الاقامة الدورية 🦋: post #2533 — TG.ME

🩸 ACUTE UPPER GI BLEEDING Initial Management — Guideline-Based Approach 🚨 UGIB is a medical emergency. الهدف الأول: Resuscitation → Risk stratification → Endoscopy → Hemostasis → Treat the cause 1️⃣ INITIAL APPROACH 🔹 ABC assessment + hemodynamic evaluation 🔹 Establish IV access • Ideally 2 large-bore peripheral IV cannulas • Consider central access إذا تعذر الحصول على reliable peripheral access 🔹 Keep patient NPO 🔹 Send appropriate investigations: • CBC • Urea/Creatinine & electrolytes • LFTs • Coagulation profile • Type & crossmatch 🔹 Use Glasgow-Blatchford Score (GBS) for pre-endoscopic risk stratification. 📌 GBS 0–1 → very-low-risk patients may be considered for outpatient management with appropriate follow-up. (PubMed) ⸻ 🔴 2️⃣ HEMODYNAMICALLY UNSTABLE Follow ABCDE 🫁 Airway Consider endotracheal intubation in selected patients with: • Altered consciousness • Severe ongoing hematemesis • Inability to protect the airway 💧 Circulation • Immediate IV crystalloid resuscitation • Treat hemorrhagic shock • Activate massive transfusion protocol when clinically indicated by massive ongoing hemorrhage. 🩸 Blood transfusion Use a generally restrictive strategy, but thresholds should be individualized in active massive bleeding or significant cardiovascular disease. ⸻ 🩸 3️⃣ RBC TRANSFUSION THRESHOLD Stable UGIB 🔻 Hb <7 g/dL → RBC transfusion is generally recommended. 🔺 A higher threshold Hb <8 g/dL may be appropriate in patients with significant cardiovascular disease. ESGE recommends a restrictive strategy targeting approximately 7–9 g/dL. (Esge) ⚠️ Clinical context matters: Do NOT delay resuscitation or transfusion in a patient with severe ongoing hemorrhage simply because the Hb has not yet fallen below 7 g/dL. ⸻ 💊 4️⃣ PRE-ENDOSCOPIC MANAGEMENT 🔹 Erythromycin Consider IV erythromycin 250 mg, 30–120 min before EGD in patients with severe or ongoing active UGIB. ➡️ Helps empty the stomach and improves endoscopic visualization. (Esge) 🔹 PPI ESGE: recommends high-dose IV PPI while awaiting endoscopy, e.g.: 💉 Pantoprazole 80 mg IV bolus → 8 mg/hour infusion ⚠️ PPI must NOT delay endoscopy. 📌 ACG: evidence was insufficient to recommend for or against routine pre-endoscopic PPI. (Esge) ⸻ ⏱️ 5️⃣ ENDOSCOPY After adequate hemodynamic resuscitation: Non-variceal UGIB 📌 Early EGD ≤24 hours Routine urgent EGD within 12 hours has not demonstrated better outcomes in stable non-variceal UGIB. (Esge) Suspected variceal bleeding 🚨 Endoscopy within 12 hours after hemodynamic resuscitation. (Esge) ⸻ 🩸 6️⃣ IF VARICEAL BLEEDING IS SUSPECTED Start treatment immediately — do NOT wait for endoscopy. 💊 Vasoactive agent • Octreotide • Terlipressin • Somatostatin 💉 Antibiotic prophylaxis • Ceftriaxone 1 g/day for up to 7 days, according to local resistance/allergy considerations. 📌 Vasoactive therapy should be started at presentation. (Esge) ⸻ 🚨 KEY TAKE-HOME UGIB → 🩺 ABCDE + Hemodynamic assessment ⬇️ 💧 Resuscitation ⬇️ 📊 Glasgow-Blatchford Score ⬇️ 🩸 Restrictive transfusion strategy ⬇️ 💊 Erythromycin ± PPI according to guideline/context ⬇️ 🔍 Early EGD ≤24 h ⬇️ 🎯 Endoscopic hemostasis ⬇️ 💊 High-dose PPI after successful hemostasis 📚 Guidelines • ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding — 2021 • ESGE Guideline: Nonvariceal Upper Gastrointestinal Hemorrhage — 2021 • ESGE Guideline: Esophagogastric Variceal Hemorrhage