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CHAPTER Practical Approach to Blood

35 Jatinder K Mokta

INTRODUCTION require admission for resuscitation and treatment. Hematemesis is defined as vomiting of blood, which is INITIAL EVALUATION (FIGURE 1) indicative of bleeding from the , , or The initial evaluation of the patient with bloody vomiting duodenum.1 Hematemesis includes vomiting of bright involves an assessment of the hemodynamic stability and red blood, suggestive of recent or ongoing bleeding, and resuscitation, and if necessary diagnostic studies (usually dark material (coffee-ground emesis), which suggests ) with the goal of both diagnoses and when bleeding that had stopped some time ago. Hemetemesis possible, treatment of the specific disorder. is often accompanied by melena which is black tarry stool that results from degradation of blood to hematin or other Evaluation of the patient includes a history, physical hemochromes by intestinal bacteria. examination, laboratory tests, and in some cases, nasogastric lavage. The information gathered as a part Gastrointestinal bleeding can be classified as overt, occult of initial evaluation is used to guide decisions regarding or obscure. triage, resuscitation, empiric medical therapy and Overt Gastro-Intestinal (GI) bleeding is visible and can diagnostic testing. present in the form of hematemesis, “coffee-ground” Past Medical History - Patients should be asked about emesis, melena, or hematochezia. Occult bleeding refers to prior episodes of upper GI bleeding, since up to 60 percent bleeding which is not clinically visible as it is microscopic of patients bleed from the same lesion.2 In addition, the bleeding. Obscure GI bleeding refers to recurrent bleeding patient’s past medical history should be reviewed to in which a source is not identified after upper endoscopy identify important co-morbid conditions. and colonoscopy. It may be either overt or occult. Potential bleeding sources suggested by a patient’s past Depending upon the site, gastrointestinal bleeding can medical history include: be classified as either upper or lower GI beed. Upper GI bleeding is hemorrhage originating from the esophagus • Varices or portal hypertensive gastropathy in a to the ligament of Treitz, at the duodenojejunal flexure patient with a history of or alcohol and lower GI bleeding originates from a site distal to the abuse. ligament of Treitz. • in a patient with a history Hemetemesis is a manifestation of acute severe upper of Helicobacter pylori, nonsteroidal anti- Gastro-Intestinal bleed. Acute GI bleeding is a major inflammatory drug (NSAIDs) use, or smoking and cause of hospital admissions in the United States, which epigastric discomfort. is estimated at 300000 patients annually. Upper GI tract • Cameron’s erosions in patient with history of large bleed is approximately four times more common than hiatal . that of lower GI tract and is a major cause of morbidity • Aorto-enteric fistula in a patient with a history of and mortality. Acute GI bleeding is more common in an abdominal or an aortic graft. men than women and its prevalence increases with age. The most common causes of acute upper GI bleeding are • Angiodysplasia in a patient with renal disease, peptic ulcer disease including from the use of aspirin and aortic , or hereditary hemorrhagic other non-steroidal anti-inflammatory drugs (NSAIDs), telangiectasia. variceal hemorrhage, Mallory-Weiss tear and neoplasms • Malignancy in a patient with a history of smoking, including gastric . Other relatively common causes alcohol abuse, or H. pylori infection. include , erosive /duodenitis, vascular ectasias and Dieulafoy’s lesions.1 and • Marginal ulcers (ulcers at an anastomotic site) in a peptic ulcer disease are major causes of upper GI bleeding patient with a gastroenteric anastomosis. in both Eastern and Western societies. Comorbid illnesses may influence patient management in Severe GI bleed is defined as documented gastrointestinal the setting of an acute upper GI bleed. Comorbid illnesses bleeding accompanied by or orthostatic may: hypotension, and a decrease in the hematocrit value by at • Make patients more susceptible to hypoxemia least 6% or a decrease in the level of at least (eg, coronary artery disease, pulmonary disease). 2 g/dL, or requires transfusion of at least two units of Such patients may need to be maintained at higher packed red blood cells.1 Patients with severe GI bleeding hemoglobin levels than patients without these 188 the patient’ssymptoms: Specific causes of upper GI bleeding may be suggested by palpitations, and cold/clammyextremities. include orthostatic dizziness, confusion, angina, severe sources. Symptoms that suggestthebleedingis severe of theevaluationbleed andasapart bleeding forpotential symptoms as part oftheassessment of theseverity of the Symptom assessment —Patientsasked about should be • • • bleeding includea completeblood count, serum obtained inpatients withacuteupper gastrointestinal Laboratory data —Laboratory tests thatshould be significant comorbidillnesses. examination shouldinclude asearchforevidenceof Finally, aswiththepast medical history,thephysical a perforationisrequiredprior toendoscopy. acute abdomenarepresent, furtherevaluation toexclude guarding, raises concern for perforation.If any