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Gastrointestinal bleeding 

Gastrointestinal bleeding

Gastrointestinal bleeding

T.A. Rockall

and H.M.P. Dowson

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date: 30 March 2017

Gastrointestinal bleeding is a common emergency, with an incidence in the United Kingdom of about 1 per 1000 adults/year. It is subdivided into upper and lower, and acute or chronic, with acute upper gastrointestinal haemorrhage further subdivided into variceal and nonvariceal bleeding. Risk stratification in acute upper gastrointestinal haemorrhage can be performed using simple clinical and endoscopic criteria that can be used to estimate the risk of mortality, which overall is about 10% for both upper and lower gastrointestinal bleeds.

The immediate management of the hypovolaemic patient is first directed towards resuscitation (see Chapter 17.3) and then to identification of the site and cause of bleeding.

Most patients (80% in upper and 85–90% in lower gastrointestinal bleeding) will stop bleeding spontaneously and should then be investigated with either endoscopy or colonoscopy as appropriate. Patients with acute ongoing haemorrhage require urgent investigation (following fluid resuscitation) by oesophagogastroduodenoscopy with a view to applying endoscopic haemostatic therapy. Therapeutic techniques include injection of adrenaline, application of heat energy, and clipping, with data from randomized controlled trials demonstrating that such endoscopic therapy is efficacious in up to 95% of patients with upper gastrointestinal bleeding. In patients with major ulcer bleeding, treatment with a high dose proton pump inhibitor following successful endoscopic therapy has been shown to reduce the risk of rebleeding (but not overall mortality). If these techniques fail to arrest bleeding, then either selective mesenteric angiography with embolization or surgery is indicated.

Uncontrolled variceal haemorrhage may be controlled with a Sengstaken–Blakemore tube as a temporary measure before more definitive treatment. Where endoscopic therapies subsequently fail, transjugular intrahepatic portosystemic shunt is a minimally invasive method of creating a portosystemic shunt, and oesophageal transection is occasionally life saving where all other attempts at haemostasis have failed.

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