Management

Depends on the underlying cause, the severity of bleeding, and the patient's overall clinical status.

Initial Assessment and Stabilization

  1. Airway, Breathing, Circulation (ABC):

    • Ensure the airway is protected, especially if the patient is at risk of aspiration.
    • Administer oxygen if needed to maintain adequate oxygenation.
    • Establish two large-bore intravenous (IV) lines for fluid resuscitation and blood products if necessary.
  2. Hemodynamic Stabilization:
    • Start crystalloid fluids (e.g., normal saline or Ringer's lactate) for initial volume resuscitation.
    • Transfuse blood if significant blood loss is present or if hemoglobin is low (e.g., <7 g/dL in most cases or <8 g/dL in cardiovascular disease patients).
  3. Monitor Vital Signs:
    • Monitor heart rate, blood pressure, urine output, and mental status for signs of ongoing shock.
  4. Place a Nasogastric (NG) Tube (if necessary):
    • May help differentiate upper gastrointestinal (GI) bleeding from lower GI bleeding and assess ongoing bleeding.

 

 

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Definitive Management

  1. Endoscopic Therapy:

    • Options include band ligation or sclerotherapy for varices, thermal coagulation, or injection therapy for ulcers.

  2. Pharmacologic Management:

    • Proton Pump Inhibitors (PPIs):
      • High-dose IV PPI (e.g., pantoprazole or esomeprazole) for suspected peptic ulcer disease.
    • Vasoactive Drugs:
      • Octreotide or terlipressin for suspected variceal bleeding.
    • Antibiotics:
      • Prophylactic antibiotics (e.g., ceftriaxone) in patients with cirrhosis to prevent infections.
    • Reversal of Coagulopathy:
      • Administer fresh frozen plasma, vitamin K, or platelets if necessary.

  3. Treatment of Varices:

    • Consider balloon tamponade (e.g., Sengstaken-Blakemore tube) or transjugular intrahepatic portosystemic shunt (TIPS) for refractory variceal bleeding.

Post-Stabilization

  1. Surveillance and Repeat Endoscopy:
    • Repeat EGD may be needed in some cases for further evaluation or treatment.
  2. Treat the Underlying Cause:
    • H. pylori eradication in peptic ulcer disease.
    • Alcohol cessation and beta-blockers for variceal bleeding.
  3. Surgery or Interventional Radiology:
    • Consider for refractory bleeding not amenable to endoscopic or pharmacologic therapy.

Important Considerations

  • Risk Stratification: Use scores like the Glasgow-Blatchford or Rockall score to assess severity and guide disposition.
  • Admit to ICU: Patients with hemodynamic instability or ongoing significant bleeding require close monitoring in an intensive care setting.
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Establish two large bore IV lines (16 gauge or larger)

Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD)

 

Treat hypotension initially with rapid, bolus infusions of Normal Saline(eg, 500 to 1000 mL per bolus; use smaller boluses and lower total volumes for patients with compromised cardiac function)

 
Transfusion:
For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ration of RBCs, plasma, and platelets, as for trauma patients
For hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCs
For hemoglobin <8 g/dL (80 g/L) in high-risk patients (eg, older adult, coronary artery disease), transfuse 1 unit RBCs and reassess the patient's clinical condition
For hemoglobin <7 g/dL (70 g/L) in low-risk patients, transfuse 1 units RBCs and reassess the patient's clinical condition
Avoid over-transfusion with possible variceal bleeding

Give plasma for coagulopathy or after transfusing four units of RBCs; give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or after transfusing four units of RBCs

 

Obtain immediate consultation with gastroenterologist; obtain surgical and interventional radiology consultation.

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Pharmacotherapy for all patients with suspected or known severe bleeding:
Give a proton pump inhibitor:

Evidence of active bleeding (eg, hematemesis, hemodynamic instability), give esomeprazole or pantoprazole, 80 mg IV

No evidence of active bleeding, give esomeprazole or pantoprazole, 40 mg IV

Endoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg IV
Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:

Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous IV infusion)

Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone)

Determine the Cause

 

++++++++++++

Establish two large bore IV lines (16 gauge or larger)

Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD)

 

Treat hypotension initially with rapid, bolus infusions of Normal Saline(eg, 500 to 1000 mL per bolus; use smaller boluses and lower total volumes for patients with compromised cardiac function)

 
Transfusion:
For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ration of RBCs, plasma, and platelets, as for trauma patients
For hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCs
For hemoglobin <8 g/dL (80 g/L) in high-risk patients (eg, older adult, coronary artery disease), transfuse 1 unit RBCs and reassess the patient's clinical condition
For hemoglobin <7 g/dL (70 g/L) in low-risk patients, transfuse 1 units RBCs and reassess the patient's clinical condition
Avoid over-transfusion with possible variceal bleeding

Give plasma for coagulopathy or after transfusing four units of RBCs; give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or after transfusing four units of RBCs

 

Obtain immediate consultation with gastroenterologist; obtain surgical and interventional radiology consultation for any large-scale bleeding¶

 
Pharmacotherapy for all patients with suspected or known severe bleeding:
Give a proton pump inhibitor:

Evidence of active bleeding (eg, hematemesis, hemodynamic instability), give esomeprazole or pantoprazole, 80 mg IV

No evidence of active bleeding, give esomeprazole or pantoprazole, 40 mg IV

Endoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg IV
Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:

Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous IV infusion)

Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone)

Determine the Cause

 

 

Management

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