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80% ulcer, gastric >duodenal.

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15% esophageal varices.

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5% Mallory–Weiss or angiodysplasia.

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Presentation:

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  • Hematemesis 75%
  • Melena in 20%
  • Hematochezia (red blood per rectum) 5%

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Differential diagnosis: hemoptysis, bleeding from mouth.

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In case of hypovolemic shock without exteriorized bleeding, remember to insert a nasogastric tube.

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Assessment of Blood Loss Severity
Blood loss (mL)<750750–1,5001,500–2,000
SBPNormalNormal≤90 mm Hg
MAPNormalNormal<60 mm Hg
HR (min1)<100≥100>120
RR (min1)14–2020–3030–40
Neurologic statusNormalAnxiousConfused
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Markers of severity—BLEED:

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  • Ongoing bleeding
  • Low SBP
  • Elevated PT
  • Erratic mental status
  • Comorbid disease

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  • Resuscitation goals:
    • MAP 60 mm Hg and SpO2 ≥95%:
      • Administer crystalloids (LR)
      • Start norepinephrine (2–5 μg/min infusion) if BP goal not reached after 1,000 mL LR
    • Transfuse RBC if Hct <24% (or 30 if h/o CAD [or high likelihood: elderly, long-standing DM, etc.]):
      • Use clinical judgment to transfuse RBC without waiting for labs if obviously massive bleed or poorly tolerated
    • Transfuse FFP if RBC given. Start with 1 U FFP/3 U RBC, but if >10 U RBC, give 1 U FFP/1 U RBC
  • EGD:
    • Insert NGT/OGT; perform irrigation with saline, GT to gravity
    • EGD performed when the patient is stabilized:
      • In the first 6 hours if active bleeding
      • Otherwise in the first 12 hours
    • Erythromycin 250 mg IV in 20 minutes, 30 minutes before EGD, to promote gastric emptying (controversial)
    • Intubate if refractory shock or altered consciousness
  • Ulcer/gastritis:
    • During EGD: ulcer sclerosis, epinephrine injection, clips if needed
    • The Forrest score assesses the prognosis and the recurrence risk of bleeding in gastric ulcer case
    • If Forrest IIa or Ia, start PPI infusion: for example, omeprazole 80 mg IV bolus, and then 8 mg/h infusion × 48 hours
    • Consider surgery if:
      • Unable to stop bleeding on EGD
      • Diameter >2 cm
      • Posterior bulb location
    • Consider embolization if unable to stop bleeding on EGD and focal (not diffuse) bleeding
    • If H. pylori on biopsies, treat with two antibiotics + PPI (consult GI)
  • Esophageal varices rupture:
    • Treat bleeding:
      • Banding or sclerotherapy during EGD (give cefazolin 1–2 g IV)
      • Octreotide 25 μg/h (no bolus) to be continued for 2–5 days
      • Antibiotics: norfloxacine 400 mg PO BID × 7 days
      • If unsuccessful, consider repeat EGD
      • If bleeding still persists: TIPS
      • Blakemore/Linton balloon: rarely used nowadays
    • Once bleeding stopped:
      • Prevent hepatic encephalopathy (lactulose, neomycin, or rifamixin)
      • Consider evacuating ascites
      • Prevent rebleeding: propranolol 80–160 mg per day (goal: limit HR increase to 25%)

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Figure 214-1. Algorithm for the Management of Upper GI Bleed
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Forrest Score for Gastric Ulcers
ForrestEndoscopic viewFrequency (%)Risk of ...

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