Template:Upper GI bleed treatment: Difference between revisions
 
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===Resuscitation===
===Resuscitation===
*Place 2 large bore IVs and monitor airway status  
*Place 2 large bore IVs (or [[sheath introducer]]/[[rapid infusion catheter]]) and monitor airway status  
*Crystalloid [[IVF]] can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)
*Crystalloid [[IVF]] can be used for initial resuscitation but should be limited due to the dilutional anemia and coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)


===Medications===
===Medications===
====Proton Pump Inhibitor====
====[[Proton pump inhibitor]]====
*[[Pantoprazole]] or esomeprazole 80mg x 1; then 8mg/hr
*[[Pantoprazole]] or esomeprazole 80mg x 1; then 8mg/hr
**Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing<ref>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. </ref>
**Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing<ref>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. </ref>
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**There is a mortality benefit in Asian patients<ref>Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; [http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer- bleeding/] </ref>
**There is a mortality benefit in Asian patients<ref>Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; [http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-peptic-ulcer- bleeding/] </ref>


====Antibiotics====
====[[Antibiotics]]====
''For short-term prophylaxis against SBP and bacteremia<ref>Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.</ref>''
''For short-term prophylaxis against SBP and bacteremia<ref>Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.</ref>''
*[[Ceftriaxone]] 1gm daily x 7 days (first line)<ref>Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.</ref>
*[[Ceftriaxone]] 1gm daily x 7 days (first line)<ref>Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.</ref>
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====Other Medications====
====Other Medications====
*[[Octreotide]] (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)<ref>Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.</ref>
*Consider [[octreotide]] (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days in patients with concern for variceal bleeding)<ref>Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.</ref>
*Vasopressin
*Consider [[vasopressin]]
**0.4 unit bolus, then infuse at 0.4 - 1 unit/min<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
**0.4 unit bolus, then infuse at 0.4 - 1 unit/min<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
**Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects<ref>Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.</ref>
**Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects<ref>Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.</ref>
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***Alternative to [[vasopressin]] with mortality benefit
***Alternative to [[vasopressin]] with mortality benefit
***Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
***Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
*No evidence for [[tranexamic acid]] (TXA); HALT-IT trial RCT underway<ref>Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.</ref>
*[[tranexamic acid]] (TXA) initially thought to help, NNT = 30, no one harmed<ref>Beyda, R., & Johari, D. (2019). Tranexamic acid for upper gastrointestinal bleeding. Academic Emergency Medicine. 2019 Oct;26(10):1181-1182  </ref>; but HALT-IT trial RCT<ref>Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.</ref> found it did not reduce death from GI bleeding<ref> The HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24-h infusion of transexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020; 395:1927-36 </ref>


===[[Blood products]]===
===[[Blood products]]===
====[[Packed red blood cell transfusion]]====
====[[Packed red blood cell transfusion]]====
*Indications:
Indications:
**Hemoglobin <7 g/dl
*Hemoglobin <7 g/dl
***In hemodynamically stable patients, the [[EBQ:Transfusion strategies for acute upper gastrointestinal bleeding | goal transfusion threshold should be 7 g/dl]]; NICE guidelines recommend avoidance of over-transfusion<ref>Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.</ref>''
**In hemodynamically stable patients, the [[EBQ:Transfusion strategies for acute upper gastrointestinal bleeding | goal transfusion threshold should be 7 g/dl]]; NICE guidelines recommend avoidance of over-transfusion<ref>Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.</ref>''
**Continued active bleeding  
*Continued active bleeding  
**Failure to improve perfusion and vital signs after infusion of 2L NS
*Failure to improve perfusion and vital signs after infusion of 2L NS
**Known varicele bleeding<ref>Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.</ref>
*Known varicele bleeding<ref>Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.</ref>


====Other Blood Products====
====Other Blood Products====
''Consider initiating [[massive transfusion]] protocol''
''Consider initiating [[massive transfusion]] protocol''
*[[Prothrombin complex concentrates]]<ref>Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.</ref>
*[[Prothrombin complex concentrates]]<ref>Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.</ref>
*Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
*[[Cryoprecipitate]] to raise fibrinogen (goal >120mg/dL)
*[[Platelets]] (goal >50-100k/μL
*[[Platelets]] (goal >50-100k/μL)
*[[FFP]] can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding<ref>Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.</ref>
*[[FFP]] can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding<ref>Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.</ref>
*Monitor for [[hypocalcemia]]


