Undifferentiated upper gastrointestinal bleeding: Difference between revisions

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*Bleeding originating proximal to ligament of Treitz
*Bleeding originating proximal to ligament of Treitz
*In the acute setting, the hemoglobin/hematocrit may be normal until dilutional anemia appears after volume resuscitation
*In the acute setting, the hemoglobin/hematocrit may be normal until dilutional anemia appears after volume resuscitation
*Older patients -> [[peptic ulcer disease]], [[esophagitis]], [[gastritis]]; younger patients -> [[Mallory-Weiss tear]]s, GI [[varices]], gastropathy
===Mortality<ref>Kumar R, Mills AM. GI Bleeding. EM Clin N Am. 2011; 29:239-52.</ref>===
*[[Peptic ulcer disease]] = 4%
*[[Variceal bleeding]] = 50%
===Risk Factors===
*Medications
**[[ASA]], [[steroids]], [[anticoagulants]], chemotherapeutic agents
**[[NSAIDs]]<ref>Gonzalez ELM et al. Variability among NSAIDs in risk of upper GI bleeding. Arthritis & Rheumatism. 2010; 62(6): 1592-1601.</ref>
*** RR of bleeding for COX-1 inhibitors is 4.5 (3.82-5.31)
*** RR of bleeding for COX-2 inhibitors is 1.88 (0.96-3.71)
*[[ETOH abuse]]
**[[Peptic ulcer disease]], [[gastritis]], [[varices]]
*Aortic graft = [[aortoenteric fistula]]
*Advanced age (>60 yr)
*Current smoker


==Prehospital==
==Prehospital==
*'''Airway:''' suction to prevent aspiration, provide oxygen as needed
*'''Airway:''' suction to prevent aspiration, provide oxygen as needed
*'''Breathing''': maintain patient is position of comfort
*'''Breathing''': maintain patient in position of comfort
*'''Circulation:''' monitor for early signs of shock, and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
*'''Circulation:''' monitor for early signs of shock and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
*[[Antiemetics]] can be given to decrease nausea and vomitting
*[[Antiemetics]] can be given to decrease nausea and vomiting
*Assume the patient is hepatitis positive and wear appropriate personal protective gear
*Assume the patient is hepatitis positive and wear appropriate personal protective gear


==Clinical Features==
==Clinical Features==
===History===
===History===
*Hematemesis
*[[Hematemesis]]
*Coffee-ground emesis
**Coffee-ground emesis
*Melena + age <50 suggests upper GI bleed
*[[Vomiting]] + retching followed by hematemesis is more likely [[Mallory-Weiss]] (esophageal)
*[[Vomiting]] + retching followed by hematemesis = Mallory-Weiss
*[[Melena]]
*Aortic graft = aortoenteric fistula
*[[Syncope]] or presyncope
*Meds
*[[Dyspepsia]], [[epigastric pain]] or heartburn
**[[ASA]], steroids, [[NSAIDs]], anticoagulants
*ETOH abuse
**Peptic ulcer disease, gastritis, varices


===Physical Exam===
===Physical Exam===
*Tachycardia, hypotension
*[[Tachycardia]], [[hypotension]]
**Normal vital signs do not preclude the possibility of a severe bleed
*[[Altered mental status]] -> poor cerebral perfusion
*Pallor
**In the stable patient may indicate the anemia of a subacute/chronic bleed, in the unstable patient may indicate poor perfusion and massive blood loss
*Liver disease
*Liver disease
**Spider angiomata, palmar erythema, jaundice, gynecomastia
**Spider angiomata, palmar erythema, [[jaundice]], gynecomastia, [[hepatomegaly]], [[ascites]]
*Coagulopathy
*[[Coagulopathy]]
**Petechiae/purpura
**[[Petechiae]]/[[purpura]]
*ENT exam
*ENT exam
**Swallowed blood may result in coffee-ground emesis or melena
**Swallowed blood may result in coffee-ground emesis or melena
*Rectal exam
*Rectal exam
**Only 20% of patients with a positive fecal occult have an identified upper GI bleed. UGI Bleed should not be ruled out based on a negative test<ref>Allard J  et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.</ref>
**Only 20% of patients with a positive fecal occult have an identified upper GI bleed.<ref>Allard J  et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.</ref>


