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Lacerations of the gastroesophageal junction cause 5 10% of cases of upper gastrointestinal bleeding Many patients report a history of heavy alcohol use or retching Less than 10% have continued or recurrent bleeding
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Vascular anomalies are found throughout the gastrointestinal tract and may be the source of chronic or acute gastrointestinal bleeding They account for 7% of cases of acute upper tract bleeding Vascular ectasias (angiodysplasias) have a bright red stellate appearance They may be part of systemic conditions (hereditary hemorrhagic telangiectasia, CREST syndrome) or may occur sporadically There is an increased incidence in patients with chronic renal failure Dieulafoy s lesion is an aberrant, large-caliber submucosal artery, most commonly in the proximal stomach that causes recurrent, intermittent bleeding
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specific or O-negative blood Central venous pressure monitoring is desirable in some cases, but line placement should not interfere with rapid volume resuscitation A nasogastric tube should be placed in all patients with suspected active upper tract bleeding The aspiration of red blood or coffee grounds confirms an upper gastrointestinal source of bleeding, though 10% of patients with confirmed upper tract sources of bleeding have nonbloody aspirates especially when bleeding originates in the duodenum An aspirate of bright red blood indicates active bleeding and is associated with the highest risk of further bleeding, and complications, while a clear aspirate identifies patients at lower initial risk Erythromycin (250 mg) administered intravenously 30 minutes prior to upper endoscopy promotes gastric emptying of clots and improves quality of endoscopic examination Efforts to stop or slow bleeding by gastric lavage with large volumes of fluid are of no benefit and expose the patient to an increased risk of aspiration Periodic reaspiration of the nasogastric tube serves as an indicator of ongoing bleeding or rebleeding
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2 High risk Patients with active bleeding manifested by hematemesis or bright red blood on nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid resuscitation, serious comorbid medical illness, or evidence of advanced liver disease require admission to an intensive care unit (ICU) Emergent endoscopy should be performed after adequate resuscitation, usually within 12 hours 3 Low to moderate risk All other patients are admitted to a step-down unit or medical ward after appropriate stabilization for further evaluation and treatment Patients without evidence of active bleeding undergo nonemergent endoscopy usually within 12 24 hours In some centers, these patients undergo urgent upper endoscopy to help decide appropriate triage Based on the findings at endoscopy, patients deemed to be at low risk of rebleeding may be discharged and monitored as outpatients
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Specific treatment of the various causes of upper gastrointestinal bleeding is discussed elsewhere in this chapter The following general comments apply to most patients with bleeding
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B Blood Replacement
The amount of fluid and blood products required is based on assessment of vital signs, evidence of active bleeding from nasogastric aspirate, and laboratory tests Sufficient packed red blood cells should be given to maintain a hematocrit of 25 30% In the absence of continued bleeding, the hematocrit should rise 4% for each unit of transfused packed red cells Transfusion of blood should not be withheld from patients with brisk active bleeding regardless of the hematocrit It is desirable to transfuse blood in anticipation of the nadir hematocrit In actively bleeding patients, platelets are transfused if the platelet count is under 50,000/mcL and considered if there is impaired platelet function due to aspirin or clopidogrel use (regardless of the platelet count) Uremic patients (who also have dysfunctional platelets) with active bleeding are given three doses of desmopressin (DDAVP), 03 mcg/kg intravenously, at 12-hour intervals Fresh frozen plasma is administered for actively bleeding patients with a coagulopathy and an INR > 15 In the face of massive bleeding, 1 unit of fresh frozen plasma should be given for each 5 units of packed red blood cells transfused
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