The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. A number of medications may improve outcomes depending on the source of the bleeding. Peptic ulcers Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. Proton pump inhibitor (PPI) treatment before endoscopy may decrease the need for endoscopic haemostatic treatment, however it is not clear if this treatment reduces mortality, the risk of re-bleeding, or the and the need for surgery. Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal. In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance. There is tentative evidence of benefit for tranexamic acid which inhibits clot breakdown. Somatostatin and octreotide, while recommended for varicial bleeding, have not been found to be of general use for non variceal bleeds. After treatment of a high risk bleeding ulcer endoscopically giving a PPI once or a day rather than as an infusion appears to work just as well and is less expensive (the method may be either by mouth or intravenously). Variceal bleeding For initial fluid replacement, colloids or albumin is preferred in people with cirrhosis. Medications typically include octreotide or, if not available, vasopressin and nitroglycerin to reduce portal venous pressures. Terlipressin appears to be more effective than octreotide, but it is not available in many areas of the world. It is the only medication that has been shown to reduce mortality in acute variceal bleeding. This is in addition to endoscopic banding or sclerotherapy for the varices. If this is sufficient then beta blockers and nitrates may be used for the prevention of re-bleeding. If bleeding continues, balloon tamponade with a Sengstaken-Blakemore tube or Minnesota tube may be used in an attempt to mechanically compress the varices. This may then be followed by a transjugular intrahepatic portosystemic shunt. In those with cirrhosis, antibiotics decrease the chance of bleeding again, shorten the length of time spent in hospital, and decrease mortality. Octreotide reduces the need for blood transfusions and may decrease mortality. No trials of vitamin K have been conducted. Blood products The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm. In those in shock O-negative packed red blood cells are recommended. If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma (FFP) should be administered to prevent coagulopathies. In alcoholics FFP is suggested before confirmation of a coagulopathy due to presumed blood clotting problems. Evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and moderate bleeding, including in those with preexisting coronary artery disease. If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or prothrombin complex may decrease mortality. Evidence of a harm or benefit of recombinant activated factor VII in those with liver diseases and<unk>  is not determined. A massive transfusion protocol may be used, but there is a lack of evidence for this indication. Procedures The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed The benefits versus risks of placing a nasogastric tube in those with upper<unk>  are not determined. Endoscopy within 24 hours is recommended, in addition to medical management. A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. Prokinetic agents such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. They also decrease the amount of blood transfusions required. Early endoscopy decreases hospital and the amount of blood transfusions needed. A second endoscopy within a day is routinely recommended by some but by others only in specific situations. Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found. High and low dose PPIs appear equivalent at this point. It is also recommended that people with high risk signs are kept in hospital for at least 72 hours. Those at low risk of re-bleeding may begin eating typically 24 hours following endoscopy. If other measures fail or are not available, esophageal balloon tamponade may be attempted. While there is a success rate up to 90%, there are some potentially significant complications including aspiration and esophageal perforation. Colonoscopy is useful for the diagnosis and treatment of lower<unk> . A number of techniques may be employed including clipping, cauterizing, and sclerotherapy. Preparation for colonoscopy takes a minimum of six hours which in those bleeding briskly may limit its applicability. Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem. Angiographic embolization may be used for both upper and lower GI bleeds. Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered.
Gastrointestinal bleeding
Internal bleeding
Lower gastrointestinal bleeding
Upper gastrointestinal bleeding
Enteropathy
Rectal bleeding
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