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UPPER GI BLEEDING

Initial Assessment

  1. Consider discharge from ER and outpatient EGD if all criteria are met

    1. ACG 2012: BUN <18.2 mg/dL, Hg >13 g/dL (men) or 12 g/dL (women), systolic BP ≥110 mmHg, pulse <100 bpm, and no history of melena, syncope, cardiac failure, liver disease

    2. NICE 2012: If Blatchford score is 0 (BUN <18.6 mg/dL, Hgb ≥13 g/dL for males or ≥12 g/dL for females, systolic blood pressure ≥110 mmHg, HR <100, no melena, syncope, hepatic disease, heart failure)

  2. Perform Endoscopy

    1. AASLD 2007, WGO 2013: Within 12 hours

    2. NICE 2012: Within 24 hours or immediately after resuscitation if unstable

    3. ACG 2012: Within 24 hours or 12 hours if unstable

Acute Medical Management

  1. Antibiotic prophylaxis for variceal bleeding (AASLD 2007, WGO 2013)

    1. Give fluoroquinolone or cephalosporin for 7 days1

  2. Somatostatin/somatostatin analogues (AASLD 2007, NICE 2012, WGO 2013)

    1. Start at presentation

      1. AASLD: Somatostatin, octreotide, vapreotide, or terlipressin

      2. NICE: Terlipressin (not available in the United States)

      3. WGO: Terlipressin or somatostatin preferred over somatostatin analogues

  3. PPI for non-variceal bleeding

    1. ACG: Start PPI at presentation: 80 mg IV bolus + 8 mg/h infusion ×72 hours2 (ACG 2012)

    2. NICE: Don't give PPI before endoscopy; give PPI after endoscopy if evidence of recent non-variceal bleeding (NICE 2012)

  4. Resuscitative measures

    1. Hemoglobin transfusion threshold

      1. AASLD: <8 g/dL (AASLD 2007)

      2. ACG: ≤7 g/dL; higher if evidence of intravascular volume depletion or comorbidities (i.e., coronary artery disease) (ACG 2012)

      3. NICE, WGO: No specific goal (NICE 2012, WGO 2013)

    2. Other blood products

      1. If actively bleeding (NICE 2012)

        1. Transfuse platelets if <50k

        2. Transfuse fresh frozen plasma if INR >1.5× normal with subsequent cryoprecipitate if not at goal

        3. Give prothrombin complex if on warfarin

    3. Other resuscitative measures (WGO 2013)

      1. Consider tracheal intubation if acute or massive variceal bleeding to avoid bronchial aspiration of food or blood

Interventions

  1. Balloon tamponade (AASLD 2007, WGO 2013)

    1. As temporizing measure ×24 hours while awaiting TIPS or endoscopic therapy

  2. Therapeutic EGD for endoscopic variceal ligation or sclerotherapy (AASLD 2007, ACG 2012, NICE 2012, WGO 2013)

    1. First-line therapy

    2. ACG 2012: Repeat EGD up to two times for persistent bleeding

  3. TIPS (AASLD 2007, NICE 2012, WGO 2013)

    1. If bleeding not controlled with EGD

    2. Child A or Child B with recurrent variceal hemorrhage

    3. NICE: If esophageal variceal bleeding not controlled by band ligation

    4. WGO: If bleeding is uncontrolled or recurring despite EGD and pharmacotherapy

  4. Other procedures

    1. ACG 2012: Transcatheter arterial embolization or surgery if refractory bleeding

    2. NICE 2012: Interventional radiology preferably over surgery if rebleed after EGD

Management After Stabilization

  1. Non-selective beta blockers

    1. Start propranolol or nadolol 24 hours after stabilization (AASLD 2007)

    2. Adjust to maximal dose (25% of resting heart rate reduction up to 55 bpm) (WGO 2013)

  2. Isosorbide 5-mononitrate

    1. AASLD 2007: Consider giving with beta blocker (small benefit; often poorly tolerated due to hypotension and renal hypoperfusion)

    2. WGO 2013: Don't use routinely; consider for young patients, Child-Pugh A, if failed sclero- and pharmacotherapy

  3. Liver transplant referral

    1. AASLD 2007: Refer if Child-Pugh ≥7 or MELD ≥15

    2. WGO 2013: Refer if recurrent bleed or Child-Pugh B or C

  4. Adjusting other medications

    1. Aspirin (ACG 2012)

      1. For secondary prevention, restart within 7 days, ideally ...

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