==Differential Diagnosis==
==Differential Diagnosis==
*[[Peptic ulcer disease]] (most common cause)
{{UGIB DDX}}
*[[Gastritis]]/[[esophagitis]]
*Gastric/esophageal varices
*[[Mallory-Weiss tear]]
*Malignancy
*[[Aortoenteric fisulta]]
*[[Boerhaave]]
*Dieulafoy's lesion
*Angiodysplasia
*Hemobilia
*Hemorrhagic gastritis, EtOH
*Celiac
*Dengue
*Other intrabdominal bleeds
**Hemorrhagic pancreatitis
**Splenic rupture
**Subcapsular cavernous hemangiomas
**Peliosis hepatis
 
===Mimics of GI Bleeding===
*[[Hemoptysis]]
*[[Vaginal Bleeding (Main)|Vaginal]]/[[Hematuria|Urethra]] bleeding
*ENT bleeding
*Dietary (Iron, bismuth, beets)


==Evaluation==
==Evaluation==
[[File:Sengstaken-Blakemore_scheme_EN.png|thumbnail|Sengstaken-Blakemore Tubel]][[File:Sengstaken-Blakemore_tube_EN-2.png|thumbnail|Sengstaken-Blakemore Tube Placement]]
{{UGIB evaluation}}
===Workup===
*2 large bore IVs
*Type and cross
*CBC & serial hemoglobin
*Chemistry
**BUN/Cr >30 suggests UGI if no history of renal failure (increased absorption/digestion of hb)
*Coags
*LFTs
*Guiac
*?ECG (if >50 yo or if suspicious for silent MI)
*?CXR (if suspect perforation)
 
===NG Lavage Controversy===
*'''Pros'''<ref name="ali">Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.</ref>
**Positive aspirate proves strong evidence for an UGI source of bleeding
**Can assess presence of ongoing active bleeding
**Can prepare patient for endoscopy
*'''Cons'''<ref name="ali"></ref>
**Uncomfortable
**Negative aspirate does not conclusively exclude UGI source
**Provides useful information in only minority of patients without hematemesis
**[[Erythromycin]] 200mg IV can provide equal endoscopy conditions as lavage<ref>Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.</ref>


==Management==
==Management==
{{Upper GI bleed treatment}}
{{Upper GI bleed treatment}}
===Special Circumstances===
*Acute variceal bleeding
**[[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>
**Judicious IVF and blood products
**Emergency endoscopy for ligation, banding, and/or sclerotherapy
**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>
***Recommend administering antibiotics prior to endoscopy or as soon as possible after endoscopy
***[[Ciprofloxacin]] IV or PO 500mg BID x7 days
***OR [[ceftriaxone]] 1gm daily x 7 days
****Indicated for patients with cirrhosis or history of [[ETOH abuse]] (regardless of whether bleeding is variceal or not)
****More effective than [[quinolones]]<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>
*Vasopressin associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia <ref>GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507</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>
**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<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>
===[[Intubation]]===
*Protection of airway from massive aspiration, especially prior to endoscopy
*Does not seem to 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>
*Have bed-side [[Push-dose pressors|push-dose pressors]] on hand
*'''NO CHRISTMAS'''<ref>Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/</ref>
**'''N'''GT (salem sump to remove stomach contents)
***Varices not contraindication to NGT
***Consider metoclopramide 10mg IV
**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
**'''R'''SI - consider halving dosages for lost blood volume
***Etomidate or ketamine for sedation
***Succinylcholine and vecuronium increases LES tone
**'''I'''ntubation with strong chance for first pass
**'''S'''low and gentle BVM breathes at 10 breathes/min if first pass fails
**'''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
**'''A'''ntibiotics not needed in early phase of aspiration
***Chemical pneumonitis in first 24 hours, no bacterial pneumonia
***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
***May require pressors and fluids
***Consider withholding early antibiotics, but doing the rest of the sepsis treatments


==Disposition==
==Disposition==
===Admission===
===Admission===
*Anyone with a [[Glasgow-Blatchford Bleeding Score]] above 0 (see discharge section below); consider the clinical Rockall risk score too<ref>Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.</ref>
*Age >60yr
*Age >60yr
*Transfusion required
*Transfusion required
*Initial Sys BP < 100
*Red blood in NG lavage
*History of cirrhosis or ascites on exam
*History of vomiting red blood


===Consider Discharge===
===Consider Discharge===
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*BUN <18
*BUN <18
*hemoglobin >13 (men), hemoglobin >12 (women)
*hemoglobin >13 (men), hemoglobin >12 (women)
*Sys BP >110
*Systemic BP >110
*HR <100
*Heart rate <100
*Patient did NOT present with melena
*Patient did NOT present with melena
*Patient did NOT present with syncope
*Patient did NOT present with syncope
Line 160: Line 87:


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]

Revision as of 15:14, 20 October 2019

Background

Mortality[1]

