วันอาทิตย์ที่ 23 พฤศจิกายน พ.ศ. 2568

Acute Upper GI Bleeding

 🩺 Acute Upper GI Bleeding

DEFINITION

Upper GI bleeding = เลือดออก proximal to ligament of Treitz
Typical presentations:

  • Hematemesis – red blood หรือ coffee-ground
  • Melena – black tarry stool (LR 5–6)
  • Hematochezia – อาจพบใน massive UGI bleed (~10–15%)

CLINICAL PRESENTATION & INITIAL EVALUATION

Key symptoms

  • Hematemesis → upper source
  • Melena → 90% upper source
  • Hematochezia → severe rapid upper bleed possible
  • Occult bleeding → anemia symptoms

Evaluate hemodynamic stability

Signs of hypovolemia

  • HR >100
  • Orthostatic hypotension
  • Hypotension in supine
  • Cold/clammy skin, confusion, presyncope, angina

Important point: Hb อาจยังไม่ลดทันที (equilibration 24–72 hr)

Important history

  • Cirrhosis → varices, PHG
  • NSAIDs, antiplatelets, anticoagulants → PUD
  • H. pylori history → ulcer
  • Prior aortic graft → aortoenteric fistula
  • Alcohol → erosions, ulcer
  • Cardiovascular disease → higher Hb threshold
  • CKD/HF → risk of fluid overload

Physical exam

  • Melena → LR 24 for UGI source
  • Severe tenderness/rebound → consider perforation → do not scope
  • Look for cirrhosis signs (ascites, jaundice)

Labs

  • CBC, BMP, LFTs, coags
  • BUN/Cr ratio >30:1 หรือ >100:1 → suggest UGI bleed
  • ECG + troponins for CAD patients
  • Monitor Hb q2–12 hr

IMMEDIATE MANAGEMENT

Triage

  • Unstable/active bleeding → ICU
  • Early GI consult in all patients
  • Consider surgery/IR early if:
    • rapid exsanguination
    • suspected aortoenteric fistula
    • pseudoaneurysm
  • OPD case สามารถทำได้ ถ้า Glasgow-Blatchford score (GBS) 0-1 โดยสามารถกลับมารพ.ได้ทันที + F/U GI ภายใน 3 วัน ให้ oral PPI standard dose

Intravenous Access

  • Unstable → 2 × 16G or large-bore central (Cordis)
  • Stable → 2 × 18G

Fluid resuscitation

  • Unstable → bolus crystalloid 500–1000 mL; reassess
  • Avoid overload in CKD/HF
  • Consider pressors in shock

NPO

All patients remain NPO until endoscopic plan defined.

PRE-ENDOSCOPIC MEDICATIONS

Proton Pump Inhibitors (PPI)

Use if hemodynamic instability or ongoing bleeding:

  • Esomeprazole 80 mg IV bolus → repeat 40 mg IV if scope delayed >12 hr
  • PPI before endoscopy ↓need for endoscopic therapy but not mortality

Suspected Variceal Bleed

  • Octreotide infusion (or terlipressin outside US)
  • Ceftriaxone prophylaxis
  • Avoid PPI unless nonvariceal cause suspected

Pre-endoscopy prokinetic

Erythromycin 250 mg IV 30–90 min before endoscopy →

  • Better visualization
  • ↓need for second-look

Metoclopramide not recommended

 TRANSFUSION & COAGULATION MANAGEMENT

1. Packed RBC (PRBC)

Restrictive strategy preferred:

  • Transfuse if Hb <7 g/dL
  • Maintain Hb ≥7 g/dL
    Evidence: Lower mortality & rebleeding vs threshold 9 g/dL.

Exceptions

  • CAD, ACS → higher target (see disease-specific guidelines)

Massive Bleeding

Do NOT wait for Hb; transfuse based on hemodynamics.

2. Platelets

  • Active bleeding → keep platelets >50,000/µL
  • For endoscopy → >20,000/µL acceptable; if active bleed try for >50,000
  • Platelet transfusion not useful for antiplatelet reversal; may be harmful.

3. Anticoagulants

Hold in all patients initially.
Reversal:

  • DOACs → give reversal agent only if life-threatening bleeding
  • Warfarin → PCC preferred to FFP
  • Heparin → protamine

4. Coagulopathy from liver disease

  • Elevated INR not equal high bleed risk
  • Do NOT use FFP solely to correct INR
  • Follow variceal bleed protocol

ENDOSCOPY

Indications

All patients with suspected UGI bleed.

Timing

  • Within 24 hours for most
  • Variceal bleed: within 12–24 hours
  • No need to delay for mild INR elevation or anemia
  • Very early (<6–12 hr) → not beneficial & possibly harmful

Risks

  • Aspiration
  • Sedation events
  • Perforation
  • Worsening bleeding during therapy

Intubate only if: massive hematemesis, altered mental status, unable to protect airway.

Post-endoscopic risk stratification

Using modified Forrest classification for ulcers:

  • High-risk: Ia, Ib, IIa, IIb → require endoscopic therapy + IV PPI + admission 72 hr
  • Low-risk: IIc, III → can discharge if stable

OTHER DIAGNOSTICS

If endoscopy inconclusive & patient unstable

  • CT angiography (CTA)
  • Interventional angiography → can directly embolize

If stable

  • Colonoscopy if melena or hematochezia persists
  • If negative → evaluate small bowel (capsule, deep enteroscopy)

Contraindicated

  • Barium swallow/UGI series → interferes with endoscopy/IR

🧾 FAST ER/ICU CHECKLIST (Practical Use)

Immediately

  • ABCs
  • 2 large-bore IV
  • Fluid bolus
  • Type & cross
  • PPI IV bolus
  • If cirrhosis → octreotide + ceftriaxone
  • NPO
  • GI consult
  • Monitor Hb, lactate, V/S
  • Consider airway if massive hematemesis

Transfusion

  • PRBC if Hb <7 (higher threshold if CAD)
  • Platelets >50k if active bleed
  • Reverse anticoagulants only if severe bleed

Endoscopy

  • Within 24 hr (variceal 12–24 hr)
  • Consider erythromycin pre-procedure

 

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