NS
- Varicele bleeding[5]
- In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl
- NICE guidelines recommend avoidance of over-transfusion[6]
Other Blood Products
- Prothrombin complex concentrates[7]
- Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
- Platelets (goal >50-100k/μL
- FFP can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding[8]
Endoscopy
- Endoscopy should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[9]
Early endoscopy does not necessarily improve clinical outcomes[10]
Balloon tamponade with Sengstaken-Blakemore Tube
- For life-threatening hemorrhage if endoscopy is not available)
- Tube consists of gastric and esophageal balloons
- First inflate gastric balloon; if bleeding continues inflate esophageal balloon
- Esophageal pressure must not exceed 40-50 mmHg
- First inflate gastric balloon; if bleeding continues inflate esophageal balloon
- Adverse reactions are frequent
- Mucosal ulceration
- Esophageal/gastric rupture
- Tracheal compression (consider intubation prior to balloon insertion)
- ↑ Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.
- ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
- ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
- ↑ Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.
- ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
- ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
- ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
- ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
- ↑ Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
- ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.