Treatment process of acute upper gastrointestinal bleeding

Treatment process of acute upper gastrointestinal bleeding.  Patients with upper gastrointestinal bleeding usually have hematemesis and melena as the main clinical manifestations.

01  Introduction

Let us follow the consensus of experts and learn about the diagnosis and treatment of acute upper gastrointestinal bleeding. The so-called food in hand, don’t panic in the heart, learn more, it is always right!

02  What is upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding refers to the bleeding caused by lesions of the digestive tract above the flexion ligament, including the esophagus, stomach, duodenum, bile duct, and pancreatic duct.

03 Classification of upper gastrointestinal bleeding

According to the cause of bleeding, it is divided into two types: non-varices bleeding and varicose bleeding.

According to the bleeding speed and severity, it can be divided into general acute upper gastrointestinal bleeding and dangerous acute upper gastrointestinal bleeding. The former refers to: low bleeding, stable vital signs, and good prognosis. The principle of treatment is to closely observe the changes in the condition, give symptomatic treatment such as acid suppression and hemostasis, and elective diagnosis and treatment of the cause. The latter refers to the hemodynamic disorder and organ dysfunction caused by massive upper gastrointestinal bleeding within 24 hours, the ratio is 15-20%. The early risk should be stratified, and bleeding patients should be divided into high-risk and low-risk.

Predictors of dangerous upper gastrointestinal bleeding include difficult to correct hypotension, red or coffee-like gastric contents in nasogastric tube aspirates, tachycardia, and progressive decline in hemoglobin or <80g/l.

The most common clinically dangerous upper gastrointestinal bleeding is bleeding involving larger blood vessels, including severe peptic ulcer bleeding, bleeding from esophageal gastric varices (EGVB), bleeding from malignant tumors that erode large blood vessels, and bleeding from serious underlying diseases Patients with poor tolerance to low hemoglobin. In addition, it is also seen in patients with coagulation dysfunction caused by other reasons such as chronic liver disease and anticoagulant drug application.

Coagulation dysfunction (INR>1.5) is an independent risk factor for death from acute non-varices upper gastrointestinal bleeding.

04  Common causes of upper gastrointestinal bleeding

Most (80-90%) of acute upper gastrointestinal bleeding in clinical work is non-varices bleeding. The most common causes include gastroduodenal peptic ulcer (20-50%) and gastroduodenal erosion ( 8-15%), erosive esophagitis (5-15%), cardia mucosa tear (8-15%), arteriovenous malformation/graft arteriovenous fistula (GAVE) (5%), other causes are Dieulafoy disease , Upper digestive tract malignant tumors, etc.

It can be seen from the above description that acute peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, and varicose rupture bleeding is the cause of the highest fatality rate of upper gastrointestinal bleeding. Bleeding caused by malignant tumors accounts for 5% of all upper gastrointestinal bleeding. 79% of tumor patients have bleeding as the first symptom, and 75% of them have metastatic lesions at the time of bleeding. Blood coagulation disorders such as taking anticoagulant drugs, antiplatelet drugs, non-steroidal anti-inflammatory drugs, hemophilia, leukemia, malignant histiocytosis, aplastic anemia, thrombocytopenic purpura, diffuse intravascular coagulation (DIC ), liver dysfunction, renal dysfunction, sepsis, epidemic hemorrhagic fever, etc. can also cause gastrointestinal bleeding.

05   Clinical manifestations of upper gastrointestinal bleeding

Patients with upper gastrointestinal bleeding usually have hematemesis and melena as the main clinical manifestations, and they also have atypical symptoms such as dizziness, fatigue, and syncope to the emergency department.

Hematemesis in patients with upper gastrointestinal bleeding can be dark red or even bright red with blood clots (large bleeding), and symptoms of hemorrhagic peripheral circulatory failure can occur. Symptoms such as dizziness, palpitations, sweating, fatigue, and dry mouth may occur when the amount of bleeding exceeds 400ml. The above symptoms are significant when the amount of bleeding exceeds 700ml, as well as fainting, cold limbs, pale skin, and decreased blood pressure; when the amount of bleeding exceeds 1000ml Can produce shock.

In patients with upper gastrointestinal bleeding, urea nitrogen will rise, and fever below 38.5°C will occur. What needs to know is that in the early stage of bleeding, the red blood cell count, hemoglobin, and hematocrit may not change at the early stage, and continue to decrease after a few hours.

06  Urgent evaluation of upper gastrointestinal bleeding

It is easy to make the diagnosis of acute upper gastrointestinal bleeding for patients who are treated with typical hematemesis, melena or bloody stool. For patients with atypical symptoms such as dizziness, fatigue, and syncope, emergency physicians should remain highly vigilant, especially those with unstable hemodynamics, pale complexion, and unexplained acute hemoglobin reduction. Identify or rule out the possibility of upper gastrointestinal bleeding. Cardiopulmonary resuscitation should be started immediately for patients with loss of consciousness, respiratory arrest, and untouchable large arterial pulses.

The emergency assessment of upper gastrointestinal bleeding includes consciousness judgment, airway assessment, respiratory assessment and hemodynamic status assessment.

Impairment of consciousness is not only one of the important manifestations of the severity of acute blood loss, but also an important reason for patients with vomiting and aspiration, leading to death from asphyxiation and falling pneumonia. If the patient’s Glasgow coma score (GCS score) is less than 8 points, it means that the patient is in a coma and needs extra attention. If there is any obstruction of the airway, necessary measures should be taken to keep it open. Patients with gastrointestinal hemorrhage may have abnormal respiratory rate and respiratory rhythm, and may have decreased oxygenation if they have respiratory distress (such as the three-concave sign). For patients suspected of having upper gastrointestinal bleeding, pulse, blood pressure, and capillary refill time should be measured in time to estimate blood loss and determine whether the patient’s hemodynamic status is stable. The following manifestations suggest that the patient’s hemodynamic status is unstable and should be admitted to the emergency room immediately to start fluid resuscitation: heart rate>100 beats/min, systolic blood pressure <90mmHg (or the systolic blood pressure is relatively normal without the use of drugs to lower blood pressure) Decrease> 30mmHg), cold extremities, paroxysmal syncope or other shocks, and persistent hematemesis or hematochezia.

07  Emergency treatment of upper gastrointestinal bleeding

For patients with upper gastrointestinal bleeding, “OMI” should be routinely adopted, namely: oxygen inhalation (O), monitoring (M) and establishment of venous access (I). For patients with severe bleeding, two or more unobstructed venous access should be opened, and if necessary, a central venous catheter should be used, and blood should be actively matched to start fluid resuscitation. Record hourly urine output.

All patients with acute upper gastrointestinal hemorrhage must be absolutely bedridden, and patients with impaired consciousness should tilt their heads to one side to avoid hematemesis and aspiration. Patients who are conscious and able to cooperate can have a gastric tube indwelled and flushed, which is helpful for judging active bleeding, but for patients with liver cirrhosis, EGBV and poor cooperation, they should be cautious when lowering the gastric tube to avoid aggravated bleeding.

Treatment of EGBV: ①Restricted fluid resuscitation strategy; ②Hemoglobin<70g/l is the threshold for the infusion of concentrated red blood cells, but it should be combined with the patient’s comorbidities, age, hemodynamics and bleeding; ③EGBV patients should use vasoactive drugs , It is recommended to use acid-suppressive drugs (proton pump inhibitors, H2 receptor antagonists) and somatostatin for 5 days; ④Upper gastrointestinal endoscopy (within 12h) should be performed as soon as possible after admission; ⑤For high-risk patients who have failed treatment, It may be considered as early as possible to perform transjugular intrahepatic portal-systemic stent shunt (TIPS). ⑥ Preventive use of broad-spectrum antibacterial drugs.

Commonly used resuscitation fluids include physiological saline, balance fluid, artificial colloids and blood products. Regardless of whether blood products or colloidal fluid can be obtained immediately, it is often advocated to inject crystal fluid first. Patients with co-infection should disable or use artificial colloids with caution. In the absence of control of gastrointestinal bleeding, blood products should be used early.

