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Diagnosis and management of upper gastrointestinal haemorrhage in the critically ill 

Diagnosis and management of upper gastrointestinal haemorrhage in the critically ill
Chapter:
Diagnosis and management of upper gastrointestinal haemorrhage in the critically ill
Author(s):

Tasneem Pirani

and Tony Rahman

DOI:
10.1093/med/9780199600830.003.0177
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date: 30 November 2020

Upper gastrointestinal haemorrhage is a medical emergency that may present with haematemesis and/or melena. An exhaustive history and careful examination aids in identifying the cause of bleeding and directing appropriate management. Validated scoring systems exist to guide the urgency of endoscopic therapy, although these should not be used in isolation, but in conjunction with complete patient assessment. The initial priority should be to resuscitate and stabilize the patient using the airway, breathing, circulation, and disability framework. Resuscitation should be guided by clinical and physiological parameters. Patients should be managed in an environment where vital signs such as heart rate, blood pressure, respiratory rate, conscious level, and urine output are monitored at least hourly. Attempts should be made to correct coagulopathy. Specialist advice should be sought from haematologists for guidance on the most appropriate use of packed red cells and blood products. Over-transfusion should be avoided. Initiation of pre-endoscopy proton pump inhibitor therapy, in particular to avoid definitive endoscopic therapy, is not recommended. Diagnostic endoscopy and therapy should be conducted within 24 hours of presentation. Numerous endoscopic therapies exist—when epinephrine is used for local tamponade and vasoconstriction, application of dual modality treatment is recommended. In cases where endoscopic therapy fails or is not possible, radiological diagnosis, and embolization may become necessary. Occasionally, surgery is required for definitive treatment—close liaison with surgeons is therefore necessary, especially where initial endoscopy is considered suboptimal or re-bleeding occurs.

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