signs of an and associated with reboundtenderness or involuntary The presence of ,especially if severe • • • Signs ofhypovolemiainclude: component oftheassessment of hemodynamic stability. —The physical examinationis a key • • • • • be consideredinsuchpatients. encephalopathy). Endotracheal intubation should Predispose to aspiration(eg,, hepatic transfusions offreshfrozenplasmaorplatelets. hepatic dysfunction).Suchpatientsmayneed significant thrombocytopenia, coagulopathies, (eg, control to difficult more is that bleeding in Result resuscitation. may needmoreinvasive monitoringduring (eg, renaldisease,heartfailure).Suchpatients transfusions blood or resuscitation fluid of setting to volumeoverloadPredispose patients inthe disorders. hypotension. Blood volume loss of atleast40percent:Supine from recumbencytostanding). in heartrateof20beatsperminutewhenmoving pressure of more than20mmHg and/oran increase Resting hypotension (adecrease in thesystolic blood hypovolemia: Blood volume loss of at least15 percent: Orthostatic moderate to tachycardia. Mild weight loss,cachexia. involuntary satiety, early , Malignancy: abdominal distention. gastropathy: ,weakness, fatigue,anorexia, Variceal hemorrhageorportalhypertensive prior tohematemesis. coughing or retching, Emesis, tear: Mallory-Weiss reflux, dysphagia. Esophageal ulcer: , gastroesophageal pain Peptic ulcer: Epigastric or rightupperquadrant 3 3 total amount of crystalloid fluid volume needed to correct (>20:1 or >100:1, respectively). nitrogen (BUN)-to-creatinineorurea-to-creatinineratio havetypically upper GIbleeding anelevated bloodurea may have decreasedrenalperfusion,patientswithacute small bowelthe absorbed asitpassesthrough andpatients Because bloodis suggestchronicbleeding. deficiency or cells blood red Microcytic cells. blood Patients withacutebleedingshould have normocytic red depending upontheseverity ofthebleed. hemoglobin level ismonitoredeveryhours, twotoeight can lead to a falsely low hemoglobin value. The initial resuscitation. It should be keptinmind that overhydration during administered fluid by and vascularspace the into fluid extravascular of influx the by diluted is blood the after 24hoursormore) the hemoglobinwilldecline as is losingwholeblood.Withthe patient time(typically bleeding willoftenbeatthepatient’sbaselinebecause The initialhemoglobininpatientswithacuteupperGI symptoms suchaschestpainordyspnea. a historyofcoronaryarterydisease, or patientswith myocardial ,suchasolderadults,patientswith may beindicatedinpatientswho are atriskfor a addition, serialelectrocardiograms and cardiac enzymes chemistries, liver tests,andcoagulationstudies.In treatment-associated complications. stabilization isessentialprior toendoscopy to minimize Fluid resuscitation — facilitate endoscopyanddecrease theriskofaspiration. hematemesis or altered respiratory or mental status may Elective endotracheal in patientswithongoing intubation inserted whoneedclosemonitoringduringresuscitation. intravenous cathetersoracentralvenous lineshouldbe . Two peripheral or larger) largecaliber (16gauge oxygen bynasalcannulaandshould receive nothingper General support —Patients should receive supplemental low-risk patients. management maybe appropriate forsome Outpatient oflow- medical risk patientsreceive electrocardiogram monitoring. the exception aregular with patients to admitted all admitted ward, be can patients Other urinary outputasaguidetorenalperfusion. is mandatory toallowacontinuous evaluation of the monitoring, andpulseoximetry.Foleycatheterplacement automated bloodpressuremonitoring,electrocardiogram an intensive to admitted for resuscitationandcloseobservationcare unit with be should hematochezia) or red bloodpernasogastrictube, hematemesis, bright by orthostatic hypotension)oractive bleeding(manifested (shock, All patientswithhemodynamicinstability (ie, airway,management. circulation) ofinitial breathing, patient beginswithassessing and addressing the ABCs Triage —Resuscitation ofahemodynamicallyunstable administering bloodproducts solutions may be used to attain volume restoration prior to the 2008SIGNguideline, eithercolloid or crystalloid more likelythebleedingisfromanupperGIsource. GENERAL MANAGEMENT (FIGURE 2) Adequate resuscitation and 7 4,5 A roughguidelineforthe The higher theratio, 6 According to According 4 CHAPTER 35 189 20 intra- In patients 22 By contrast, high By contrast, high 15-17 been shown to significantly In addition, there were no In addition, there were In the setting of active upper GI upper active of setting the In 21 not 14 19 Lao et al have demonstrated that high- demonstrated Lao et al have 18 bleeding from an ulcer, acid suppressive therapy with H2 therapy suppressive acid an ulcer, bleeding from receptor antagonists has of ulcer rebleeding. the rate lower dose intravenous omeprazole can accelerate the resolution can accelerate the resolution omeprazole intravenous dose reduce the need for of stigmata of recent hemorrhage and endoscopic therapy. Somatostatin and its analogs Somatostatin the in used is analog octreotide, its or Somatostatin, the reduce also may bleeding and variceal treatment of causes. risk of bleeding due to nonvariceal The suggested dosing of intravenous pantoprazole pantoprazole intravenous of dosing suggested The by 8-mg/h followed and is 80-mg bolus for 48-72 hours. Oral infusion. The infusion is continued PPI therapy length also decrease the and intravenous and need for blood of hospital stay, rebleeding rate, treated with ulcers in patients with high-risk transfusion endoscopic therapy. in patients with lesions PPIs may also promote hemostasis other than ulcers. This likely because neutralization occurs of blood clots. of gastric acid leads to the stabilization Prokinetics been have Both erythromycin and metoclopramide bleeding. The in patients with acute upper GI studied gastric goal of using a prokinetic agent is to improve by clearing the visualization at the time of endoscopy residue. Erythromycin of blood, clots, and food stomach have likely to are in patients who be considered should those as such in their stomach, blood large amount of a A reasonable dose is 3 mg/kg bleeding. with severe 20 to 30 minutes, 30 to 90 minutes prior to over venously endoscopy. Erythromycin Erythromycin has also been compared with nasogastric that trial with 253 patients randomized A lavage. nasogastric lavage erythromycin alone with compared plus erythromycin found alone and nasogastric lavage that the quality of visualization did not differ significantly among the three groups. Acid suppression Acid upper acute with the hospital to admitted Patients pump treated with a proton are typically GI bleeding GI bleeding with acute upper can inhibitor Patients (PPI). (IV) PPI. It can be be intravenous empirically on an started confirmation continued until presentation and started at the bleeding the source of of bleeding. Once of the cause for need and treated (if possible), the been identified has can be determined. ongoing acid suppression acid suppression examined the role of have studies Several (with or without before or after endoscopy given therapeutic intervention). dose antisecretory therapy with an intravenous infusion therapy with an intravenous antisecretory dose of a PPI significantly with standard treatment in patients with compared reduces the ratebleeding ulcers. rebleeding of differences among the groups with regard to procedure duration, rebleeding rates, need for second endoscopy, number of transfused units of blood, and mortality. If the 13 12 In addition, because 11 for patients at increased risk g/L) Try to maintain the hemoglobin Try to maintain the 8-10 (90 g/dL (70g/L). g/dL of suffering adverse events in the setting those with unstable coronary artery anemia, such as of significant bleeding and patients with active disease. However, despite an hypovolemia may require apparently normal hemoglobin It is particularly important overtransfusion to avoid bleeding, as it can in patients with suspected variceal Transfusing the bleeding [9]. of precipitate worsening bleeding to a hemoglobin variceal patients with suspected should be avoided. >10 g/dL (100 g/L) a low platelet count (< bleeding and with active Patients should be transfused with platelets. 50,000/microL) to with a coagulopathy that is not due Patients INR >1.5) should (prolonged with plasma (FFP). The be transfused with fresh frozen with cirrhosis management of coagulopathies in patients accurate an not is the INR because complicated more is because cirrhosis in patients with of hemostasis measure factors. it only reflects changes in procoagulant stable, urgent Provided the patient is hemodynamically simultaneously with endoscopy can usually proceed until the not be postponed should and transfusion in patients with an However, coagulopathy is corrected. INR ≥3, attempt to correct the INR to <3 prior to starting after the FFP being given with additional an endoscopy, endoscopy if high-risk stigmata for recurrent bleeding performed and therapy was found or if endoscopic were the INR is still >1.5. This approach is based on data that safe in patients who are mildly is suggest endoscopy to moderately anticoagulated. at a level at of a ≥ level 9 patient is taking the medications because of a recent (less than one year) or acute coronary stent placement vascular syndrome, when possible, a cardiologist should be consulted prior to stopping the agent or giving a platelet transfusion. Platelet transfusions should also be considered in transfusions should also be considered Platelet received patients with life-threatening bleeding who have antiplatelet agents such as aspirin or clopidogrel. the is the hypovolemia each milliliter Replace rule. 3-for-1 of blood loss with 3 mL of crystalloid fluid. This restores coexisting severe with Patients volume. plasma the lost and pulmonary such as cardiovascular medical illnesses, artery catheter insertion pulmonary may require , performance cardiac monitor hemodynamic to closely phase. during the early resuscitative profiles resuscitation respond to initial pressure fails to If the blood efforts, the rateincreased. of fluid administrationinitiate — The decision to Blood transfusions blood be should Initiate blood individualized. be must transfusions for hemoglobin is < 7 g/dL (70 g/L) transfusions if the those with stable coronary artery most patients (including the hemoglobin at a maintaining with a goal of disease), level ≥ 7 packed red blood cells do not contain coagulation factors, do packed red blood cells transfusion of a unit of FFP should be considered after four units of packed red blood cells. every

GASTROENTEROLOGY 190 days. ceftriaxone, 1 gevery24 hours,administeredforseven 500 levofloxacin, 400 ciprofloxacin, including fluoroquinolones, oral norfloxacin, 400 are antibiotics prescribed commonly is unknown.The most and durationofantibiotic type individualized. medications or administer reversal agents needs to be without reversal, andthusthedecision to discontinue should beweighed againsttheriskofcontinuedbleeding However, thethromboticriskofreversing anticoagulation GI bleeding. upper with held inpatients should be agents When possible,anticoagulants andantiplatelet Anticoagulants andantiplatelet agents rates ofmortalityandbacterialinfections. with variceal bleeding is associated with adecrease in the that administrationofanantibiotictocirrhotic patients suggested have Meta-analyses mortality. increased have develop aninfectionwhilehospitalized. Such patients up toanadditional50percent bleeding; gastrointestinal of patientswithcirrhosis who arehospitalizedwith Bacterial infectionsarepresentinupto20percent Antibiotics for patients withcirrhosis events. controlling variceal bleedingandcause fewer adverse for sclerotherapy as effective as are analog]) vasopressin octreotide, somatostatin,terlipressin[along-acting vasoactiveA meta-analysishasshownthat drugs(e.g., adjunctive therapyinsomecases. nonvariceal upperGIbleeding,butitcanbeused as acute with recommended for routineuseinpatients infusion at a rate of 50 mcg per hour. Octreotide is not intravenous bolus of 50 mcg, followed by a continuous with suspected variceal bleeding, octreotide is given as an electrocardiogram, CXR – Chest X-Ray, –Chest CXR GE-Gastroenterologist.electrocardiogram, BLOOD GROUPING AN Fig. 1:Algorithmfor theinitialmanagementofsevere upper gastrointestinal (UGI)bleeding. bloodcount, CBC-Complete LFT – liver function test, test,LFT –liver RFT–renal function ECG- function Up co en If the pa� PPI CXR, n d p 23 sid m o er end sc a NA er b y o be p ADM H SO ent is ic tr IS egi o st s TO GA co nnin art eat IS RY, p STRIC SI kno ed bef y m ON D SEV ( g P en o g

