Emergency Management of Acute Upper Gastrointestinal Bleeding

Acute upper gastrointestinal (GI) bleeding is a life-threatening medical emergency that requires prompt intervention. Immediate medical care and a systematic approach can significantly improve patient outcomes. Here are the essential steps in managing acute upper GI bleeding:

Initial Stabilization

Fasting and Intravenous Fluids: As soon as an upper GI bleed is suspected, the patient should be placed on nothing-by-mouth (NPO) status to prevent aspiration and further irritation. Intravenous (IV) access should be established immediately for fluid resuscitation, typically with isotonic saline or lactated Ringer's solution.

Pharmacological Intervention

Medication Therapy: Proton pump inhibitors (PPIs) are commonly administered intravenously to reduce gastric acid secretion and promote clot stability. In cases of esophageal or gastric variceal bleeding, somatostatin or octreotide may be used to reduce portal pressure and control bleeding. Additionally, local hemostatic agents such as thrombin may be given orally or topically, along with systemic hemostatic support using intravenous hemocoagulase.

Blood Product Replacement

Transfusion Support: If significant blood loss occurs or if the patient develops signs of hypovolemia or anemia, packed red blood cells (PRBCs) should be transfused. Fresh frozen plasma (FFP) or platelets may also be required if coagulopathy is present or if the international normalized ratio (INR) is elevated.

Nutritional Support

Total Parenteral Nutrition (TPN): Due to the necessity of fasting, patients often require nutritional support through total parenteral nutrition. This provides essential electrolytes, vitamins, and trace elements to maintain metabolic balance and support recovery during the acute phase.

Invasive Procedures

Endoscopic and Mechanical Interventions: For bleeding varices, especially in patients with underlying liver disease, balloon tamponade using a Sengstaken-Blakemore tube may be employed temporarily to control hemorrhage. Endoscopic variceal ligation (EVL) or sclerotherapy can be performed to achieve definitive hemostasis.

In non-variceal causes such as peptic ulcers or acute gastric mucosal injury, early upper endoscopy within 24 hours is recommended. During this procedure, interventions such as endoscopic clipping, epinephrine injection, or irrigation with cold saline can effectively stop the bleeding and reduce the risk of rebleeding.