rapid overview of emergency management of gastrointestinal bleeding

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🌱 來自: initial management of gastrointestinal bleeding

rapid overview of emergency management of gastrointestinal bleeding🚧 施工中

Major causes

Peptic ulcer, esophagogastric varices, arteriovenous malformation, tumor, esophageal (Mallory-Weiss) tear

Clinical features

History

• Use of: NSAIDs, aspirin, anticoagulants, antiplatelet agents
• Alcohol abuse, previous GI bleed, liver disease, coagulopathy
• Symptoms and signs: Abdominal pain, hematemesis or “coffee ground” emesis, passing melena/tarry stool (stool may be frankly bloody or maroon with massive or brisk upper GI bleeding)

Examination

• Tachycardia; orthostatic blood pressure changes suggest moderate to severe blood loss; hypotension suggests life-threatening blood loss (hypotension may be late finding in healthy younger adult)
• Rectal examination is performed to assess stool color (melena versus hematochezia versus brown)
• Significant abdominal tenderness accompanied by signs of peritoneal irritation (eg, involuntary guarding) suggests perforation

Diagnostic testing

• Obtain type and crossmatch for hemodynamic instability, severe bleeding, or high-risk patient; obtain type and screen for hemodynamically stable patient without signs of severe bleeding
• Obtain hemoglobin concentration (note that measurement may be inaccurate with acute severe hemorrhage), platelet count, coagulation studies (prothrombin time with INR), liver enzymes (AST, ALT), albumin, BUN, and creatinine
• Nasogastric lavage may be helpful if the source of bleeding is unclear (upper or lower GI tract) or to clean the stomach prior to endoscopy

Treatment

• Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output (if nasogastric tube in place)
• Do NOT give patient anything by mouth
• Establish two large bore IV lines (16 gauge or larger)
• Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD)
• Treat hypotension initially with rapid, bolus infusions of isotonic crystalloid (eg, 500 to 1000 mL per bolus; use smaller boluses and lower total volumes for patients with compromised cardiac function)

Transfusion:

• For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ration of RBCs, plasma, and platelets, as for trauma patients
• For hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCs
• For hemoglobin <8 g/dL (80 g/L) in high-risk patients (eg, older adult, coronary artery disease), transfuse 1 unit RBCs and reassess the patient’s clinical condition
• For hemoglobin <7 g/dL (70 g/L) in low-risk patients, transfuse 1 units RBCs and reassess the patient’s clinical condition
• Avoid over-transfusion with possible variceal bleeding
• Give plasma for coagulopathy or after transfusing four units of RBCs; give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or after transfusing four units of RBCs

Obtain immediate consultation with gastroenterologist; obtain surgical and interventional radiology consultation for any large-scale bleeding¶

Pharmacotherapy for all patients with suspected or known severe bleeding:

• Give a proton pump inhibitor:
• Evidence of active bleeding (eg, hematemesis, hemodynamic instability), give esomeprazole or pantoprazole, 80 mg IV
• No evidence of active bleeding, give esomeprazole or pantoprazole, 40 mg IV
• Endoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg IV

Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:

• Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour continuous IV infusion)
• Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone)

Balloon tamponade may be performed as a temporizing measure for patients with uncontrollable hemorrhage likely due to varices using any of several devices (eg, Sengstaken-Blakemore tube, Minnesota tube); tracheal intubation is necessary if such a device is to be placed; ensure proper device placement prior to inflation to avoid esophageal rupture

• An important but uncommon cause of gastrointestinal hemorrhage is vascular-enteric fistula, typically aortoduodenal fistula related to erosion of a prosthetic aortic graft.

• Minimally invasive techniques to control bleeding include sclerotherapy, embolization, and other vascular occlusion techniques. For patients with massive hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used to limit blood loss and support perfusion of vital organs until the sites of bleeding can be directly controlled.