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risk ofvariceal bleedingwithin1year. C cirrhosis, and red color signs on varices have the highest large esophagealvarices,with Child(orChild-Pugh)class large varicesthan 5 mmindiameter.Patients aregreater of the lumen, are less than 5 Small varices thatis,thoseoccupyinglessthanonethird of esophagealvaricesEndoscopic grading issubjective. whereas those with a flat spot or clean based ulcer do not. hemostasis, endoscopic from most benefit clot) adherent major stigmata ofulcerhemorrhage(spurting,NBVV, or for . length of stay, risk of recurrent bleedingand the need endoscopic targeted of benefit treatment, resultinginreduced morbidity, hospital the has and diagnosis confirm to bleeding GI upper acute with patients most in endoscopy within24hofpresentationisrecommended IIC); andclean-basedulcer(ForrestIII). (Forrest spot pigmented flat IIB); (Forrest clot adherent or nonbleedingvisiblevessel (NBVV; ForrestIIA); oozing bleeding(ForrestIB);pigmentedprotuberance ulcers, as follows: active spurtingbleeding(ForrestIA); tocategorize isused evaluation endoscopic during peptic findings bleeding of 3) (Fig. classification Forrest The problems, canbedischargedhome. stable vitalsignsandhemoglobin,noothermedical Mallory-Weiss nonbleeding tears, erosive orhemorrhagicgastropathy)whohave ulcers, clean-based (e.g., endoscopic from benefit vessel) hemostatic therapy,whilepatientswithlow-risklesions visible a or bleeding active with ulcers varices, (e.g., findings endoscopic risk is considered the investigation ofchoice. In patientswithacuteupperGIbleeding,endoscopy Upper endoscopy in patients inwhom hemorrhage fromfundal varices intrahepatic portosystemic shunt) should be considered EVL isanoption. Otherwise, A TIPS(transjugular such ascyanoacrylateis preferred,whereavailable. endoscopic variceal obturation using tissue adhesives In patientswhobleed from gastric fundal varices, • • • • into fourgroups: varices, described by Sarin et al.divides gastric varices Gastric of classification endoscopic used commonly Most requires fewer sessionsto achieve variceal obliteration. fewer complications thanendoscopic sclerotherapy and and prevention ofrebleeding,andisassociated with ligation is preffered therapy for initial control of bleeding acute esophagealvariceal bleeding.Endoscopic variceal terlipressin) (somatostatin oritsanaloguesoctreotideandvapreotide; variceal ligationcombinedwithPharmacologicaltherapy SPECIFIC DIAGNOSTIC STUDY AND MANAGEMENT IGV2 (2%)–isolatedantral varices esophageal varices IGV1 (8%)–isolated fundic varices without the fundus GOV2 (16%)–whenesophagealvarices extendinto the lessercurvature GOV1 (74%)–whenesophagealvarices extendinto 27 is thepreferredtherapyforcontrolof Patients withmajor bleeding andhigh- mm in diameter, whereas 1 Patients with 26 1 Earlyupper Endoscopic 1 CHAPTER 35 191

Discharge No active No active Bleeding No endoscopic therapy weiss tear weiss -

Mallory

26 2 days - 1 Ward for for Ward Active Active Bleeding Endoscopic Endoscopic therapy

3 - 2 upper gastroduodenal bleeding are 92%-98% and 30%- 100%, respectively. Risks of upper endoscopy include aspiration, side-effects - Bleed or Bleed -

EVL + IV EVL + vasoactive (eg, drug octreotide or Terlipresine ) ICU ICU for 1 day 2 for Ward day Esophageal Varices Esophageal Acute Upper GI Upper Acute Hemetemesis

Oral PPI and and Oral PPI early discharge Flat Flat pigmented spot or clean base

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hrs) (active bleeding, bleeding, (active ) Clot or NBVV, Major stigmata stigmata Major

electro Combination Combination endoscopic (hemostasis eg epinephrine inection and multipolar High dose PPI (IV (IV PPI dose High for Bolus+Infusion 72 PPI by oral IV, intravenous; NBVV, nonbleeding visible vessel; PPI, proton pump inhibitor; EVL, Endoscopic Variceal Ligation Variceal EVL, pump inhibitor; Endoscopic PPI, proton nonbleeding visible vessel; NBVV, intravenous; IV, Fig. 3: Endoscopic stigmata of recent peptic ulcer bleeding. A, Active bleeding with spurting. B, Visible vessel (arrow) with an (arrow) vessel Visible bleeding with spurting. A, Active B, peptic ulcer bleeding. of recent 3: Endoscopic stigmata Fig. adjacent clot. C, An adherent clot. D, Slight oozing of blood after washing in the center of an ulcer without a clot or visible vessel. in the center Slight washing of blood after oozing D, clot. C, An adherent adjacent clot. Fig. 2: Algorithm for the endoscopic and medical management of severe GI – hemorrhage, following hemodynamic stabilization. hemodynamic stabilization. following GI – hemorrhage, the endoscopic and medical 2: Algorithm for management of severe Fig. cannot be controlled or in whom bleeding recurs despite bleeding recurs whom in or be controlled cannot combined pharmacological and endoscopic therapy. The reported sensitivity and specificity of endoscopy for GASTROENTEROLOGY 192 perforation ofthebowel wall. the riskofbariumperitonitisifthereisapre-existing (GBS) have beendeveloped andvalidated. such astheRockallScore and GlasgowBlatchfordScore risk scores Risk scores —ForacuteupperGIbleeding, • • • • • Bleeding ConferenceGroup. Upper Gastrointestinal tools isrecommended the InternationalConsensus by acute upperGIbleeding,andtheuseofriskstratification useful forriskstratificationofpatientswhopresentwith Endoscopic, clinical, andlaboratoryfeaturesmaybe with subsequentinvestigations orsurgery, may interfere of acuteupperGIbleedingbecausethey Upper GI barium studies are contraindicated in the setting for uncontrolled bleeding gastric ulcer. surgery, suchasanexplorationandpartialgastrectomy should proceedtourgent GI bloodloss,patient upper If thepatientisunstablewithlargevolume stability. investigationnext dependsonthepatient’shemodynamic the treated, or identified be cannot site bleeding a which bleeding whereupperendoscopyisnon-diagnosticin GI diagnostic tests-Incasesofacuteupper Other selected patientswithhighriskofre-bleeding stated itmaybeusefulin second lookendoscopybut remains endoscopy use of Recommendations did notrecommendroutine first on controversial. The 2010 International Consensus achieved is hemostasis The practiceofroutinesecond look endoscopy after massive upperGIbleeding. in thecaseof be securedbyendotrachealintubation should The airway intervention. therapeutic attempting from sedation,perforation,andincreasedbleedingwhile such as bloodurea nitrogen and hemoglobin. Therefore, hepatic disease, cardiac failure and laboratoryparameters blood pressure, pulse,presenceofmelena, syncope, upon thepatient’s clinical presentation such as systolic based is GBS the findings, endoscopic uses score Rockall analysis included: meta- a in identified rebleeding with associated Factors enteroscopy. deep smallbowel enteroscopy,andrarely,intraoperative nuclear scintigraphy,whichcandetectactive bleeding, include CT angiography, catheterangiographyand Other diagnostictestsforacuteupperGIbleeding repeat endoscopymaybeconsidered. hemodynamically stablewithlowvolumebleeding, help localizethesource of bleeding.Ifthepatientis endoscopy may beausefuladjunctduringsurgeryto RISK STRATIFICATION lesser gastriccurvature) Ulcer location(posteriorduodenalbulborhigh studies) Large ulcersize(greaterthan1to3cminvarious Active ofendoscopy bleedingatthetime Hemoglobin lessthan10 g/L beats perminute) less than 100mmHg, heart rategreaterthan100 Hemodynamic instability (systolicblood pressure 29 31 28 Intraoperative 30 32 anddueto 27 Whilethe 27

