see also: [[Lower gastrointestinal bleeding|Lower GI bleed]], [[Balloon Tamponade GI varices|Oesophageal balloon tamponade]] > [!references]- > - [Dunn - Upper_GI_haemorrhage](x-devonthink-item://8042AAFB-59BB-4F27-9FDB-FD9D064666CC) > - [NEJM 2020: Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding.](bookends://sonnysoftware.com/ref/DL/259032) → [the bottom line summary](cubox://card?id=7188067418202178606)(cubox); here is the [online link](https://www.thebottomline.org.uk/summaries/em/timing-of-endoscopy-for-acute-upper-gastrointestinal-bleeding/) > - [BMJ 2019 - UGIB management](cubox://card?id=7223101291700945950) > **STEP 1:** Confirm that it IS haematemesis or upper GI bleeding and NOT [[Haemoptysis]] or [[Lower gastrointestinal bleeding|Lower GI bleed]] or posterior [[epistaxis]] # causes - peptic ulcer - Duodenal ulcer - Mallory weiss tear (consider if from stomach but frank blood) # management - [[Permissive hypotension]] (most effective when combined with definitive endoscopic care) -- mentation is also a decent resus target - so if the patient is sitting in resus all night to "scope in the morning," this isn't such a good strategy - *note that hypotension is associated with odds ratio ~10 of mortality* - transfuse pRBC if ==Hb <70== unless major haemodynamic instability - lower mortality than transfusion at Hb < 90 - higher transfusion target if known coronary artery disease >90 - endpoints: Hb > 70 or 90, plt > 50 - [[Warfarin, DOAC, heparin reversal|Reverse anticoagulation]] - note that vitamin K may be ineffective if hepatic synthetic function is impaired. 10mg IV - [[Prothrombinex]] 50 IU/kg - endpoint: INR < 1.5, pt <1.5x normal - no evidence for TXA - IDC - ceftriaxone 1g in patients with cirrhosis and suspected variceal bleeding - PPI 80mg IV bolus then 8mg/H infusion - reduces hospital LOS and active bleeding - per Dunn, does not appear to reduce transfusion requirements, recurrent bleeding, or mortality - +/- control bleeding with balloon tamponade +/- octreotide 50mcg IV or terlipressin 2g IV - endoscopy - give erythromycin 250mg IV 30 min before endoscopy to increase gastric mobility and visualisation - sclerotherapy, banding/ligation ## Variceal bleeding treatment - will need banding or sclerotherapy **[[octreotide]]** - somatostatin analogue - splanchnic vasoconstrictor - adverse effect: nausea - contraindications (rare): septic shock, asthma, uncontrolled HTN, ACS, age > 70, pregnancy - benefits: - reduce portal venous pressure and active bleeding - reduce transfusion requirement > dose: *50-100 mcg bolus* > then infusion 25-50 mcg/h for 48 hours **Terlipressin** - vasopressin prodrug - also used for tx hepato-renal syndrome - can be given by IV bolus (reconstituted powder) - dose: *slow IV injection 1.7mg* (2 vials) - +/- 0.85mg Q4H - [[Long QT|prolongs QT]] ### Sengstaken-Blackemore tube See: [[Balloon Tamponade GI varices]] ### angiography - for erosions not controlled by endoscopy ## When to scope? - the [2020 NEJM study](bookends://sonnysoftware.com/ref/DL/259032) "Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding" is often cited by gastro as a reason to delay because patients with delay btwn 6-24 hours had no increase 30 day mortality - "We also ==excluded patients who were in hypotensive shock or whose condition did not stabilize after initial resuscitation, since they required urgent intervention==" - however, in this trial, the rate of ulcers with active bleeding or visible vessels were 48% in the delayed group and 66% in the early group, so perhaps earlier cases still needed the endoscopy - Pts with Glasgow-Blatchford score of ≥ 12 included - "We monitored these patients closely and offered emergency endoscopy if there were signs of further bleeding (i.e., fresh hematemesis or hematochezia, hypotensive shock, or both)" - intention-to-treat analysis - "==Emergency endoscopy was performed in 20 patients (7.8%) in the early-endoscopy group because of new-onset signs of bleeding==: hypotension in 11 patients, fresh hematemesis in 6, fresh melena in 2, and a substantial decrease in hemoglobin level in 1." - Also, *82 patients had a GBS 12 or greater but were not randomised* – ==32 of these were admitted with shock and underwent emergency endoscopy== - of note, this study did include pts with varices (9.7% urgent group, 7.3% in delayed) - Mean SBP in pts was ~108; HR >100 in only 1/3 of pts - [dutch study](cubox://highlight?id=7223104077649936504) showed some survival benefit of delaying endoscopy 6 hours in unstable patients to resuscitate them # Glasgow Blatchford score - pt with score <3 not thought due to variceal bleeding can be discharged with 1 week follow up (Dunn) - Most guidelines say ≤ 1 ![[Pasted image 20240515230012.png]] | GBS score | timeframe for endoscopy | | ----------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | 0-3 | outpatient treatment<br>(dunn's says <3) | | 1-6 | ideally gastroscopy within 24 hours | | 7-11 | must have endoscopy within 24 hours (↑ chance requiring endoscopic intervention, re-bleeding, and death) | | ≥ 12 | must have endoscopy within 12 hours | | urgent / immediate endoscopy: | - suspected variceal bleeding (GBS score is not applicable for suspected variceal bleeding, although trial above did include variceal cases)<br>- if the risk of clinical deterioration is considered high<br>- severe large volume UGIB |