80% ulcer, gastric >duodenal.
5% Mallory–Weiss or angiodysplasia.
- Hematemesis 75%
- Melena in 20%
- Hematochezia (red blood per rectum) 5%
Differential diagnosis: hemoptysis, bleeding from mouth.
In case of hypovolemic shock without exteriorized bleeding, remember to insert a nasogastric tube.
Assessment of Blood Loss Severity
|Blood loss (mL)||<750||750–1,500||1,500–2,000|
|SBP||Normal||Normal||≤90 mm Hg|
|MAP||Normal||Normal||<60 mm Hg|
Markers of severity—BLEED:
- Ongoing bleeding
- Low SBP
- Elevated PT
- Erratic mental status
- Comorbid disease
- 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
- 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
- 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%)
Figure 214-1. Algorithm for the Management of Upper GI Bleed
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