clinical intervention, rebleeding,andmortality. the Rockallscore withregardtopredictingtheneedfor as wellit outperformed asthefullBlatchfordscoreandthat itperformed that found score modified the of study and pulse.Thescorerangesfrom0to16. A prospective blood urea nitrogen,hemoglobin,systolic blood pressure, modified the Glasgow Blatchfordscore,iscalculatedusingonlythe as known score, the of version simpler A emergency departmentsetting of suspected acute upper GI bleeding, such as in the the GBSmaybebestsuitedforinitialriskevaluation rebleeding, since most rebleeding occurs duringthistime. since mostrebleeding rebleeding, have should be hospitalized for 72hours to monitor for who patients Most signs). receivedstigmata for high-risk endoscopictreatment vital of stability and careunit orintensive (depending upontheseverity ofbleeding,comorbidities, setting amonitored in admitted If patientsdonotmeetthesecriteria,patientshouldbe follow-up andconfidenceinthediagnosis. upon individual-patientfactors,suchasreliabilityfor However, thedecision to dischargeapatientalsodepends • • • • • can bedischargedhome: As a general rule,patientswho meet thefollowingcriteria scores hasyet beenadoptedwidely. todecisions regarding patientdischarge.Noneofthepublishedrisk directly betied must system stratification However, for these systems to besuccessful, the risk 3. 2. 1. deciding thespecifictherapy. endoscopy is themainstayofinitialinvestigations and resuscitation should precede anyinvestigations. Upper patients withactive GIbleeding whoareunstable,acute GI bleedinginbothEasternandWestern societies. In varices andpepticulcerdiseasearemajorcausesofupper a widerangeofpathologies.Esophageal can becausedby Hemetemesis isamanifestationofacutesevere GIbleeding REFERENCES CONCLUSION 92:491. gastrointestinal endoscopy.MedClinNorth Am 2008; gastrointestinal bleeding:from initial evaluation upto upper acute of management Initial D. Friedel MS, Cappell study of1,4000patients.JAMA 1969;207:1477. tract hemorrhage. gastrointestinal A 23-year prospective Palmer ED. The vigorous diagnostic approachtoupper- editors. Edition. Elsevier Medicine2010 LJ, Brandt In: S, and Fordtran’sGastrointestinal andLiver Disease.9th Bleeding. Frience Gastrointestinal M, DM. Feldman Jensen TJ, Savides Have nocomorbidities or ulcerbleedingwithhigh-riskstigmata) active bleeding,bleedingfromaDieulafoy’slesion, with ahighriskofrebleeding(eg,variceal bleeding, Haveis notassociated asourceofbleedingthat endoscopy upper on identified source bleeding likely a Have Have anormalhemoglobin Have stablevitalsigns 33 Sleisenger CHAPTER 35 193 J Antibiotic Emergency et al: R, Ann Intern Med 1997; Ann Intern Tur-Kaspa M, Brezis K, L: I, Pagliaro G, Pietrosi G, Tarantino Pateron D, Vicaut E, Debuc E, et E, et E, Debuc infusion al. Erythromycin D, Vicaut Pateron a bleeding: gastrointestinal upper for lavage gastric or Emerg Med Ann trial. controlled randomized multicenter 2011; 57:582. octreotide or S. Somatostatin TF, Birgisson Imperiale in the and placebo with H2 antagonists compared upper gastrointestinal nonvariceal acute of management a meta-analysis. hemorrhage: 127:1062. D’Amico bleeding for variceal drugs vasoactive sclerotherapy versus A Cochrane meta-analysis. 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