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A History and Physical Examination
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The physician s impression of the bleeding source is correct in only 40% of cases Signs of chronic liver disease implicate bleeding due to portal hypertension, but a different lesion is identified in 25% of patients with cirrhosis A history of dyspepsia, NSAID use, or peptic ulcer disease suggests peptic ulcer Acute bleeding preceded by heavy alcohol ingestion or retching suggests a Mallory-Weiss tear, though most of these patients have neither
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Virtually all patients with upper tract bleeding should undergo upper endoscopy within 24 hours of arriving in the emergency department The benefits of endoscopy in this setting are threefold 1 To identify the source of bleeding The appropriate acute and long-term medical therapy is determined by the cause of bleeding Patients with portal hypertension will be treated differently from those with ulcer disease If surgery is required for uncontrolled bleeding, the source of bleeding as determined at endoscopy will determine the approach 2 To determine the risk of rebleeding Patients with a nonbleeding Mallory-Weiss tear, esophagitis, gastritis, and ulcers that have a clean, white base have a very low risk of rebleeding It may be safe and cost-effective to discharge such patients from the emergency department or from the medical ward with subsequent outpatient follow-up Patients with ulcers that are actively bleeding or have a visible vessel or who have variceal bleeding require closer observation in an ICU or step down unit 3 To render endoscopic therapy Hemostasis can be achieved in actively bleeding lesions with endoscopic
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A preliminary assessment of risk based on several clinical factors aids in the resuscitation as well as the rational triage of the patient Clinical predictors of increased risk of rebleeding and death include age > 60 years, comorbid illnesses, systolic blood pressure < 100 mm Hg, pulse > 100 beats/min, and bright red blood in the nasogastric aspirate or on rectal examination 1 Very low risk Reliable patients without serious comorbid medical illnesses or advanced liver disease who have normal hemodynamics, no evidence of overt bleeding (hematemesis or melena) within 48 hours, a negative nasogastric lavage, and normal laboratory tests do not require hospital admission and can undergo further evaluation as outpatients as indicated
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Bardou M et al Meta-analysis: proton-pump inhibition in highrisk patients with acute peptic ulcer bleeding Aliment Pharmacol Ther 2005 Mar 15;21(6):677 86 [PMID: 15771753] Carbonell N et al Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial Am J Gastroenterol 2006 Jun;101 (6):1211 5 [PMID: 16771939] Das A et al Prediction of outcome of acute GI hemorrhage: a review of risk scores and predictive models Gastrointest Endosc 2004 Jul;60(1):85 93 [PMID: 15229431] Esrailian E et al Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis Gastroenterol Clin North Am 2005 Dec;34(4):589 605 [PMID: 16303572] Targownik LA et al Trends in management and outcomes of acute nonvariceal upper gastrointestinal bleeding: 1993 2003 Clin Gastroenterol Hepatol 2006 Dec;4(12):1459 1466 [PMID: 17101296]
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modalities such as cautery, injection, or endoclips About 90% of bleeding or nonbleeding varices can be effectively treated immediately with injection of a sclerosant or application of rubber bands to the varices Similarly, 90% of bleeding ulcers, angiomas, or Mallory-Weiss tears can be controlled with either injection of epinephrine, direct cauterization of the vessel by a heater probe or multipolar electrocautery probe, or application of an endoclip Certain nonbleeding lesions such as ulcers with visible blood vessels, and angiomas are also treated with these therapies Specific endoscopic therapy of varices, peptic ulcers, and Mallory-Weiss tears is dealt with elsewhere in this chapter
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1 Acid inhibitory therapy H2-receptor antagonists do not stop acute bleeding or reduce the incidence of rebleeding Intravenous proton pump inhibitors (esomeprazole or pantoprazole, 80 mg bolus, followed by 8 mg/h continuous infusion for 72 hours) reduce the risk of rebleeding in patients with peptic ulcers with high-risk features (active bleeding, visible vessel, or adherent clot) after endoscopic treatment Intravenous lansoprazole has been withdrawn from the US market by the FDA, so is no longer used for this indication High doses of oral proton pump inhibitors (esomeprazole 40 mg or lansoprazole 60 mg, twice daily for 5 days) may also be effective Pending the results of endoscopic examination, it may be reasonable to initiate therapy with a high-dose proton pump inhibitor (intravenously or orally) in patients with suspected peptic ulcer bleeding 2 Octreotide Continuous intravenous infusion of octreotide (100 mcg bolus, followed by 50 100 mcg/h) reduces splanchnic blood flow and portal blood pressures and is effective in the initial control of bleeding related to portal hypertension It is administered promptly to all patients with active upper gastrointestinal bleeding and evidence of liver disease or portal hypertension until the source of bleeding can be determined by endoscopy 3 Vasoactive agents Intravenous vasopressin is no longer used in the treatment of upper gastrointestinal bleeding In countries where it is available, terlipressin may be preferred to octreotide for the treatment of bleeding related to portal hypertension because of its sustained reduction of portal and variceal pressures and its proven reduction in mortality
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