Meckel's diverticulum medical therapy: Difference between revisions
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==Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula== | ==Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula== | ||
The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below. | The process of initial [[Cardiopulmonary resuscitation|resuscitation]] in patients with [[lower gastrointestinal bleeding]] due to any [[pathology]] (including Meckel's diverticulum) is similar and includes the steps enlisted below. | ||
===Initial Evaluation=== | ===Initial Evaluation=== | ||
*In patients with [[Acute (medicine)|acute]] [[lower gastrointestinal bleeding]] who are unstable rapid assessment and [[Cardiopulmonary resuscitation|resuscitation]] should be initiated even before diagnostic evaluation.<ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid19881516">{{cite journal |vauthors=Barnert J, Messmann H |title=Diagnosis and management of lower gastrointestinal bleeding |journal=Nat Rev Gastroenterol Hepatol |volume=6 |issue=11 |pages=637–46 |year=2009 |pmid=19881516 |doi=10.1038/nrgastro.2009.167 |url=}}</ref><ref name="pmid18346685">{{cite journal |vauthors=Barnert J, Messmann H |title=Management of lower gastrointestinal tract bleeding |journal=Best Pract Res Clin Gastroenterol |volume=22 |issue=2 |pages=295–312 |year=2008 |pmid=18346685 |doi=10.1016/j.bpg.2007.10.024 |url=}}</ref><ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid24294124">{{cite journal |vauthors=Raphaeli T, Menon R |title=Current treatment of lower gastrointestinal hemorrhage |journal=Clin Colon Rectal Surg |volume=25 |issue=4 |pages=219–27 |year=2012 |pmid=24294124 |pmc=3577609 |doi=10.1055/s-0032-1329393 |url=}}</ref><ref name="pmid23737154">{{cite journal |vauthors=Ghassemi KA, Jensen DM |title=Lower GI bleeding: epidemiology and management |journal=Curr Gastroenterol Rep |volume=15 |issue=7 |pages=333 |year=2013 |pmid=23737154 |pmc=3857214 |doi=10.1007/s11894-013-0333-5 |url=}}</ref><ref name="pmid21603524">{{cite journal |vauthors=Beck DE, Margolin DA, Whitlow CB, Hammond KL |title=Evaluation and management of gastrointestinal bleeding |journal=Ochsner J |volume=7 |issue=3 |pages=107–13 |year=2007 |pmid=21603524 |pmc=3096402 |doi= |url=}}</ref><ref name="pmid23018607">{{cite journal |vauthors=Triadafilopoulos G |title=Management of lower gastrointestinal bleeding in older adults |journal=Drugs Aging |volume=29 |issue=9 |pages=707–15 |year=2012 |pmid=23018607 |doi=10.1007/s40266-012-0008-1 |url=}}</ref> | *In patients with [[Acute (medicine)|acute]] [[lower gastrointestinal bleeding]] who are unstable, rapid assessment and [[Cardiopulmonary resuscitation|resuscitation]] should be initiated even before diagnostic evaluation.<ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid19881516">{{cite journal |vauthors=Barnert J, Messmann H |title=Diagnosis and management of lower gastrointestinal bleeding |journal=Nat Rev Gastroenterol Hepatol |volume=6 |issue=11 |pages=637–46 |year=2009 |pmid=19881516 |doi=10.1038/nrgastro.2009.167 |url=}}</ref><ref name="pmid18346685">{{cite journal |vauthors=Barnert J, Messmann H |title=Management of lower gastrointestinal tract bleeding |journal=Best Pract Res Clin Gastroenterol |volume=22 |issue=2 |pages=295–312 |year=2008 |pmid=18346685 |doi=10.1016/j.bpg.2007.10.024 |url=}}</ref><ref name="pmid26925883">{{cite journal |vauthors=Strate LL, Gralnek IM |title=ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding |journal=Am. J. Gastroenterol. |volume=111 |issue=4 |pages=459–74 |year=2016 |pmid=26925883 |pmc=5099081 |doi=10.1038/ajg.2016.41 |url=}}</ref><ref name="pmid24294124">{{cite journal |vauthors=Raphaeli T, Menon R |title=Current treatment of lower gastrointestinal hemorrhage |journal=Clin Colon Rectal Surg |volume=25 |issue=4 |pages=219–27 |year=2012 |pmid=24294124 |pmc=3577609 |doi=10.1055/s-0032-1329393 |url=}}</ref><ref name="pmid23737154">{{cite journal |vauthors=Ghassemi KA, Jensen DM |title=Lower GI bleeding: epidemiology and management |journal=Curr Gastroenterol Rep |volume=15 |issue=7 |pages=333 |year=2013 |pmid=23737154 |pmc=3857214 |doi=10.1007/s11894-013-0333-5 |url=}}</ref><ref name="pmid21603524">{{cite journal |vauthors=Beck DE, Margolin DA, Whitlow CB, Hammond KL |title=Evaluation and management of gastrointestinal bleeding |journal=Ochsner J |volume=7 |issue=3 |pages=107–13 |year=2007 |pmid=21603524 |pmc=3096402 |doi= |url=}}</ref><ref name="pmid23018607">{{cite journal |vauthors=Triadafilopoulos G |title=Management of lower gastrointestinal bleeding in older adults |journal=Drugs Aging |volume=29 |issue=9 |pages=707–15 |year=2012 |pmid=23018607 |doi=10.1007/s40266-012-0008-1 |url=}}</ref> | ||
*The initial steps in the management of a patient with [[lower gastrointestinal bleeding]] are to assess the severity of [[bleeding]], and then institute [[fluid]] and other measures of resuscitation as needed. | *The initial steps in the management of a patient with [[lower gastrointestinal bleeding]] are to assess the severity of [[bleeding]], and then institute [[fluid]] and other measures of resuscitation as needed. | ||
*Once [[Hemodynamics|hemodynamic]] stability is achieved, nasogastric lavage should be performed to rule | *Once [[Hemodynamics|hemodynamic]] stability is achieved, nasogastric lavage should be performed to rule out an [[Upper gastrointestinal bleeding|upper GI]] source. | ||
*Equilibration between the [[Blood vessel|intravascular]] and extravascular volumes cannot be achieved until 24 to 72 hours after [[bleeding]] has occurred. | *Equilibration between the [[Blood vessel|intravascular]] and extravascular volumes cannot be achieved until 24 to 72 hours after [[bleeding]] has occurred. | ||
===Role of Nasogastric tube (NGT)=== | ===Role of Nasogastric tube (NGT)=== | ||
*[[Gastric lavage|Nasogastric tube (NGT) lavage]] is recommended in all [[Patient|patients]] with [[lower gastrointestinal bleeding]] once the [[patient]] is stabilized. | *[[Gastric lavage|Nasogastric tube (NGT) lavage]] is recommended in all [[Patient|patients]] with [[lower gastrointestinal bleeding]], once the [[patient]] is stabilized. | ||
*A carefully placed [[Nasogastric intubation|nasogastric tube (NGT)]] with irrigation and [[Aspiration (medicine)|aspiration]] of [[bile]] is necessary to ensure sampling of [[Duodenum|duodenal]] contents. | *A carefully placed [[Nasogastric intubation|nasogastric tube (NGT)]] with irrigation and [[Aspiration (medicine)|aspiration]] of [[bile]] is necessary to ensure sampling of [[Duodenum|duodenal]] contents. | ||
*If there is a bloody [[Nasogastric intubation|NGT]] aspirate, then an [[esophagogastroduodenoscopy]] ([[Esophagogastroduodenoscopy|EGD]]) is warranted (11 to 15% of cases of “negative” [[Nasogastric intubation|NGT]] aspirates are due to [[Upper gastrointestinal bleeding|upper GI bleeding]]). | *If there is a bloody [[Nasogastric intubation|NGT]] aspirate, then an [[esophagogastroduodenoscopy]] ([[Esophagogastroduodenoscopy|EGD]]) is warranted (11 to 15% of cases of “negative” [[Nasogastric intubation|NGT]] aspirates are due to [[Upper gastrointestinal bleeding|upper GI bleeding]]). | ||
| Line 53: | Line 53: | ||
* 2 large-bore, peripheral intravenous lines | * 2 large-bore, peripheral intravenous lines | ||
* Can consider [[Central venous catheter|large-bore central venous catheter]] or [[Intraosseous infusion|intraosseous]] line if rapid | * Can consider [[Central venous catheter|large-bore central venous catheter]] or [[Intraosseous infusion|intraosseous]] line if rapid transfusion is needed | ||
|- | |- | ||
|'''Blood transfusion''' | |'''Blood transfusion''' | ||
| | | | ||
* Resuscitate with 1:1:1 of packed [[Red blood cell|red blood cells]] (PRBCs) to [[fresh frozen plasma]] ([[Fresh frozen plasma|FFP]]) to [[Platelet|platelets]] | * Resuscitate with 1:1:1 of packed [[Red blood cell|red blood cells]] (PRBCs) to [[fresh frozen plasma]] ([[Fresh frozen plasma|FFP]]) to [[Platelet|platelets]] | ||
* Consider massive [[Blood transfusion|transfusion]] protocol | * Consider massive [[Blood transfusion|transfusion]] protocol | ||
| Line 85: | Line 85: | ||
*Two large caliber (16-gauge) peripheral catheters or a [[Central venous catheter|central venous line]] should be inserted in patients who are [[hemodynamically unstable]]. | *Two large caliber (16-gauge) peripheral catheters or a [[Central venous catheter|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]]. | *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 lactate|Ringer's solution]] over 30 minutes is preferred treatment for patients with [[Bleeding|active bleeding]] before [[Blood type|blood type matching]] and blood [[transfusion]]. | *Infusion of 500 mL of [[normal saline]] or lactated [[Ringer's lactate|Ringer's solution]] over 30 minutes is the preferred treatment for patients with [[Bleeding|active bleeding]] before [[Blood type|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 complications of fluid overload. | *Intensive monitoring with a [[pulmonary artery catheter]] is recommended to monitor the response of initial resuscitation efforts and any complications of [[fluid]] overload. | ||
*If the [[blood pressure]] fails to respond to initial [[Cardiopulmonary resuscitation|resuscitation]], the rate of [[fluid]] administration should be increased and urgent intervention (eg, [[Angiogram|angiography]]) considered. | *If the [[blood pressure]] fails to respond to initial [[Cardiopulmonary resuscitation|resuscitation]], the rate of [[fluid]] administration should be increased and urgent intervention (eg, [[Angiogram|angiography]]) should be considered. | ||
===Blood transfusion=== | ===Blood transfusion=== | ||
*Patients with severe [[bleeding]] need to be transfused.<ref name="pmid24063362">{{cite journal |vauthors=Al-Jaghbeer M, Yende S |title=Blood transfusion for upper gastrointestinal bleeding: is less more again? |journal=Crit Care |volume=17 |issue=5 |pages=325 |year=2013 |pmid=24063362 |pmc=4056793 |doi=10.1186/cc13020 |url=}}</ref><ref name="pmid23281973">{{cite journal |vauthors=Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C |title=Transfusion strategies for acute upper gastrointestinal bleeding |journal=N. Engl. J. Med. |volume=368 |issue=1 |pages=11–21 |year=2013 |pmid=23281973 |doi=10.1056/NEJMoa1211801 |url=}}</ref> | *Patients with severe [[bleeding]] need to be transfused.<ref name="pmid24063362">{{cite journal |vauthors=Al-Jaghbeer M, Yende S |title=Blood transfusion for upper gastrointestinal bleeding: is less more again? |journal=Crit Care |volume=17 |issue=5 |pages=325 |year=2013 |pmid=24063362 |pmc=4056793 |doi=10.1186/cc13020 |url=}}</ref><ref name="pmid23281973">{{cite journal |vauthors=Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C |title=Transfusion strategies for acute upper gastrointestinal bleeding |journal=N. Engl. J. Med. |volume=368 |issue=1 |pages=11–21 |year=2013 |pmid=23281973 |doi=10.1056/NEJMoa1211801 |url=}}</ref> | ||
*[[Fresh frozen plasma|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]]. | *[[Fresh frozen plasma|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]]. | ||
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| Line 110: | Line 110: | ||
===Triage and consultations === | ===Triage and consultations === | ||
* | *Visible [[rectal]] [[bleeding]] warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of [[bleeding]] and the [[patient]] [[Comorbidity|comorbidities]]. | ||
*A gastroenterology consultation should be obtained early in the hospital course of patients with acute [[Lower gastrointestinal bleeding|lower GI bleeding]]. | *A [[gastroenterology]] consultation should be obtained early in the [[hospital]] course of [[Patient|patients]] with acute [[Lower gastrointestinal bleeding|lower GI bleeding]]. | ||
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! colspan="1" style="background:#efefef;" |Evaluation setting | ! colspan="1" style="background:#efefef;" |Evaluation setting | ||
Revision as of 23:37, 4 January 2018
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Meckel's diverticulum medical therapy On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Iron replacement to correct anemia. In major bleeding, a blood transfusion may be needed.
Medical Therapy
- Initial medical management of symptomatic Meckel's diverticulum is directed toward management of clinical manifestations of complicated cases of Meckel's diverticulum associated with:[1][2][3][4][5][6][7][8][9][10][11]
- In order to manage complications, treatment administered is as follows:
- Intravenous lines for:
- Fluid therapy
- Electrolyte therapy
- Nasogastric decompression for patients with symptoms and signs of intestinal obstruction
- For patients with gastrointestinal bleeding:
Initial Resuscitation in patients with lower gastrointestinal bleed due to Meckel's diverticula
The process of initial resuscitation in patients with lower gastrointestinal bleeding due to any pathology (including Meckel's diverticulum) is similar and includes the steps enlisted below.
Initial Evaluation
- In patients with acute lower gastrointestinal bleeding who are unstable, rapid assessment and resuscitation should be initiated even before diagnostic evaluation.[12][13][14][12][15][16][17][18]
- The initial steps in the management of a patient with lower gastrointestinal bleeding are to assess the severity of bleeding, and then institute fluid and other measures of resuscitation as needed.
- Once hemodynamic stability is achieved, nasogastric lavage should be performed to rule out an upper GI source.
- Equilibration between the intravascular and extravascular volumes cannot be achieved until 24 to 72 hours after bleeding has occurred.
Role of Nasogastric tube (NGT)
- Nasogastric tube (NGT) lavage is recommended in all patients with lower gastrointestinal bleeding, once the patient is stabilized.
- A carefully placed nasogastric tube (NGT) with irrigation and aspiration of bile is necessary to ensure sampling of duodenal contents.
- If there is a bloody NGT aspirate, then an esophagogastroduodenoscopy (EGD) is warranted (11 to 15% of cases of “negative” NGT aspirates are due to upper GI bleeding).
- Obtaining clear fluid favors a lower GI source of bleeding.
| Workup and Initial Management | |
|---|---|
| Initial Evaluation |
|
| Supportive Therapy |
|
| Blood transfusion |
|
Assessment of severity of bleeding
| Bleeding severity | Vital signs | Blood loss |
|---|---|---|
| Minor | Normal | <10% |
| Moderate | Postural hypotension | 10-20% |
| Severe | Shock | >25% |
Fluid resuscitation
- 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 the 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 complications of fluid overload.
- If the blood pressure fails to respond to initial resuscitation, the rate of fluid administration should be increased and urgent intervention (eg, angiography) should be considered.
Blood transfusion
- Patients with severe bleeding need to be transfused.[19][20]
- 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.
| Indications for transfusion | |
|---|---|
| Age | Target Hematocrit |
| Elderly patient ( >45) | 30% |
| Younger patient (<45) | 25% |
| Patients with portal hypertension | 28% |
Triage and consultations
- Visible rectal bleeding warrants an immediate evaluation in all cases. The timing and setting of the evaluation depends upon the severity of bleeding and the patient comorbidities.
- A gastroenterology consultation should be obtained early in the hospital course of patients with acute lower GI bleeding.
| Evaluation setting | Patient catagories |
|---|---|
| ICU | Patients with high-risk features |
| Outpatient | Patients with low-risk features† |
| Regular Ward | Most other patients can be admitted to a regular medical ward♦ |
| |
Risk stratification
- Clinical features can predict the risk of complications in patients with presumed acute lower GI bleeding. These features may also be used to categorize patients as either low or high risk.
- The presence of more number of high-risk features directly correlate with the likelihood of a poor outcome.
| High-risk features |
|---|
|
References
- ↑ Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, Mew D (2006). "Complications of Meckel's diverticula in adults". Can J Surg. 49 (5): 353–7. PMC 3207587. PMID 17152574.
- ↑ Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ (1994). "Surgical management of Meckel's diverticulum. An epidemiologic, population-based study". Ann. Surg. 220 (4): 564–8, discussion 568–9. PMC 1234434. PMID 7944666.
- ↑ Hong J, Park SB (2017). "A case of retroperitoneal abscess: A rare complication of Meckel's diverticulum". Int J Surg Case Rep. 41: 150–153. doi:10.1016/j.ijscr.2017.10.012. PMID 29078157.
- ↑ Lequet J, Menahem B, Alves A, Fohlen A, Mulliri A (2017). "Meckel's diverticulum in the adult". J Visc Surg. 154 (4): 253–259. doi:10.1016/j.jviscsurg.2017.06.006. PMID 28698005.
- ↑ Cotter TG, Buckley NS, Loftus CG (2017). "Approach to the Patient With Hematochezia". Mayo Clin. Proc. 92 (5): 797–804. doi:10.1016/j.mayocp.2016.12.021. PMID 28473039.
- ↑ Rosat A, Pérez E, Oaknin HH, Mendiz J, Hernández G, Barrera M (2016). "Spontaneous hemoperitoneum caused by meckel's diverticulum in an elder patient". Pan Afr Med J. 24: 314. doi:10.11604/pamj.2016.24.314.10384. PMC 5267917. PMID 28154669.
- ↑ Rattan KN, Singh J, Dalal P, Rattan A (2016). "Meckel's diverticulum in children: Our 12-year experience". Afr J Paediatr Surg. 13 (4): 170–174. doi:10.4103/0189-6725.194671. PMC 5154221. PMID 28051045.
- ↑ Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC (2017). "The many faces of Meckel's diverticulum and its complications". J Med Imaging Radiat Oncol. 61 (2): 225–231. doi:10.1111/1754-9485.12505. PMID 27492813.
- ↑ Chabowski M, Szymanska-Chabowska A, Dorobisz T, Janczak D, Jelen M, Janczak D (2016). "A massive bleeding from a gastrointestinal stromal tumor of a Meckel's diverticulum". Srp Arh Celok Lek. 144 (3–4): 219–21. PMID 27483571.
- ↑ Srisajjakul S, Prapaisilp P, Bangchokdee S (2016). "Many faces of Meckel's diverticulum and its complications". Jpn J Radiol. 34 (5): 313–20. doi:10.1007/s11604-016-0530-x. PMID 26932405.
- ↑ Alfa-Wali M, Wardle S, Nizar S, Bloom IT (2016). "Atypical presentation of a Meckel's diverticulum". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-214464. PMID 26884080.
- ↑ 12.0 12.1 Strate LL, Gralnek IM (2016). "ACG Clinical Guideline: Management of Patients With Acute Lower Gastrointestinal Bleeding". Am. J. Gastroenterol. 111 (4): 459–74. doi:10.1038/ajg.2016.41. PMC 5099081. PMID 26925883.
- ↑ Barnert J, Messmann H (2009). "Diagnosis and management of lower gastrointestinal bleeding". Nat Rev Gastroenterol Hepatol. 6 (11): 637–46. doi:10.1038/nrgastro.2009.167. PMID 19881516.
- ↑ Barnert J, Messmann H (2008). "Management of lower gastrointestinal tract bleeding". Best Pract Res Clin Gastroenterol. 22 (2): 295–312. doi:10.1016/j.bpg.2007.10.024. PMID 18346685.
- ↑ Raphaeli T, Menon R (2012). "Current treatment of lower gastrointestinal hemorrhage". Clin Colon Rectal Surg. 25 (4): 219–27. doi:10.1055/s-0032-1329393. PMC 3577609. PMID 24294124.
- ↑ Ghassemi KA, Jensen DM (2013). "Lower GI bleeding: epidemiology and management". Curr Gastroenterol Rep. 15 (7): 333. doi:10.1007/s11894-013-0333-5. PMC 3857214. PMID 23737154.
- ↑ Beck DE, Margolin DA, Whitlow CB, Hammond KL (2007). "Evaluation and management of gastrointestinal bleeding". Ochsner J. 7 (3): 107–13. PMC 3096402. PMID 21603524.
- ↑ Triadafilopoulos G (2012). "Management of lower gastrointestinal bleeding in older adults". Drugs Aging. 29 (9): 707–15. doi:10.1007/s40266-012-0008-1. PMID 23018607.
- ↑ Al-Jaghbeer M, Yende S (2013). "Blood transfusion for upper gastrointestinal bleeding: is less more again?". Crit Care. 17 (5): 325. doi:10.1186/cc13020. PMC 4056793. PMID 24063362.
- ↑ Villanueva C, Colomo A, Bosch A, Concepción M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santaló M, Muñiz E, Guarner C (2013). "Transfusion strategies for acute upper gastrointestinal bleeding". N. Engl. J. Med. 368 (1): 11–21. doi:10.1056/NEJMoa1211801. PMID 23281973.