Risk Factors

Prehospital

  • Airway: suction to prevent aspiration, provide oxygen as needed
  • Breathing: maintain patient in position of comfort
  • Circulation: monitor for early signs of shock and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
  • Antiemetics can be given to decrease nausea and vomiting
  • Assume the patient is hepatitis positive and wear appropriate personal protective gear

Clinical Features

History

Physical Exam

  • Tachycardia, hypotension
    • Normal vital signs do not preclude the possibility of a severe bleed
  • Altered mental status -> poor cerebral perfusion
  • Pallor
    • In the stable patient may indicate the anemia of a subacute/chronic bleed, in the unstable patient may indicate poor perfusion and massive blood loss
  • Liver disease
  • Coagulopathy
  • ENT exam
    • Swallowed blood may result in coffee-ground emesis or melena
  • Rectal exam
    • Only 20% of patients with a positive fecal occult have an identified upper GI bleed.[3]

Differential Diagnosis

Upper gastrointestinal bleeding

Mimics of GI Bleeding

Evaluation

Workup

  • 2 large bore IVs (or sheath introducer)
  • Type and cross
  • CBC & serial hemoglobin
  • Chemistry
    • BUN/creatinine >30 suggests UGI if no history of renal failure (increased absorption/digestion of hb)
  • Coags
  • LFTs
  • Fibrinogen
  • Guiac
    • More useful for diagnosing chronic occult bleeding (it could be positive for up to 2 weeks after an acute bleed)
    • False-positive: vitamin C, red meat, methylene blue, bromide preparations, turnips, horseradish
  • ECG (if >40 yo or if suspicious for silent MI, especially from demand ischemia)
  • CXR (if suspect perforation)

NG Lavage Controversy

  • Pros[4]
    • Positive aspirate proves strong evidence for an upper GI source of bleeding
    • Can assess presence of ongoing active bleeding
    • Can prepare patient for endoscopy
  • Cons[4]
    • Uncomfortable
    • Negative aspirate does not conclusively exclude upper GI source
    • Provides useful information in only minority of patients without hematemesis
    • Erythromycin 200mg IV can provide equal endoscopy conditions as lavage[5]

Diagnosis

  • Endoscopy frequently required for definitive diagnosis of underlying etiology

Management

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[6]
    • Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[7][8]
    • There is a mortality benefit in Asian patients[9]

Antibiotics

For short-term prophylaxis against SBP and bacteremia[10]

  • Ceftriaxone 1gm daily x 7 days (first line)[11]
  • 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)[12]
  • Consider vasopressin
    • 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[13]
    • Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[14]
    • Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [15]
    • 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[16]
  • tranexamic acid (TXA) initially thought to help, NNT = 30, no one harmed[17]; but HALT-IT trial RCT[18] found it did not reduce death from GI bleeding[19]

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[21]

Other Blood Products

Consider initiating massive transfusion protocol

Other Interventions

Balloon tamponade with Sengstaken-Blakemore Tube

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[24]

  • Early endoscopy does not necessarily improve clinical outcomes[25]
  • Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
    • Achieves endoscopy conditions equal to lavage[26]

Intubation

Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[27]

NO CHRISTMAS[28]

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[29]
  • 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

Disposition

Admission

Consider Discharge

If Glasgow-Blatchford Bleeding Score of 0 (<1% chance of requiring intervention):[31]. Must meet ALL of the following:

  • BUN <18
  • hemoglobin >13 (men), hemoglobin >12 (women)
  • Systemic BP >110
  • Heart rate <100
  • Patient did NOT present with melena
  • Patient did NOT present with syncope
  • No hepatic disease
  • No cardiac failure

See Also

References

  1. Kumar R, Mills AM. GI Bleeding. EM Clin N Am. 2011; 29:239-52.
  2. Gonzalez ELM et al. Variability among NSAIDs in risk of upper GI bleeding. Arthritis & Rheumatism. 2010; 62(6): 1592-1601.
  3. Allard J et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.
  4. 4.0 4.1 Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.
  5. Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.
  6. 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.
  7. Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  8. 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
  9. Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  10. Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.
  11. 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.
  12. Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.
  13. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  14. 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.
  15. GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507
  16. Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  17. Beyda, R., & Johari, D. (2019). Tranexamic acid for upper gastrointestinal bleeding. Academic Emergency Medicine. 2019 Oct;26(10):1181-1182
  18. 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.
  19. 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
  20. Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  21. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  22. Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  23. Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  24. Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
  25. Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  26. 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.
  27. Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
  28. Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/
  29. 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
  30. Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.
  31. Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.