Most patients with upper gastrointestinal bleeding do not need to transfusion blood products, but blood transfusion should be considered when the following conditions exist: systolic blood pressure <90mmHg or a decrease from baseline systolic blood pressure>30mmHg; hemoglobin <70g/dl; hematocrit <25%; heart rate ＞120 times/min. It should be noted that it is not advisable to transfusion alone without crystalloid or colloidal fluid, because the blood is concentrated after acute blood loss. At this time, blood transfusion alone cannot effectively improve the microcirculation ischemia and hypoxia. When a large amount of stored blood is transfused, 10ml calcium gluconate should be supplemented intravenously for every 600ml blood transfusion.

Do not inject platelets for patients with active bleeding and stable hemodynamics; for patients with active bleeding and platelet counts <50×109/L; for patients with fibrinogen concentration <1g/l or activated partial thrombin Patients whose original time (international standardization ratio)>1.5 times the normal value were given fresh frozen plasma.

For patients with portal hypertension and bleeding from esophageal varices, the recovery of blood volume should be cautious. Excessive blood transfusion or transfusion may cause continued or re-bleeding. In the process of fluid resuscitation, avoid using only normal saline for volume expansion, so as not to aggravate or accelerate the accumulation of ascites or other extravascular fluids.

Fluid resuscitation and blood transfusion treatment need to achieve the following goals: systolic blood pressure 90-120mmHg; pulse <100 beats/min; urine output>40ml/h; blood Na<140mmol/l; consciousness or improvement; no significant dehydration.

For patients with massive blood loss, the blood transfusion reaches 80g/l hemoglobin and the hematocrit is 25-35%. It should not be excessive to avoid re-bleeding.

Under the premise of active fluid replacement, if the patient’s blood pressure still cannot rise to a normal level, in order to ensure blood perfusion of important organs, vasoactive drugs can be appropriately selected.

08  Second evaluation of gastrointestinal bleeding

After the life-threatening condition is relieved, fluid resuscitation and drug treatment are started in patients with massive bleeding, or when the patient’s condition is mild and the vital signs are stable for the first time, the prognostic assessment-comprehensive assessment is started. The content of prognosis assessment mainly includes: medical history, comprehensive physical examination and laboratory examination, etc. Through this assessment, the patient’s severity, possible disease diagnosis, active bleeding and bleeding prognosis are judged.

Detailed medical history is helpful to make a preliminary judgment on the cause of bleeding, and a comprehensive physical examination is required. Patients with gastrointestinal bleeding should complete blood cell analysis and examination. Patients usually have hemorrhagic anemia after acute massive bleeding, but in the early stage of bleeding, the patient’s hemoglobin concentration, red blood cell count, and hematocrit have no significant changes. The upper gastrointestinal bleeding is 2-5 hours, and the white blood cell count can rise to (10- 20) ×109/L, can return to normal 2-3 days after hemostasis. Improved liver and kidney function in patients with gastrointestinal bleeding can assist in the identification. In general azotemia, blood urea nitrogen often begins to rise a few hours after bleeding, reaching a peak at 24-48h, and returning to normal after 3-4d. If active bleeding has stopped, blood volume has been basically corrected but urine output is still low, and urea nitrogen remains high at the same time, the possibility of renal dysfunction due to prolonged shock or original kidney disease should be considered. For gastrointestinal bleeding, coagulation function is very important and can help determine whether the bleeding is primary or secondary.

09 Judgment of active bleeding

Active bleeding should be considered in the following clinical situations: ①The frequency of hematemesis or melena increases, the vomit changes from brown to bright red, or the excreted stool changes from black dry stool to loose stool or dark red bloody stool, or accompanied by bowel sounds Active; ②After rapid infusion and blood transfusion, the performance of peripheral circulatory failure has not been significantly improved, or although it is temporarily improved and then worsened, the central venous pressure is still fluctuating, slightly stable and then decreased; ③Red blood cell count, hemoglobin and hematocrit continue Decrease, the reticulocyte count continues to increase; ④ In the case of sufficient fluid and urine, blood urea nitrogen continues or increases again. ⑤ There is more fresh blood in the gastric tube aspirate.

010  Emergency clinical treatment

First of all, it is necessary to judge the patient’s life status, monitor body temperature, pulse, respiration, blood pressure and pupils, understand the occurrence and development of the disease, and stabilize and restore the patient’s vital signs.

Second, it needs to be clear that drug therapy is still the first choice for acute upper gastrointestinal bleeding. The combined medication regimen for severe acute upper gastrointestinal bleeding is: intravenous somatostatin + proton pump inhibitor. When varicose bleeding is highly suspected, vasopressin + antibiotics are combined on this basis, and the cause is determined, and then the treatment plan is adjusted according to the specific situation. The use of proton pump inhibitors requires intragastric ph>4 to reach more than 8h per day and ph>6 to reach more than 20h per day. Among various proton pump inhibitor drugs, esomeprazole is the drug with a faster onset. High-dose esomeprazole is recommended as one of the drug options for the emergency treatment of acute upper gastrointestinal bleeding. Usage: After 80 mg esomeprazole is injected intravenously, continue intravenous pumping or drip at a rate of 8 mg/h. Conventional dose of proton pump inhibitor treatment: esomeprazole 40 mg intravenously, once every 12 hours. Proton pump inhibitor injections include pantoprazole, omeprazole, lansoprazole, rabeprazole, etc., which are all effective anti-acid and hemostatic drugs. Commonly used H2 receptor antagonist injections include famotidine and ranitidine. The method of using famotidine for injection is: 20 mg + 20 ml of saline intravenous bolus, 2 times a day; the method of using ranitidine is: 50 mg/time, diluted slowly by intravenous bolus (over 10 min), every 6- Dosing once at 8h.

Third, hemostatic therapy can be performed. What needs to be known is that blood transfusion to correct blood coagulation is an integral part of hemostatic therapy. For patients with platelet deficiency, avoid the use of aspirin combined with clopidogrel intensified antiplatelet therapy; for patients with hemophilia, first infuse coagulation factors and use proton pump inhibitors at the same time; for patients with coagulation dysfunction, current treatment views: ①transfusion Fresh frozen plasma was injected; ②Tranexamic acid was given first to supplement fibrinogen; ③The blood component transfusion guided by thromboelastography monitoring. The hemostatic treatment standard for patients with coagulation dysfunction: new oral anticoagulants increase the risk of gastrointestinal bleeding, but after treatment corrected, the international normalized ratio (INR) is 1.5-2.5, endoscopic treatment can be performed. For people with coagulation dysfunction, vitamin K can be injected intravenously. To prevent secondary fibrinolysis, antifibrinolytic drugs such as hemostatic acid can be used; traditional Chinese medicines such as Yunnan Baiyao also have certain effects. Sucralfate suspension or frozen norepinephrine solution (8mg of norepinephrine, 100-200ml of ice saline can be added to those inserted into the gastric tube). Preventive application of antibiotics in patients with liver cirrhosis and patients with acute upper gastrointestinal bleeding significantly reduces bacterial infections, reduces all-cause mortality, bacterial infection mortality, rebleeding events and hospitalization events.

Fourth, use somatostatin. After intravenous injection of somatostatin, it takes effect within 1 min, and the peak concentration can be reached within 15 min. The half-life is about 3 min, which is beneficial to the early and rapid control of acute upper gastrointestinal bleeding. Usage: The first dose of 250ug is given by rapid intravenous drip (or slow bolus), followed by 250ug/h intravenous pump (or drip), and the course of treatment is 5 days. For high-risk patients, the choice of high-dose (500ug/h) continuous intravenous pumping or infusion of somatostatin is superior to conventional doses in improving visceral hemodynamics, controlling bleeding and improving survival. For acute upper gastrointestinal bleeding that is difficult to control, rapid intravenous drip of 250ug can be repeated according to the condition, up to 3 times. Octreotide is a synthetic 8-peptide somatostatin analogue. After subcutaneous injection, the absorption is rapid and complete. The plasma concentration can reach the peak at 30 minutes, and the elimination half-life is 100 minutes. After intravenous injection, its elimination is biphasic, with half-lives of 10 minutes and 90 minutes, respectively.

Usage: In the acute bleeding period, it should be administered intravenously, starting with a rapid intravenous drip of 50ug, followed by 25-50ug/h continuous intravenous pumping or dripping, and the course of treatment is 5 days. Vapratide is a newly synthesized somatostatin analogue. Usage: After intravenous injection of 50ug, maintain at 50ug/h.

