Upper gastrointestinal bleeding initial resuscitation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

In patients with acute upper GI bleeding who are unstable rapid assessment and resuscitation should be initiated even before diagnostic evaluation. The initial steps in the management of a patient with UGIB is to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed. Once hemodynamic stability is achieved, a proper clinical history, physical examination, and initial laboratory findings are crucial not only in determining the likely sources of bleeding but also in directing the appropriate intervention. Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred. Nasogastric lavage should be performed if the presence or source of bleeding is unknown. Upper gastrointestinal endoscopy is the primary diagnostic tool, performed for both diagnosis and treatment of active bleeding. The American Society for Gastrointestinal Endoscopy guidelines recommends upper endoscopy within 24 hours of presentation in all patients with UGIB. Angiography and tagged erythrocyte scan are rarely needed but may be used to diagnose active UGIB, particularly in patients where EGD is contraindicated. Also, upper gastrointestinal tract radiographic studies using barium are generally not advised, as they may obscure visualization during EGD.

Initial Management

Management of upper GI bleeding includes:

Initial resuscitation

• The initial steps in the management of a patient with UGIB is to assess the severity of bleeding, and then institute fluid and blood resuscitation as needed.
• Any patient with hemodynamic instability or who is actively bleeding should be admitted to the ICU for monitoring and resuscitation
• The patient’s hemodynamic status is of great importance in determining the degree of severity and triage status.

Criteria for Admission of patient
Age >60yr Transfusion required. Initial Sys BP < 100. Red blood in NG lavage. History of cirrhosis or ascites on examination.

Supportive Therapy

• Supportive care includes administration of supplemental oxygen, IV fluid administration, and monitoring of urine output.
• Two large caliber (16-gauge) peripheral catheters or a central venous line should be inserted in patients who are hemodynamically unstable.
• The rate of fluid resuscitation is proportional to the severity of bleeding with the goal of restoring and maintaining the patient’s blood pressure.
• Infusion of 500 mL of normal saline or lactated Ringer's solution over 30 minutes is preferred treatment for patients with active bleeding before blood type matching and blood transfusion.
• Intensive monitoring with a pulmonary artery catheter is recommended to monitor the response of initial resuscitation efforts and any falls in blood pressure:

Correlation between physical signs and the severity of upper gastrointestinal bleeding
Physical signs	Bleeding severity
	Mild	Moderate	Severe
Blood loss	<1L	1-2L	>2L
Systolic blood pressure	<120	100-119	<99
Orthostasis	-	-	+
Tachycardia	<100	101-120	>140
Skin	Warm, well perfused	Diaphoretic	Cool–cold, clammy
Urine output(ml/hour)	>25	10-25	Negligible
Respiratory rate	14-20	20-30	>35
Sensorium	Alert	Anxious	Confused/Drowsy

Blood transfusion

• Patients with severe bleeding will need to be transfused:

Indications for transfusion Based on the patient’s age and presence of comorbid conditions.
AGE	Target Hematocrit
Elderly patient ( >45)	30%
Younger patient (<45)	25%
patients with portal hypertension	28%

• Fresh frozen plasma, platelets, or both should be given to patients with coagulopathy who are actively bleeding and to those who have received more than 10 units of packed erythrocytes:

WORKUP AND INITIAL TREATMENT Initial Resuscitation
Initial Evaluation	Airway Breathing, Circulation
Supportive Therapy	Ensure patent and protected airway. Intubate if needed. Consider mechanical ventilation. 2 large-bore, peripheral intravenous lines. Can consider large-bore central venous catheter or intraosseous line if rapid transfuser will be needed.
Blood transfusion	Resuscitate with 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets. Consider massive transfusion protocol. Resuscitate to a target hemoglobin of 7 mg/dL. Consider Sengstaken-Blakemore tube for control of immediately life-threatening upper GI bleeding.

National Institute for Health and Care Excellence (NICE) guidline

The National Institute for Health and Care Excellence (NICE) guidline on blood product management in upper GI bleeding:

• Platelets should only be given if the patient is actively bleeding or hemodynamically unstable and has a platelet count of <50×109/L.
• Fresh frozen plasma should be given if the fibrinogen level is <1 g/L or the prothrombin time (PT) or activated partial thromboplastin time is >1.5 times normal.
• Prothrombin complex should be provided to those on warfarin and actively bleeding.
• Recombinant factor VIIa should only be used when all of the above measures have failed.

Acute GI bleeding

Initial evaluation and resuscitation

Uppe GI endoscopy

Source found

Undiagnostic

Specific Treatment

Unstable

Stable

Urgent CT

Repeat Endoscopy/Angiograpghy

No source identified

Angioembolization

Endoscopic intervention

TIPS

Surgery

Surgery (Laprotomy)

Sclerotherapy

Banding

Injection

Thermocoagulation

Clips

Upper GI bleeding. Adapted from ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding