Gastrointestinal bleeding resident survival guide: Difference between revisions

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==Definition==
==Overview==
Gastrointestinal bleeding refers to any bleeding that occurs in gastrointestinal tract from the pharynx to the rectum.
Gastrointestinal bleeding refers to any bleeding that occurs in gastrointestinal tract from the pharynx to the rectum.


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* [[Gastric ulcer]]
* [[Gastric ulcer]]
* [[Gastric varices]]
* [[Gastric varices]]
* [[Aorto-entric fistula]]
* [[Aorto-enteric fistula]]
* [[Hemosuccus pancreaticus]]
* [[Hemosuccus pancreaticus]]
* [[Superior mesenteric artery syndrome]]
* [[Superior mesenteric artery syndrome]]


===Common Causes===
===Common Causes===
* [[Common cause 1]]
* Upper gastrointestinal bleeding
* [[Common cause 2]]
** [[Duodenal ulcer]]
* [[Common cause 3]]
** [[Esophageal ulcer]]
* [[Common cause 4]]
** [[Esophageal varices]]
* [[Common cause 5]]
** [[Gastric ulcer]]
** [[Gastritis]]
** [[Mallory-Weiss tear]]
* Lower gastrointestinal bleeding
** [[Angiodysplasia]]
** [[Anal fissure]]
** [[Colonic polyps]]
** [[Diverticulitis]]
** [[Diverticulosis]]
** [[Hemorrhoids]]
** [[Infectious colitis]]
** [[Infectious diarrhea]]
** [[Inflammatory bowel disease]]
** [[Ischemic colitis]]


==Management==
==Management==
Shown below is an algorithm summarizing the approach to <nowiki>[[disease name]]</nowiki>.
===Initial Work Up for GI bleed===
{{familytree/start |summary=PE diagnosis Algorithm.}}
Shown below is an algorithm summarizing the approach to <nowiki>[[Initial work up of GI bleed]]</nowiki>.
{{familytree | | | | | | | | A01 |A01= }}  
{{familytree/start |summary=GI bleed algorithm.}}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Patient with GI bleed}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=Assess airway, intubate if required<br>Assess circulation, 2IV bore lines<br>500ml NS<br>nil per oral<br>start PPI infusion (80mg bolus followed by 8mg/h infusion)}}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{familytree | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01=Send CBC, PT/PTT<br>blood type and cross match}}
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
{{familytree | | |,|-|-|^|-|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{familytree | | D01 | | | | D02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |D01=UGIB management see below<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref> <ref name="Gralnek-2008">{{Cite journal  | last1 = Gralnek | first1 = IM. | last2 = Barkun | first2 = AN. | last3 = Bardou | first3 = M. | title = Management of acute bleeding from a peptic ulcer. | journal = N Engl J Med | volume = 359 | issue = 9 | pages = 928-37 | month = Aug | year = 2008 | doi = 10.1056/NEJMra0706113 | PMID = 18753649 }}</ref> <ref name="Khamaysi-2013">{{Cite journal  | last1 = Khamaysi | first1 = I. | last2 = Gralnek | first2 = IM. | title = Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management. | journal = Best Pract Res Clin Gastroenterol | volume = 27 | issue = 5 | pages = 633-8 | month = Oct | year = 2013 | doi = 10.1016/j.bpg.2013.09.002 | PMID = 24160923 }}</ref>
{{familytree | | | | | | | | | | |!| | | | |!| }}
 
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
|D02=LGIB management see below<ref name="pmid9707037">Zuccaro G (1998) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=9707037 Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee.] ''Am J Gastroenterol'' 93 (8):1202-8. [http://dx.doi.org/10.1111/j.1572-0241.1998.00395.x DOI:10.1111/j.1572-0241.1998.00395.x] PMID: [http://pubmed.gov/9707037 9707037]</ref>
}}
{{familytree/end}}
 
===Approach to Upper GI Bleed===
Shown below is an algorithm summarizing the approach to <nowiki>[[Upper GI bleed]]</nowiki>
{{familytree/start |summary=GI bleed algorithm.}}
{{familytree | | | | | | | | | | | | | | | | Z01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Z01=History of coffee-ground emesis, dark stools, abdominal pain, past history of Peptic ulcer disease, NSAID use, liver failure}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | Y01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Y01=Consider Upper GI bleed}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01=Initial work up of GI bleed, see above}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=UGIB}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | Twinkle  | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Twinkle= Pre-endoscopy medications: IV infusion of erythromycin (250 mg for 30 minutes), IV PPI therapy.  If varices are suspected, give octreotide (50 mcg followed by 50 mcg/hr infusion, in patients with cirrhosis give prophylactic antibiotics (IV ciprofloxacin) }}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01=Early EGD}}
{{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | |}}
{{familytree | | | | D02 | | | | | | | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | |D02=Lesion not localised| D01=Lesion localised}}
{{familytree | | | | |!| | | | | | | | | | |,|-|-|-|-|-|-|-|-|-|v|-|-|^|-|-|v|-|-|-|-|-|-|-|-|.| | | | | | | | | |}}
{{familytree | | | | E05 | | | | | | | | | E01 | | | | | | | | E02 | | | | E03 | | | | | | | E04 | | | | | | |E05=Consider mid/ lower GI bleed|E01=peptic ulcer disease|E02=Varices|E03=Esophagitis/Gastritis|E04=[[Mallory-Weiss]] tear}}
{{familytree | | | | | | | | | |,|-|-|-|-|-|+|-|-|-|-|-|.| | | |!| | | | | |!| | | | | |,|-|-|^|-|-|.| | | | | | |}}
{{familytree | | | | | | | | | F01 | | | | F02 | | | | F03 | | |!| | | | | |!| | | | | F04 | | | | F05 | | | | | |F01=Active bleeding/ Non bleeding visible vessel|F02=Adherent clot|F03=Flat spot/ clean base|F04= bleeding actively| F05=If no active bleed}}
{{familytree | | | | | | | | | |!| | | | | |!| | | | | |!| | | |!| | | | | |!| | | | | |!| | | | | |!| | | | | | |}}
{{familytree | | | | | | | | | G01 | | | | G02 | | | | G03 | | G04 | | | | G05 | | | | G06 | | | | G07 | | | | | |G01=Endoscopic therapy + IV PPI therapy|G02=+/- Endoscopic therapy + IV PPI therapy|G03=No endoscopic therapy, no IV PPI therapy| G04=Ligation/ sclerotherapy| G05=PPI therapy|G06=Endoscopic therapy (cauterization/ epinephrin injection)| G07= Observation/ supportive management}}
{{familytree/end}}
 
===Approach to Lower GI Bleed===
Shown below is an algorithm summarizing the approach to <nowiki>[[Lower GI bleed]]</nowiki>
{{familytree/start |summary=Lower GI bleed algorithm.}}
{{familytree | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01= History of frank blood per rectum, blood mixed with stool}}
{{familytree | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=Consider LGIB}}
{{familytree | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | |C01=Initial work up, see above}}
{{familytree | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | | | | | | | | |D01=Rule out anorectal outlet bleed}}
{{familytree | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | | | |E01=Rule out UGIB}}
{{familytree | | | | | | | | |,|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | | F01 | | | | | | | | | | | | | | | | | F02 | | | | | | | | | | | | | | | | | |F01=Persistent active bleed|F02=Intermittent bleed}}
{{familytree | | | | | |,|-|-|^|-|-|.| | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | G01 | | | | G02 | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | |G01=Unstable patient (colonoscopy not possible)|G02=Stable patient}}
{{familytree | | | | | |!| | | | | |!| | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | |!| | | | | H01 |-|-|-|-|v|-|-|-|-|-|-|-|-| H02 | | | | | | | | | | | |H01=Colonoscopy|H02=Colonoscopy}}
{{familytree | | | |,|-|^|-|.| | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | I01 | | I02 | | | | | | I03 | | I04 | | | | | | | | | | | | | | | | | | | | | | | | | |I01=Brisk active bleeding|I02=Slow active bleeding|I03=Lesion not identified|I04=Lesion identified}}
{{familytree | | | |!| | | |!| | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | J01 | | J02 |-| J03 |-| J04 | | J05 | | | | | | | | | | | | | | | | | | | | | | | | | |J01=Angiography|J02=Tagged RBC scan|J03=Negative|J04=Small bowel series, capsule endoscopy|J05=Colonoscopic therapy}}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | K01 | | K02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |K01=Failes|K02=Positive}}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | L01 | | L02 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |L01=Surgery|L02=Angiography}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | | | | | M01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |M01=Surgery}}
{{familytree/end}}
{{familytree/end}}
==Do's==
* Assess haemodynamic status immediately and begin resuscitative measures if required.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* Blood transfusion required to maintain Hb>7mg/dl.
* Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb> 12.0 mg/dl in women, systolic blood pressure> 110 mmHg, pulse< 100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* In patients with UGIB endoscopy should be considered with in 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
* Endoscopic therapy considered in patients with adherent clot which is resistant to vigorous irrigation.
* For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone. (Conditional recommendation)
* After endoscopic therapy, patients with actively bleeding ulcer, non bleeding visible vessel and adherent clot should be given IV PPI therapy (80 mg bolus infusion followed by 8 mg/h infusion) for 72 hours. <ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
==Dont's==
* Nasogastric lavage is not required in patients with UGIB.  (Conditional recommendation)<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* Epinephrin therapy should not be used alone.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>


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Latest revision as of 11:37, 13 March 2014

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

Overview

Gastrointestinal bleeding refers to any bleeding that occurs in gastrointestinal tract from the pharynx to the rectum.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Initial Work Up for GI bleed

Shown below is an algorithm summarizing the approach to [[Initial work up of GI bleed]].

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with GI bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess airway, intubate if required
Assess circulation, 2IV bore lines
500ml NS
nil per oral
start PPI infusion (80mg bolus followed by 8mg/h infusion)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Send CBC, PT/PTT
blood type and cross match
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UGIB management see below[1] [2] [3]
 
 
 
LGIB management see below[4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Approach to Upper GI Bleed

Shown below is an algorithm summarizing the approach to [[Upper GI bleed]]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of coffee-ground emesis, dark stools, abdominal pain, past history of Peptic ulcer disease, NSAID use, liver failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider Upper GI bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial work up of GI bleed, see above
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UGIB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-endoscopy medications: IV infusion of erythromycin (250 mg for 30 minutes), IV PPI therapy. If varices are suspected, give octreotide (50 mcg followed by 50 mcg/hr infusion, in patients with cirrhosis give prophylactic antibiotics (IV ciprofloxacin)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Early EGD
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lesion not localised
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lesion localised
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider mid/ lower GI bleed
 
 
 
 
 
 
 
 
peptic ulcer disease
 
 
 
 
 
 
 
Varices
 
 
 
Esophagitis/Gastritis
 
 
 
 
 
 
Mallory-Weiss tear
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Active bleeding/ Non bleeding visible vessel
 
 
 
Adherent clot
 
 
 
Flat spot/ clean base
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
bleeding actively
 
 
 
If no active bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopic therapy + IV PPI therapy
 
 
 
+/- Endoscopic therapy + IV PPI therapy
 
 
 
No endoscopic therapy, no IV PPI therapy
 
Ligation/ sclerotherapy
 
 
 
PPI therapy
 
 
 
Endoscopic therapy (cauterization/ epinephrin injection)
 
 
 
Observation/ supportive management
 
 
 
 
 

Approach to Lower GI Bleed

Shown below is an algorithm summarizing the approach to [[Lower GI bleed]]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of frank blood per rectum, blood mixed with stool
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider LGIB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial work up, see above
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out anorectal outlet bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out UGIB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent active bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intermittent bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient (colonoscopy not possible)
 
 
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
Colonoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Brisk active bleeding
 
Slow active bleeding
 
 
 
 
 
Lesion not identified
 
Lesion identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Angiography
 
Tagged RBC scan
 
Negative
 
Small bowel series, capsule endoscopy
 
Colonoscopic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Failes
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Assess haemodynamic status immediately and begin resuscitative measures if required.[1]
  • Blood transfusion required to maintain Hb>7mg/dl.
  • Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb> 12.0 mg/dl in women, systolic blood pressure> 110 mmHg, pulse< 100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.[1]
  • In patients with UGIB endoscopy should be considered with in 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
  • Endoscopic therapy considered in patients with adherent clot which is resistant to vigorous irrigation.
  • For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone. (Conditional recommendation)
  • After endoscopic therapy, patients with actively bleeding ulcer, non bleeding visible vessel and adherent clot should be given IV PPI therapy (80 mg bolus infusion followed by 8 mg/h infusion) for 72 hours. [1]

Dont's

  • Nasogastric lavage is not required in patients with UGIB. (Conditional recommendation)[1]
  • Epinephrin therapy should not be used alone.[1]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Laine L, Jensen DM (2012). "Management of patients with ulcer bleeding". Am J Gastroenterol. 107 (3): 345–60, quiz 361. doi:10.1038/ajg.2011.480. PMID 22310222.
  2. Gralnek, IM.; Barkun, AN.; Bardou, M. (2008). "Management of acute bleeding from a peptic ulcer". N Engl J Med. 359 (9): 928–37. doi:10.1056/NEJMra0706113. PMID 18753649. Unknown parameter |month= ignored (help)
  3. Khamaysi, I.; Gralnek, IM. (2013). "Acute upper gastrointestinal bleeding (UGIB) - initial evaluation and management". Best Pract Res Clin Gastroenterol. 27 (5): 633–8. doi:10.1016/j.bpg.2013.09.002. PMID 24160923. Unknown parameter |month= ignored (help)
  4. Zuccaro G (1998) Management of the adult patient with acute lower gastrointestinal bleeding. American College of Gastroenterology. Practice Parameters Committee. Am J Gastroenterol 93 (8):1202-8. DOI:10.1111/j.1572-0241.1998.00395.x PMID: 9707037


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