Fifth, decide whether to treat infections according to the condition. Liver cirrhosis patients with acute varicose rupture bleeding often have gastric mucosa and esophageal mucosa inflammatory edema. Preventive use of antibacterial drugs can help stop bleeding, reduce early rebleeding and infection, and improve survival.

Sixth, the choice of vasoactive drugs. Including pituitary gland, vasopressin, terlipressin, etc. In order to reduce adverse reactions, the time limit for continuous intravenous administration of high-dose vasopressin should not exceed 24 hours. Pituitrin usage is the same as vasopressin: 0.2-0.4u/min continuous intravenous pumping, the highest can be increased to 0.8u/min; the treatment should be combined with intravenous infusion according to the patient’s cardiovascular disease and response to the drug Nitrate drugs, and ensure the systolic blood pressure> 90mmhg. The recommended starting dose of terlipressin is: 2mg/4h, after the bleeding stops, it can be changed to 2 times/day, 1mg/time, and generally maintained for 5 days to prevent early rebleeding.

Seventh, the three-chamber two-balloon tube is compressed to stop bleeding. It can effectively control bleeding, but it has a high recurrence rate, aspiration pneumonia, tracheal obstruction and other complications. It is an emergency measure for hemorrhage that is difficult to control with drugs, and creates conditions for endoscopic or interventional surgery to stop bleeding. When performing airbag compression, deflate once according to the condition of 8-24h. The timing of extubation should be 24h after hemostasis. Generally, deflate and observe for 24h first. If there is still no bleeding, extubation can be performed.

Eighth, endoscopic treatment. Timing of endoscopic treatment: Compared with varicose vein rupture bleeding within 12 hours, early endoscopy within 24 hours after successful resuscitation is suitable for most patients with upper gastrointestinal bleeding. Within 24 hours of bleeding, after the hemodynamics is stable, patients without serious comorbidities should undergo emergency endoscopy as soon as possible. For patients with high-risk signs, emergency endoscopy should be performed within 12 hours. For patients suspected of bleeding from cirrhosis and varicose veins, emergency endoscopy should be performed within 12 hours after hospitalization. The predictive indicators of rebleeding after hemostasis under endoscopy include: hemodynamic instability, active bleeding on gastroscopy, ulcer size> 2cm, ulcer site in the lesser curvature of the stomach or posterior duodenum, hemoglobin <100g/l , Need blood transfusion.

Ninth, interventional therapy. Patients with uncontrollable acute bleeding should consider interventional therapy as soon as possible.

Finally, surgical treatment. Despite the various treatments mentioned above, there are still about 20% of patients with bleeding that cannot be controlled. At this time, surgical intervention is requested in time.

011  Three evaluations of upper gastrointestinal bleeding

First, the risk of rebleeding and death needs to be assessed. The Rockall scoring system is often used clinically to evaluate the risk of rebleeding and death in patients with acute upper gastrointestinal bleeding. A score ≥ 5 is considered high risk, 3-4 is considered intermediate risk, and 0-2 is considered low risk. The Blatchford score can also be used: a score ≥6 is classified as medium to high risk, and a score of <6 is classified as low risk. Or use Child-Pugh classification: ≤3 points have a better prognosis, ≥8 points have high mortality.

Second, the organ function needs to be assessed. For example, cardiac function (whether acute myocardial infarction occurs due to ischemia), respiratory function (whether ARDS is caused by a large amount of blood transfusion), central nervous function (whether there will be a disturbance of consciousness), blood coagulation function (whether there will be prolonged APTT), liver and kidney function ( Whether bilirubin is elevated, whether creatinine level is elevated), gastrointestinal function (whether there is gastrointestinal mucosal damage, need to determine bowel sounds, intra-abdominal pressure).

012  Follow up

After the patient’s condition is stable and the bleeding is controlled, the patient can be referred to a specialist ward for continued treatment or discharged for follow-up according to the condition of the original disease. For elderly patients with multiple chronic diseases or a history of liver cirrhosis, they should be hospitalized for further examination, evaluation and treatment.

(source:internet, reference only)

Disclaimer of medicaltrend.org