Template:Upper GI bleed treatment

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
• Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality
• There is a mortality benefit in Asian patients

Erythromycin

• Achieves endoscopy conditions equal to lavage
• 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

In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of over-transfusion

Indications:

• Hemoglobin <7 g/dl
• Continued active bleeding
• Failure to improve perfusion and vital signs after infusion of 2L NS
• Varicele bleeding

Other Blood Products

• Prothrombin complex concentrates
• 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

Endoscopy

• Endoscopy should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding

Early endoscopy does not necessarily improve clinical outcomes

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
• Adverse reactions are frequent
  • Mucosal ulceration
  • Esophageal/gastric rupture
  • Tracheal compression (consider intubation prior to balloon insertion)