Initial Management of Acute Upper Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy

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Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.

Section snippets

Epidemiology

UGIB is defined as bleeding proximal to the ligament of Treitz, to differentiate it from lower gastrointestinal bleeding involving the colon, and middle gastrointestinal bleeding involving the small intestine distal to the ligament of Treitz [1]. The annual incidence of hospitalization for acute UGIB is 1 per 1000 people in America [3]. It has a mortality of 7% to 10% [4]. The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that

Etiology

Major and minor causes of UGIB are listed in Box 1, and the frequency distribution of the major causes are listed in Table 1[3], [10], [11]. Peptic ulcer disease (PUD) accounts for about half of all UGIB (see Table 1) [1], [7]. Major risk factors for PUD include Helicobacter pylori infection, use of nonsteroidal antiinflammatory drugs (NSAIDs) or aspirin, smoking, alcoholism, and prior history of PUD [9], [12]. Patients who bleed after admission for another problem usually have PUD [8]. One

Clinical assessment

Patients who have UGIB must be promptly and accurately clinically assessed, as described in Box 2, to provide a rational basis for key early decisions on their medical management, as enumerated in Box 3. The medical history, physical examination, and initial laboratory values are important in assessing resuscitation requirements, triage, endoscopy timing, consultation requirements, and prognostication [15].

General therapy

Patient resuscitation includes fluid administration, blood transfusion, cardiorespiratory support, and treatment of significant comorbid diseases, such as sepsis or coronary artery disease. In patients who have severe hemodynamic or pulmonary instability, EGD should be delayed until the patient is adequately resuscitated and stabilized.

Consultation and triage

All patients who have acute UGIB require gastroenterology consultation [63]. Surgical consultation is recommended for patients who have ongoing active bleeding, massive bleeding, recurrent bleeding, bleeding associated with significant abdominal pain, acute lower gastrointestinal bleeding, variceal bleeding, and abdominal findings suggestive of an acute abdomen. Cardiology consultation is recommended in patients who have chest pain, prior severe coronary artery disease, hemodynamic instability,

Endoscopy

EGD is the prime diagnostic and therapeutic tool for UGIB. It is the procedure of choice. It accurately delineates the bleeding site and determines the specific cause, it provides a rational basis for triage of patients for routine hospital admission versus ICU admission, it helps assess the need for surgery, it provides valuable prognostic information, and it can be used to apply the recently greatly expanded armamentarium of endoscopic therapy (see the article by Cappell and Friedel elsewhere

Clinical parameters to assess bleeding severity and efficacy of therapies

Endoscopic findings, particularly SRH, help predict the risk for rebleeding in patients who have PUD, the need for blood transfusions, the length of hospital stay, and the mortality [71], [72]. The endoscopic findings are combined with the clinical presentation and initial laboratory data in clinical scoring systems for risk stratification, triage, and prognostication [73], [74], [75]. Patient evaluation and assessment with simultaneous resuscitative measures and prompt EGD optimizes UGIB

Challenges and prospects

Mortality has stubbornly persisted at 7% to 10% for nonvariceal UGIB (NVUGIB), perhaps because patients are older, sicker, and on an ever-increasing regimen of drugs that affect hemostasis. PPI use has been validated in patients bleeding from high-risk PUD, but guidelines still need clarification regarding patient stratification, medication formulation, and timing of administration [56], [57]. The role of octreotide for NVUGIB requires further study. The clinical evaluation, diagnosis, and

Summary

UGIB is a relatively common, potentially life-threatening condition that requires rapid assessment of clinical presentation, rapid resuscitative measures, and appropriate medical triage. Administration of PPIs is an important adjunctive measure for NVUGIB. EGD remains the principal diagnostic, therapeutic, and prognostic modality for NVUGIB. The article by Cappell and Friedel elsewhere in this issue reviews the diagnostic and therapeutic role of EGD for NVUGIB.

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