===[[Balloon tamponade]] with Sengstaken-Blakemore Tube===
===Other Interventions===
====[[Balloon tamponade]] (e.g., Sengstaken-Blakemore or Minnesota Tubes)====
''For life-threatening hemorrhage if endoscopy is not available''
''For life-threatening hemorrhage if endoscopy is not available''
*Tube consists of gastric and esophageal balloons
*Adverse reactions are frequent:
**First inflate gastric balloon; if bleeding continues inflate esophageal balloon
***Esophageal pressure must not exceed 40-50 mmHg
*Adverse reactions are frequent
**Mucosal ulceration
**Mucosal ulceration
**Esophageal/gastric rupture
**Esophageal/gastric rupture
**Tracheal compression (consider intubation prior to balloon insertion)
**Tracheal compression (consider intubation prior to balloon insertion)


===Endoscopy===
====Endoscopy====
*Endoscopy (for ligation, banding, and/or sclerotherapy) should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding<ref>Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.</ref>
''Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding<ref>Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.</ref>''
**Early endoscopy does not necessarily improve clinical outcomes<ref>Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493. </ref>
*Early endoscopy does not necessarily improve clinical outcomes<ref>Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493. </ref>
**Consider [[erythromycin]] 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
*Consider [[erythromycin]] 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
***Achieves endoscopy conditions equal to lavage<ref>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.</ref>
**Achieves endoscopy conditions equal to lavage<ref>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.</ref>


===[[Intubation]]===
====[[Intubation]]====
''Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events<ref>Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.</ref>''
''Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events<ref>Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.</ref>''
;NO CHRISTMAS<ref>Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/</ref>
;NO CHRISTMAS<ref>Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/</ref>
''Have bed-side [[Push-dose pressors|push-dose pressors]] on hand''
''Have bed-side [[Push-dose pressors|push-dose pressors]] on hand''
*'''N'''GT (salem sump to remove stomach contents)
*'''N'''GT ([[Nasogastric tube placement|salem sump]] to remove stomach contents)
**Varices not contraindication to NGT
**Varices not contraindication to NGT
**Consider metoclopramide 10mg IV
**Consider [[metoclopramide]] 10mg IV
***Increases tone of lower esophageal sphincter<ref>Mikami H, Ishimura N, Fukazawa K, et al. Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers. J Neurogastroenterol Motil. 2016;22(1):112-117. doi:10.5056/jnm15130</ref>
*Good pre-'''O'''xygenation critical
*Good pre-'''O'''xygenation critical
*'''C'''hest and '''H'''OB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
*'''C'''hest and '''H'''OB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
*'''R'''SI - consider halving dosages for lost blood volume
*'''R'''SI - consider halving sedation dosages for lost blood volume
**Etomidate or ketamine for sedation
**[[Etomidate]] or [[ketamine]] for sedation
**Succinylcholine and vecuronium increases LES tone
**[[Succinylcholine]] and [[vecuronium]] increases LES tone
*'''I'''ntubation with strong chance for first pass
*'''I'''ntubation with strong chance for first pass
*'''S'''low and gentle BVM breathes at 10 breathes/min if first pass fails
*'''S'''low and gentle BVM breaths at 10 breaths/min if first pass fails
*'''T'''rendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
*'''T'''rendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
*'''M'''econium aspirator may be hooked up to ETT for large bore suction
*'''M'''econium aspirator may be hooked up to ETT for large bore suction
*'''A'''ntibiotics not needed in early phase of aspiration
*'''A'''ntibiotics not needed in early phase of aspiration
**Chemical pneumonitis in first 24 hours, no bacterial pneumonia
**Chemical pneumonitis in first 24 hours, not bacterial pneumonia
**Early antibiotics may predispose patient to resistant bacterial superinfection
**Early antibiotics may predispose patient to resistant bacterial superinfection
*'''S'''IRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
*'''S'''IRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
**May require pressors and fluids
**May require pressors and fluids
**Consider withholding early antibiotics, but doing the rest of the sepsis treatments
**Consider withholding early antibiotics, but doing the rest of the sepsis treatments

Latest revision as of 19:09, 19 June 2024

Resuscitation

  • Place 2 large bore IVs (or sheath introducer/rapid infusion catheter) and monitor airway status
  • Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)

Medications

Proton pump inhibitor

  • Pantoprazole or 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][3]
    • There is a mortality benefit in Asian patients[4]

Antibiotics

For short-term prophylaxis against SBP and bacteremia[5]

  • Ceftriaxone 1gm daily x 7 days (first line)[6]
  • OR ciprofloxacin IV or PO 500mg BID x7 days
  • Indicated for:
    • Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
    • Prior to endoscopy or as soon as possible after endoscopy

Other Medications

  • Consider octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days in patients with concern for variceal bleeding)[7]
  • Consider vasopressin
    • 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[8]
    • Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[9]
    • Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [10]
    • Terlipressin (analog of vasopressin, available outside U.S.)
      • Alternative to vasopressin with mortality benefit
      • Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops[11]
  • tranexamic acid (TXA) initially thought to help, NNT = 30, no one harmed[12]; but HALT-IT trial RCT[13] found it did not reduce death from GI bleeding[14]

Blood products

Packed red blood cell transfusion

Indications:

  • Hemoglobin <7 g/dl
  • Continued active bleeding
  • Failure to improve perfusion and vital signs after infusion of 2L NS
  • Known varicele bleeding[16]

Other Blood Products

Consider initiating massive transfusion protocol

Other Interventions

Balloon tamponade (e.g., Sengstaken-Blakemore or Minnesota Tubes)

For life-threatening hemorrhage if endoscopy is not available

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

Endoscopy

Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[19]

  • Early endoscopy does not necessarily improve clinical outcomes[20]
  • Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
    • Achieves endoscopy conditions equal to lavage[21]

Intubation

Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[22]

NO CHRISTMAS[23]

Have bed-side push-dose pressors on hand

  • NGT (salem sump to remove stomach contents)
    • Varices not contraindication to NGT
    • Consider metoclopramide 10mg IV
      • Increases tone of lower esophageal sphincter[24]
  • Good pre-Oxygenation critical
  • Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
  • RSI - consider halving sedation dosages for lost blood volume
  • Intubation with strong chance for first pass
  • Slow and gentle BVM breaths at 10 breaths/min if first pass fails
  • Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
  • Meconium aspirator may be hooked up to ETT for large bore suction
  • Antibiotics not needed in early phase of aspiration
    • Chemical pneumonitis in first 24 hours, not bacterial pneumonia
    • Early antibiotics may predispose patient to resistant bacterial superinfection
  • SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
    • May require pressors and fluids
    • Consider withholding early antibiotics, but doing the rest of the sepsis treatments
  1. ↑ 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.
  2. ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  3. ↑ Sreedharan A et al. Proton Pump Inhibitor Treatment Initiated Prior to Endoscopic Diagnosis in Upper Gastrointestinal Bleeding (Review). Cochrane Database Syst Rev 2010; (7): CD005415. PMID: 20614440
  4. ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  5. ↑ Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.
  6. ↑ Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.
  7. ↑ Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.
  8. ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  9. ↑ Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.
  10. ↑ GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507
  11. ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  12. ↑ Beyda, R., & Johari, D. (2019). Tranexamic acid for upper gastrointestinal bleeding. Academic Emergency Medicine. 2019 Oct;26(10):1181-1182
  13. ↑ Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.
  14. ↑ The HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24-h infusion of transexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020; 395:1927-36
  15. ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  16. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  17. ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  18. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  19. ↑ Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
  20. ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  21. ↑ 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.
  22. ↑ Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
  23. ↑ Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/
  24. ↑ Mikami H, Ishimura N, Fukazawa K, et al. Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers. J Neurogastroenterol Motil. 2016;22(1):112-117. doi:10.5056/jnm15130
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