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Management of Acute Upper Gastrointestinal Hemorrhage

  • David SchriftEmail author
  • Carol H. Choe
Chapter

Abstract

The initial management of a patient with an acute gastrointestinal hemorrhage should focus on establishing the source of the bleeding. The presence of melena and a high BUN/sCr ratio effectively rule in an upper gastrointestinal hemorrhage. Meanwhile, the nasogastric lavage has very little value in determining the source of the hemorrhage and is one of the most painful emergency department procedures. Treatment should begin with establishing appropriate intravenous access and starting volume resuscitation. Blood transfusions should be restricted to patients that remain symptomatic despite adequate fluid resuscitation or if the hemoglobin drops below 7 g/dl. Four-factor prothrombin complex concentrate is preferred over fresh frozen plasma for the reversal of coagulopathic patients on warfarin. Hemorrhaging patients receiving new oral anticoagulants are extremely challenging and require detailed knowledge of their pharmacokinetics. All patients should undergo risk stratification with the Glasgow-Blatchford Score. High-risk patients should be admitted to the intensive care unit and undergo an urgent endoscopy. Intensive proton pump inhibitor therapy should be withheld unless a high-risk lesion is demonstrated on endoscopy. Trans-arterial embolization and emergency surgery are salvage options when endoscopy fails.

Keywords

Nasogastric lavage Glasgow-Blatchford Score Blood transfusion Proton pump inhibitor Warfarin New oral anticoagulants Dabigatran Rivaroxaban Prothrombin complex concentrate Fresh frozen plasma Trans-arterial embolization 

Supplementary material

Video 61.1

Duodenal ulcer with visible vessel (Courtesy of and © Dr. Julio Murra Saca (MPG 3370 kb))

References

  1. 1.
    Srygley D, Gerardo C, Tran T, Fisher D. Does this patient have a severe upper gastrointestinal bleed? JAMA. 2012;307(10):1072–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Tai C, Huang S, Wang H, Lee T, Chang C, Tu C, et al. High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis. Am J Emerg Med. 2007;25:273–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Sung J, Chan F, Chen M, Ching J, Ho K, Kachintorn U, et al. Asia-Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Gut. 2011;60:1170–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Barkun A, Bardou M, Kuplers E, Sung J, Hunt R, Martel M, Sinclair P, International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101–13.CrossRefPubMedGoogle Scholar
  5. 5.
    Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345–60.CrossRefPubMedGoogle Scholar
  6. 6.
    Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368:11–21.CrossRefPubMedGoogle Scholar
  7. 7.
    Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2006;(1):CD002094.Google Scholar
  8. 8.
    Palamidessi N, Sinert R, Falzon L, Zehtabchi S. Nasogastric aspiration and lavage in emergency department patients with hematochezia or melena without hematemesis. Acad Emerg Med. 2010;17:126–32.CrossRefPubMedGoogle Scholar
  9. 9.
    Huang E, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel B. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971–80.CrossRefPubMedGoogle Scholar
  10. 10.
    Singer A, Richman P, Kowalska A, Thode H. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med. 1999;33(6):652–8.PubMedGoogle Scholar
  11. 11.
    Neumann I, Letelier LM, Rada G, Claro JC, Martin J, Howden CW, Yuan Y, Leontiadis GI. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2013;(6):CD007999.Google Scholar
  12. 12.
    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):1755–62.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Sreedharan A, Martin J, Leontiadis GI, Dorward S, Howden CW, Forman D, et al. Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010;(7):CD005415.Google Scholar
  14. 14.
    Scottish Intercollegiate Guidelines Network. Management of acute upper and lower gastrointestinal bleeding: a national clinical guideline. 2008;(4.3):13–4.Google Scholar
  15. 15.
    Beggs A, Dilworth M, Powell S, Atherton H, Griffiths E. A systematic review of transarterial embolization versus emergency surgery in treatment of major nonvariceal upper gastrointestinal bleeding. Clin Exp Gastroenterol. 2014;7:93–104.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Barkun A, Bardou M, Gralnek I, Shingina A, Razzaghi A. T1941 impact of elevated INR and of Low platelet count on outcomes in acute upper GI bleeding [abstract]. Gastroenterol. 2009;136(5):A605.Google Scholar
  17. 17.
    Shingina A, Barkun A, Razzaghi A, Martel M, Bardou M, Gralnek I. RUGBE Investigators Systematic review: the presenting international normalized ratio as a predictor of outcome in patients with upper nonvariceal gastrointestinal bleeding. Aliment Pharmacol Ther. 2011;33:1010–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Stainsby D, MacLennan S, Thomas D, Isaac J, Hamilton P, et al. Guidelines on the management of massive blood loss. Br J Hematol. 2006;135:634–41.CrossRefGoogle Scholar
  19. 19.
    Lubetsky A, Yonath H, Olchovsky D, Loebstein R, Halkin H, Ezra D. Comparison of oral vs intravenous phytonadione in patients with excessive anticoagulation. Arch Intern Med. 2003;163(10):2469–73.CrossRefPubMedGoogle Scholar
  20. 20.
    Riegert-Johnson D, Volcheck G. The incidence of anaphylaxis following intravenous phytonadione: a 5-year retrospective review. Ann Allergy Asthma Immunol. 2002;89:400–6.CrossRefPubMedGoogle Scholar
  21. 21.
    Holbrook A, Witt D, Fish J, Veenstra D. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S–84.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Karaca M, Erbil B, Ozmen M. Use and effectiveness of prothrombin complex concentrates vs fresh frozen plasma in gastrointestinal hemorrhage due to warfarin usage in the ED. Am J Emerg Med. 2014;32:660–4.CrossRefPubMedGoogle Scholar
  23. 23.
    Stangier J, Rathgen K, Stahle H, Mazur D. Influence of renal impairment on the pharmacokinetics and pharmacodynamics of oral dabigatran etexilate: an open-label, parallel-group, single-centre study. Clin Pharmacokinet. 2010;49(4):259–68.CrossRefPubMedGoogle Scholar
  24. 24.
    Lindahl T, Baghael F, Blixter I, Gustafsson K, Stigendal L, Sten-Linder M, et al. Effects of the oral, direct thrombin inhibitor dabigatran on five common coagulation assays. Thromb Haemost. 2011;105:371–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Lee F, Chan A, Lau K, Chan H. Reversal of New, factor-specific oral anticoagulants by rFVIIa, Prothrombin complex concentrate and activated Prothrombin complex concentrate: a review of animal and human studies. Thromb Res. 2014;133:705–13.CrossRefPubMedGoogle Scholar
  26. 26.
    Nutescu E, Dager W, Kalus J, Lewin J, Cipolle M. Management of bleeding and reversal strategies for oral anticoagulants: Clinical practice considerations. Am J Health Syst Pharm. 2013;70:e82–97.Google Scholar
  27. 27.
    Kubitza D, Becks M, Wensing G, Voith B, Zuehlsdorf M. Safety, pharmacodynamics, and pharmacokinetics of BAY 59-7939—an oral, direct Factor Xa inhibitor—after multiple dosing in healthy male subjects. Eur J Clin Pharmacol. 2005;61:873–80.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Pulmonary and Critical Care MedicineUniversity of South Carolina School of MedicineColumbiaUSA
  2. 2.Critical Care MedicineLexington Medical CenterWest ColumbiaUSA

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