Acute upper gastrointestinal bleeding

Immediate management if shocked

• Protect airway
• keep NBM (nil by mouth)
• Insert two large-bore cannula (14–16G)
• Urgent bloods Tests CBC, Urea, Creatinine, Electrolytes, Liver function test, Glucose, Clotting screen
• Crossmatch 4–6 units
• Rapid IV crystalloid infusion up to 1L
• If signs of grade III or IV shock give blood Group specific or O Rh –ve until crossmatch done
• Otherwise continue IV fluids to maintain BP and transfuse if e.g. Hb <7
• Correct clotting abnormalities Vitamin K, FFP, platelet concentrate
• If risk of varices (e.g. known liver disease or alcohol excess), give terlipressin IV 1–2mg/6h and broad-spectrum IV antibiotics
• Consider referral to ICU,
• Consider CVP line to guide fluid replacement Aim for >5cmH2O
• CVP may mislead if there is ascites or CCF
• Catheterize and monitor urine output. Aim for >30mL/h
• Monitor vital signs every 15min until stable, then hourly
• Notify surgeons of all severe bleeds
• Urgent endoscopy for diagnosis ± control of bleeding at the earliest possible point after adequate resuscitation

Management if hemodynamically stable

• Insert two large-bore IV cannula
• Take blood for CBC, Urea, Creatinine, Electrolytes, Liver function test, Glucose, Clotting screen, and Bl. Group & save Bl. sample for matching in case transfusion needed later.
• Give IV fluids to restore intravascular volume; avoid saline if cirrhotic/varices
• Consider a CVP line to monitor and guide fluid replacement
• Organize a CXR, ECG, and check ABG
• Consider a urinary catheter and monitor hourly urine output
• Blood transfusion if significant Hb drop (<70g/L)
• Correct clotting abnormalities (vitamin K , FFP, platelets)
• If suspicion of varices (e.g. known history of liver disease or alcohol excess)
• Then give terlipressin IV (1–2mg/6h for ≤3d)
• And initiate broad-spectrum IV antibiotics (e.g. piperacillin/tazobactam IV 4.5g/8h)
• Monitor pulse, BP, and CVP (keep >5cmH20) at least hourly until stable.
• Arrange an urgent endoscopy
• If endoscopic control fails, surgery or emergency mesenteric angiography/embolization may be needed.
• For uncontrolled esophageal variceal bleeding, a Sengstaken–Blakemore tube may compress the varices, but should only be placed by someone with experience.
• In patients who have undergone successful endoscopic hemostasis,
• Give PPI (e.g. omeprazole 40mg/12h IV/PO)
• And treat if positive for H. pylori

Rebleeds

Serious event: 40% of patients who rebleed will die.

• Check vital signs every 15min
• Call senior cover for repeat endoscopy and/or surgical intervention.