Template:Upper GI bleed treatment
Contents
Resuscitation
- Place 2 large bore IVs (or sheath introducer) 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)
Medications
Proton pump inhibitor
- Pantoprazole or esomeprazole 80mg x 1; then 8mg/hr
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
- In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of over-transfusion[15]
- 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
- Prothrombin complex concentrates[17]
- Cryoprecipitate 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[18]
- Monitor for hypocalcemia
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[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
- Etomidate or ketamine for sedation
- Succinylcholine and vecuronium increases LES tone
- 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