What is the initial treatment for upper GI bleeding (UGIB)?

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
  • Print
Answer

The goal of medical therapy in upper gastrointestinal (GI) bleeding (UGIB) is to correct shock and coagulation abnormalities and to stabilize the patient so that further evaluation and treatment can proceed. In addition to intravenous (IV) fluids, patients may need transfusion of packed red blood cells. High doses of proton pump inhibitors (PPIs) may reduce the need for endoscopic therapy (see Treatment with proton pump inhibitors).

Various methodologies have been proposed to quantitate rebleeding risk (eg, Rockall score, Baylor score), with several instruments gaining more widespread acceptance. [74] The Blatchford score (range 0-23) in particular can reliably triage patients with presumed UGIB, to hospital discharge for outpatient management with a score of 0, representing a less than 1% chance of requiring intervention, [54] rather than inpatient admission and performance of endoscopy.

The 2008 Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of acute upper and lower GI bleeding recommends that an initial (pre-endoscopic) Rockall score be calculated for all patients presenting with an acute UGIB. In patients with an initial Rockall score >0, endoscopy is recommended for a full assessment of bleeding risk. [45]

Resuscitation of a hemodynamically unstable patient begins with assessing and addressing the "ABCs" (ie, airway, breathing, circulation) of initial management. (Baradarian et al demonstrated that early, aggressive resuscitation can reduce mortality in acute UGIB. [75] )

Patients presenting with severe blood loss and hemorrhagic shock present with mental status changes and confusion. In such circumstances, patients cannot protect their airway, especially when hematemesis is present. In these cases, patients are at an increased risk for aspiration, which is a potentially avoidable complication that can significantly affect morbidity and mortality. This situation must be recognized early, and patients should be electively intubated in a controlled setting. A multidisciplinary approach, with pulmonologists or intensivists in an intensive care unit (ICU) setting is desirable. Some centers have a dedicated GI bleeding team that utilizes treatment protocols beginning from the emergency department, progressing to the acute-care bed, assuring a controlled setting for endoscopy and delivering optimized in-hospital and postdischarge care.

Intravenous access must be obtained. Bilateral, 16-gauge (minimum), upper extremity, peripheral intravenous lines are adequate for volume resuscitative efforts. Poiseuille’s law states that the rate of flow through a tube is proportional to the fourth power of the radius of the cannula and is inversely related to its length. [27] Thus, short, large-bore, peripheral intravenous lines are adequate for rapid fluid infusion. The 2008 SIGN guideline indicates either colloid or crystalloid solutions may be used to attain volume restoration prior to administering blood products. [45]

There are remarkably few data on optimal fluid resuscitation pathways or algorithms, and very often the approach is based on the patient’s clinical presentation. The choice of fluids, infusion rates, and various in points are largely individual or institutionally driven.

A study published by Kaplan et al indicated that skin temperature on physical examination in combination with serum bicarbonate levels correlated well with the level of systemic perfusion. [76]  Foley catheter placement is helpful to allow a continuous evaluation of the urinary output as a guide to renal perfusion.

Patients with severe coexisting medical illnesses, such as cardiovascular and pulmonary diseases, may require pulmonary artery catheter insertion to closely monitor hemodynamic cardiac performance profiles during the early resuscitative phase.

After the ABCs have been addressed, assess the patient's response to resuscitation, based on evidence of end organ perfusion and oxygen delivery.

Consultation with a surgeon should be considered for all patients with GI hemorrhage. Depending on the patient’s comorbidities, subspecialty consultation is often needed and mirrors the trend in healthcare toward a multidisciplinary team approach.

Once the maneuvers to resuscitate are underway, it is often very helpful to insert a nasogastric tube and perform an aspirate and lavage procedure. This should be the first procedure performed to determine whether the GI bleeding is emanating from above or below the ligament of Treitz. If the stomach contains bile but no blood, UGIB is less likely. If the aspirate reveals clear gastric fluid, a duodenal site of bleeding may still be possible.

In a retrospective review of 1190 patients, Luk et al found that positive nasogastric-tube aspirate findings were 93% predictive of an upper GI source of bleeding. [77]

According to a study performed by the American Society for Gastrointestinal Endoscopy (ASGE), however, a nasogastric-tube aspirate finding can be negative even in the setting of a large duodenal bleeding ulcer. The study compared nasogastric-tube aspirate findings with endoscopic findings of the bleeding source. [33] The investigation revealed that 15.9% of patients with a clear nasogastric-tube aspirate, 29.9% of patients with coffee-ground aspirate, and 48.2% of patients with red blood aspirate had an active upper GI source of bleeding at the time of endoscopy.

A study correlated mortality with the color of the fluid from the nasogastric-tube aspirate and the color of the stool. [2] As shown in the following table, the color of the nasogastric-tube aspirate can be a prognostic indicator.

Table 4. Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortality Rate (Open Table in a new window)

Nasogastric Aspirate Color

Stool Color

Mortality, %

Clear

Brown or red

6

Coffee-ground

Brown or black

8.2

Red

19.1

Red blood

Black

12.3

Brown

19.4

Red

28.7

UGIB = upper gastrointestinal bleeding.

See Pediatric Gastrointestinal Bleeding for more information on this topic.


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!