Upper gastrointestinal bleeding medical therapy
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Upper gastrointestinal bleeding Microchapters |
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Differentiating Upper Gastrointestinal Bleeding from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Treatment
Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vitals signs are continuously monitored.
Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the lesion identifies, and can include:
- injection of adrenaline or other sclerotherapy
- electrocautery
- endoscopic clipping
- or banding of varices
Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.
Pharmacotherapy includes the following:
- Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding.
- Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America.
- Terlipressin is a somatostatin analog most commonly used in Europe for variceal upper GI hemorrhage.
- Antibiotics are prescribed in upper GI bleeds associated with portal hypertension
If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.
Refractory bleeding
Refractory cases of upper GI hemorrhage may require:
- Repeat esophagogastroduodenoscopy
- Anti-fibrinolytics, such as tranexamic acid
- Angiography to identify and possibly occlude the feeder vessel
- Recombinant Factor VII is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage
- Balloon tamponade
- Surgery, to oversew or remove the area of hemorrhage
Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion.